Letters from Maine

Experience may not always the best teacher


 

“In medicine, a lack of experience may not actually be a bad thing.” The words leapt off my tablet, and my blood pressure hit the stratosphere. How could a 30-year-old physician who is still doing his cardiology fellowship have the nerve to take a cheap shot at one of the cornerstones of my identity? (“For Doctors, Age May Be More Than a Number,” by Haider Javed Warraich, The New York Times, Jan. 6, 2018.) My reputation as a skilled pediatrician was built on the breadth and depth of my clinical experience. In the first 30 years of my professional career, I had participated in more than 300,000 patient encounters. Wasn’t that effort good for something?

Doctor using stethoscope on a child. Darrin Klimek/Thinkstock
I stopped reading, set the tablet down, and went for a brisk walk around the neighborhood, hoping to get my emotions under control before reading on. Refreshed and tempered by the subzero air, I read on and discovered that Dr. Warraich had done his homework and offered some evidence to support his claim that, at least in medicine, experience may be overvalued.

He wrote that in a study of hospitalists (BMJ. 2017;357:j1797), the patient death rate increased steadily from 10.8% for physicians younger than 40 years to 12.1% for those 6o years and older, except those physicians treating a high volume of patients. He also cites a study in which the authors analyzed 62 studies of quality of care. The investigators found that slightly more than half of the studies “report decreasing performance with increasing years in practice” (Ann Int Med. 2005 Feb 15;142[4]:260-73).

Still in a defensive mode, I decided to chase down the references and take a closer look. In the study demonstrating patient mortality increasing with physician age, we must consider that these physicians were hospitalists and the patients were elderly. The observations may not be applicable to those seeing younger patients in a primary care office setting.

Another caveat listed by the authors is that the association between increasing patient mortality with increasing physician age did not hold true “among physicians with high volumes of patients.” As a high-volume practitioner myself, I found this comforting. It may be that there is some threshold effect in which a little experience is a negative but a ton of experience is a plus. Experience can teach efficiency. But, of course, efficiency doesn’t always equate with quality.

The study citing a decline in quality of care with physician age is a bit more troublesome. However, it may be that, rightly or wrongly, older physicians who have seen the tide go in and out enough times are more hesitant to accept and adhere to “evidence-based” quality measures that they see as ephemeral.

Dr. William G. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years.

Dr. William G. Wilkoff

It was Dr. Warraich’s citation from the journal Cancer that I had the most difficult time rationalizing. This study found that younger physicians were more likely to discuss end of life issues with patients (Cancer. 2010 Feb 15;116[4]:998-1006). I suspect this is a valid observation as I have always struggled with discussing subjects such as sexuality and end of life issues with patients.

After what for me was an inflammatory opening, Dr. Warraich’s article closes with the observation that “mentorship is a two-way street.” Any physician who has worked with medical students and inquisitive house officers realizes that our surplus of experience always can stand to gain a little refreshing from those who have little of their own.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

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