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IMPROVING PATIENT CARE

Improving Patient Care is a special section within Annals supported in part by the U.S. Department of Health and Human Services (HHS) Agency for Healthcare Research and Quality (AHRQ). The opinions expressed in this article are those of the authors and do not represent the position or endorsement of AHRQ or HHS.

Systematic Review: The Relationship between Clinical Experience and Quality of Health Care

Niteesh K. Choudhry, MD; Robert H. Fletcher, MD, MSc; and Stephen B. Soumerai, ScD

15 February 2005 | Volume 142 Issue 4 | Pages 260-273

Background: Physicians with more experience are generally believed to have accumulated knowledge and skills during years in practice and therefore to deliver high-quality care. However, evidence suggests that there is an inverse relationship between the number of years that a physician has been in practice and the quality of care that the physician provides.

Purpose: To systematically review studies relating medical knowledge and health care quality to years in practice and physician age.

Data Sources: English-language articles in MEDLINE from 1966 to June 2004 and reference lists of retrieved articles.

Study Selection: Studies that provided empirical results about knowledge or a quality-of-care outcome and included years since graduation or physician age as explanatory variables.

Data Extraction: We categorized studies on the basis of the nature of the association between years in practice or age and performance.

Data Synthesis: Overall, 32 of the 62 (52%) evaluations reported decreasing performance with increasing years in practice for all outcomes assessed; 13 (21%) reported decreasing performance with increasing experience for some outcomes but no association for others; 2 (3%) reported that performance initially increased with increasing experience, peaked, and then decreased (concave relationship); 13 (21%) reported no association; 1 (2%) reported increasing performance with increasing years in practice for some outcomes but no association for others; and 1 (2%) reported increasing performance with increasing years in practice for all outcomes. Results did not change substantially when the analysis was restricted to studies that used the most objective outcome measures.

Limitations: Because of the lack of reliable search terms for physician experience, reports that provided relevant data may have been missed.

Conclusions: Physicians who have been in practice longer may be at risk for providing lower-quality care. Therefore, this subgroup of physicians may need quality improvement interventions.

Editors' Notes Context While "practice makes perfect" in some situations, physicians' knowledge and performance may decline with the passage of time. Contribution Of 62 published studies that measured physician knowledge or quality of care and described time since medical school graduation or age, more than half suggested that physician performance declined over time for all outcomes measured. Only 1 study showed improved performance for all outcomes measured. Implications This review should provoke careful study of the relationship of physician experience and the quality of care. It also raises concerns about the adequacy of continuing professional education in medicine. –The Editors

 

Author and Article Information

From Harvard Medical School and Harvard Pilgrim Health Care, Brigham and Women's Hospital, and the Harvard PhD Program in Health Policy, Boston, Massachusetts.

Grant Support: By the Harvard Pilgrim Health Care Foundation. Dr. Choudhry is also supported by the Harvard Medical School Fellowship in Pharmaceutical Policy Research, a Frank Knox Scholarship from Harvard University, and a Canadian Institutes of Health Research Postdoctoral Fellowship. Dr. Soumerai is an investigator in the HMO Research Network Center for Education and Research in Therapeutics, funded by the U.S. Agency for Healthcare Research and Quality.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Niteesh K. Choudhry, MD, Department of Ambulatory Care and Prevention, Harvard Medical School, 133 Brookline Avenue, 6th Floor, Boston, MA 02215; e-mail, choudhry{at}fas.harvard.edu.

Current Author Addresses: Drs. Choudhry, Fletcher, and Soumerai: Department of Ambulatory Care and Prevention, Harvard Medical School, 133 Brookline Avenue, 6th Floor, Boston, MA 02215.

Related articles in Annals:

Editorials
"Practice Makes Perfect" ... Or Does It?
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Annals 2005 142: 302-303. [Full Text]  

Summaries for Patients
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