Thursday, May 19, 2005

Thoughts on what does clinical experience bring to the table.

An interesting editorial appeared in ACP Journal CLub ( May/June 2005/volume 142 no. 3 p A-8) entitled " Does clinical experience make up for failure to keep up to date?" by GR Norman and KW Eva , both PhDs from McMaster University.(this publication requires a subscription).
They suggest the following thesis:Physicians in practice tend to not keep up but this seems to have little impact in patient outcomes.(Interestingly, they quote articles claiming that board certification and subspecialization both are associated with an absolute mortality difference (Norcini JJ, et al Med Educ 2002: 36;853-859)) As I have blogged about before,I am not convinced how prevalent the tendency is to not "keep up" or how valid the data is demonstrating that but the authors present some interesting ideas, at least some which is back up with some data and make several comments worthy of repeating.
They say experience makes docs make decisions rapidly. It is as if a vast medical storehouse of clinical cases is stored and a pattern-recognition process is triggered and a diagnosis is reached without conscious reflection. The authors also make the point that adherence to practice guidelines may be optimal-in some sense-at the population level but when an experienced physician considers a given cases, he may deliberately deviate from the guideline to more appropriately take care of the individual patient's needs.Less experienced docs tend more to adhere to the prescibed practice approach. So if we equate "quality" with adherence to guidelines are we really getting it right or is that just the easy way to claim we are evaluating physician's care?
It is probably too simple to say that young docs go by guidelines more and older docs have more experience based context into which to put things but there may be a trend in that direction.
Older docs can improve the degree to which they are current on guidelines-even if they decide if they are applicable or not on a case by case basis-but the only way young docs get the experience is to get to be old docs.

2 comments:

MD said...

I think this whole "older doc vs. young doc" business is a colossal waste of time.

There are far more important issues in medicine to study and talk about for us to be even thinking about this nonsense.

For example, a really important area is medical error and the reasons why doctors make errors in diagnosis and treatment, and what can be done to improve the status quo.

Now, you might be able to find, through some ponderous research technique with little reliability, that a slightly higher proportion of one group, say older docs, makes decisions without resorting to the evidence.

My question is, so what? It's a finding that does very little to help us because you can't really use that data in any meaningful way.

If you put the resources into it, I'm sure it would be possible to discover that, oh, docs who make medical errors more frequently wear plain white boxers instead of colored ones, say, or some such nonsense. But this information has absolutely zero value in helping us with real issues, such as mistakes in medicine.

Instead of wasting so much time and money looking at "older docs" vs. "younger docs", the researchers who studied this would have been much more helpful if they tried to identify effective methods how docs can better stay up to date, or identify what the most important factor is in doctors not staying up to date, or even whether being up to date has any bearing on outcomes (the BMJ had a theme issue last year - Does EBM lead to better outcomes? ie. what's the evidence for EBM?).

Research should not be done just because it is possible to do it. In a world of finite resources, we should research what matters.

Anonymous said...

I agree that much "research" is done because they can.It seems to me that we have a lot more of the "fishing expedition" type article since the advent of the general medicine sections of medical departments.