Wednesday, February 16, 2005

Are Older Doctors Dumber?

The results of a systematic review in the Annals of Internal Medicine have created headlines around the US. Most, like this one from the Boston Globe (Greater Risk Seen With Older Doctors), suggest that older doctors are, well, dumber than younger ones. My wife, seeing the headline, and observing that I had progressed to a certain age, said this morning, "shouldn't you look into this one." So I did.

The study in the Annals of Internal Medicine [Choudry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med 2005; 142: 260-273] searched the literature search to find 62 articles that analyzed physician knowledge or performance according to the the physicians' age. Summaries of the 62 studies were broken down by study purpose: 12 involved written tests of knowledge; 17, adherence to guidelines or practice standards for diagnosis, screening, or prevention assessed by self-report, e.g., by surveys or interviews; 7, adherence to such standards assessed by chart audit; 5, adherence to guidelines or practice standards for treatment assessed by self-report; 13, adherence to guidelines or practice standards for treatment assessed by chart audit; and 7, directly measured patient outcomes.

The review did not screen out articles of poor methodologic quality, or rate the methodologic quality of any article. So it did not eliminate articles whose specific standards for physician performance were not evidence-based, such as tests of knowledge not related to the physicians' practices. Furthermore, it included articles regardless of their study architecture, age, sample size, patient selection criteria, whether and how they controlled for patients' characteristics, and effect size and its precision. Thus, this review's results could well have been biased by poorly designed or performed studies, and studies which are unlikely to generalize to modern physicians.

I did not have time to re-review every article, but a quick perusal made me more concerned that the most striking results showing older physicians performing worse were contributed by the methodologically weakest articles. For example, of the 13 articles that looked at adherence to standards for treatment by chart audit, only 6 showed what the authors called a consistently negative effect of increasing age. Of these,
  • one was published 34 years ago, and included only 37 physicians;
  • one, of treatment of depression, did not account for the severity of the patients' symptoms, and had a very small effect size (OR=1.12, CI 1.01, 1.24);
  • one used a standard of care for inappropriate drug selection that might be debated;
  • one used that same standard, did not adjust for patients' clinical characteristics, and had a very small effect size (OR=1.14);
  • one was published 21 years ago, and used practice standards defined by consensus, not evidence; and
  • one was published 20 years ago, included only 66 physicians, and again used practice standards defined by a panel, not evidence.
The article failed to acknowledge the methodologic weaknesses of the studies it summarized. But I am very concerned that its conclusions were biased by these weakness. Thus I think its basic conclusion, that older doctors are dumber, is not strongly supported by the evidence.

Yet an accompanying commentary, [Weinberger SE, Duffy FD, Cassel CK. "Practice makes perfect" ... or does it? Ann Intern Med 2005; 142: 302-303.], hailed the article as showing that physicians "must embrace the concepts behind maintenance of certification, which provides an opportunity to prevent the outcomes demonstrated...." Since Choudry's review did not include any studies of recertification, I think this conclusion goes even farther beyond its data.

Even though physicians seem beset on all sides by powerful organizations, sometimes that stand to profit by reducing physician autonomy, I believe that our professional values mandate serious, ongoing examination of our own performance. (I have actually published a few studies which do just that.) However, the principles of clinical epidemiology apply to such studies just as they apply to studies of patients. We do no one any favors by rushing to negative conclusions about physician performance without examining the strength of the relevant evidence.

2 comments:

Wallace Sampson MD said...

As an "older" and retired, I can attest to difficulties keeping up with new concepts and data. Yet before retirement at 67, I was aware of judgment matters and problems not handled well by younger docs. Knowledge deficits I handled by looking things up with greater frequency than at age 30, and by asking questions.
I have not read the article, but I had thought long about the problem and had concluded that each decacde and "age" brought with it both advantages and deficits. I wonder about the indicators chosen for the study and if there were an agenda behind it.
A look at Pubmed articles by the lead author shows a tendency to study or expose common accepted perceptions. Not a bad thing, as that is how we learn, but one wonders about the intricate methodology and the questions asked, and about a PM mindset.

W Sampson

Wallace Sampson MD said...

As an "older" and retired, I can attest to difficulties keeping up with new concepts and data. Yet before retirement at 67, I was aware of judgment matters and problems not handled well by younger docs. Knowledge deficits I handled by looking things up with greater frequency than at age 30, and by asking questions.
I have not read the article, but I had thought long about the problem and had concluded that each decade and "age" brought with it both advantages and deficits. I wonder about the indicators chosen for the study and if there were an agenda behind it.
A look at Pubmed articles by the lead author shows a tendency to study or expose common accepted perceptions. Not a bad thing, as that is how we learn, but one wonders about the methodology as described by Dr. Poses, and about a PM mindset.
Furthermore, this journal has come under some review of concern for the type and nature of its published articles - favoring sectarian methods (CAM) and subtly favoring physician crtiques.
Some things to keep in mind.
W Sampson