The July 05, 2005. issue of the Annals of Internal Medicine contains several letters critical of an earlier Annals article by Choudhry,Fletcher and Soumerai, the accompanying editorial and even raises questions of "conflicts of interest". The article in question concluded that older physicians may provide lower quality care and need quality improvement interventions.
The journal requires a subscription for full text viewing so here are some of the highlights.
Dr. Martin Samuels of Harvard ( to whom I will always be grateful for his classic "dizzy patient" lecture) and Dr. Allan Ropper question the method of article selection used by Choudhry but more than that he accuses the author of writing a "potentially destructive" article. They go on to say "... age brings 2 things: graciousness and time to realize that fads in treatment and medical reform come and go".
They continue to say "Choudhry and colleagues' review glorifies information, algorithms, and consensus statement and has the unfortunate, probably unintended effect of diminishing experience and judgment. However, its publication is not unexpected. It is part and parcel of an unfortunate course of events in medicine where quantification inadvertently undermines quality while masquerading as evidence. ( ref: clinical experience and quality of health care. Samuels, MA and Ropper, Allan H. Annals of Internal Medicine Vol. 143 number 1 pg 84 5 july 2005.)
Dr. Poses (of HCRENEWAL) and Dr. Joseph Diaz also lists point by point methodological weaknesses of the paper. (ref. same as above pg 84-85)
A similar critique from Poses is available here.
Conflicts of interest have attracted much attention of late, mainly focused on the antics of Big Pharma and their purported manipulation of the medical literature. Dr. Elizabeth W. Loder, also on the Harvard Medical School faculty in her letter( same reference as above,pg 86) raises interesting questions regarding one of the authors -Dr. Robert Fletcher-and his role as co-editor of a section of the product known as UpToDate .Dr. Loder expresses surprise that no potential conflict of interest was reported with the article. Where is the conflict? Loder goes on to say that in interviews following the article's publication, Fletcher, identified computerized databases as a principal solution to the quality problems recognized by the publication in the annals. UpToDate is self described on its web site as a comprehensive evidence-based clinical information source available on the webl and CD-ROM. While the failure to disclose may be no more than an oversight, some may be concerned with the perception of self interest and conflict of interest.
Coincidently, the day I read Dr. Loder's letter, my wife-also a physician-received a promotional letter for UpToDate from Dr. Robert H. Fletcher. The second paragraph says " Old habits of keeping up do not serve us well enough. This is what I found in a recently published study in the Annals of Internal Medicine. The longer the time since graduation from medical school, the less physicians knew about and used new, evidence-based practices." I have not had the opportunity to use UpToDate. It may well live up to the promotional claims. One wonders what is the evidence that use of this product will lead physicians to engage in more " evidence-based practices." (Fletcher's letter does quote a survey of subscribers that found 91 plus % changed "management based on their use" of the product.)
The Annals deserves credit for publishing these and other letters critical of the article and the editorial. However, the headlines generated by the article and the interviews by the press with the authors are not neutralized by the rebuttal and critiques expressed in the letters.
The thoughts of Samuels and Ropper expess a vision of what a good physician should be that looks beyond the simplistic reliance on conformity with guidelines as a measure of quality care and places value on maturity and judgment and experience.