Heart of the Matter

Practice Does Make Perfect


The competency of older physicians is being questioned as a result of a recent study that concludes “physicians with more experience may paradoxically be at risk for providing lower-quality care.” An accompanying editorial, which challenges the headline of this column, all but reads us oldies out of the profession until we are reeducated into the new method of care.

I admit to some bias on this topic. The authors indicate that older physicians don't adhere to guidelines like the young ones do and therefore adversely affect the quality of care. However, the authors were unable to provide any convincing data to suggest that noncompliance affected outcome, and admitted that the study was limited and not entirely reliable (Ann. Intern. Med. 2005;142:260-73,302-3).

Prior to the meteoric increase in guidelines in the 1990s, doctors were on their own to make medical decisions, based on the knowledge of pathophysiology, physical diagnosis, and the paucity of drugs available to them. Since the development of guidelines, many young physicians think they have little need for these arcane concepts because they can turn to their PalmPilot for the answers. Laboratory data have become the driving force for decision making: Give me the ejection fraction or the percent stenosis, and I will give you the therapy. Never mind that guidelines are meant to guide and are not written in stone. Forget that fewer than 20% of the patients we treat actually fit into any particular guideline, or that guidelines are constructed largely from clinical trials of patients who only vaguely resemble the general population. And don't forget that guidelines are continually changing, as is science itself.

Deviation from guidelines may in fact represent the vanguard of better medicine. Consider that for years, guidelines for the treatment of ST-segment elevation MI said that every patient should receive intravenous β-blockade unless bradycardia or hypotension is present. Many physicians, young and old, deviated from that dictum, assuming that patients in acute heart failure could do very poorly. Guidelines changed, and recent trials, including COMMIT/CCS-2—see page 18—confirm that such treatment actually may increase mortality.

The young physicians I work with are terrific—well motivated and very smart. They have been schooled in the use of guidelines, but they often lose sight of the patient in their attempt to practice evidence-based medicine. They are using guidelines as a haven in the morass of the uncertainties of decision making and in a false sense of protection from malpractice.

The dissemination of evidence from clinical trials has unquestionably improved the quality of care of cardiac patients worldwide. These trial data have been incorporated into quality standards and care guidelines with great success. Skilled and sensitive physicians, regardless of their age, will take guidelines and apply them to their patients. However, they may appropriately decide to deviate from those guidelines. Adherence to guidelines is an imperfect measure of physician performance. Perhaps older physicians, because of their experience, can function more easily outside the guidelines.

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