It's an image enshrined in popular culture: the wise old doctor who knows how best to treat patients because of his years of clinical experience.
Or does he?
Not according to a team of researchers at Harvard Medical School, who analyzed 62 studies conducted over the past four decades and found precisely the opposite -- that the quality of care provided to patients was inversely related to a doctor's experience and age.
Nearly three-quarters of the studies found that older doctors were less likely to adhere to guidelines for cancer screening, to use proper medications to treat heart attacks or to adopt other evidence-based treatments. One of the most striking results came from a 2000 study of 4,546 internists, cardiologists and family physicians, which found that patient mortality increased by 0.5 percent for every year after a doctor graduated from medical school.
"I was surprised by the consistency of the association," said lead author Niteesh K. Choudhry, a 33-year-old internist at Brigham and Women's Hospital in Boston. But Choudhry, whose report in the Annals of Internal Medicine was funded in part by the federal Agency for Healthcare Research and Policy, cautioned against equating older doctors with inferior care.
"There are so many variables that determine the quality of a physician," he said. "These are general findings. There are certainly physicians who've been around a long time who are excellent, just as there are young physicians who are really horrible."
Experts speculate that a key reason for the performance gap may be the explosion in medical knowledge and the inadequacy of continuing medical education (CME) to help doctors keep pace. Many CME courses, which are required of most physicians, are held in desirable locations such as Aspen and Maui and often consist of sessions in which participants "sit in a chair and take notes and doze off," observed Christine Cassel, the 58-year-old president of the American Board of Internal Medicine.
Other efforts to boost competence are necessary, said Cassel, co-author of a companion editorial, which declared that "the profession cannot ignore this striking finding." Physicians, she said, need help distinguishing "what you need to know and what needs to be at your fingertips" because about 10,000 clinical trials are issued annually.
Each of the 24 specialty boards that comprise the American Board of Medical Specialties now requires that their members take periodic exams to maintain their board certification, she said. Older doctors are typically exempt from these requirements.
Cassel said that in the largest specialty, internal medicine, about half of the 150,000 practicing internists have been grandfathered in because they passed board exams before 1990. Nationally about 87 percent of physicians are board certified.
To world-famous heart surgeon Michael DeBakey, who at 96 is still practicing full time at Baylor College of Medicine in Houston where he is chancellor emeritus, the study underscores the importance of competence, rather than age.
As with people in all professions, DeBakey said, doctors vary tremendously in their abilities, a reality that is often overlooked. "I suspect 20 years from now a study would find the same thing" as the Harvard researchers did. Most physicians who are very good early in their careers, he said, will probably retain these skills as they age.
DeBakey said he keeps up by "reading all the journals, writing articles, doing research" and teaching. He said he stopped operating on patients about nine years ago.
Alan Pocinki, 45, an internist who practices in the District, said the Harvard study has limitations. Adhering to practice guidelines and measuring performance on recertification exams as some studies did, he said, does not measure a doctor's diagnostic capabilities, clinical judgment or other skills, which often accompany experience.
Pocinki said he is reminded of a saying popular among his medical school classmates at Cornell that "the top third of the class were the smartest and made the best researchers, the middle third made the best doctors and the bottom third made the most money."
Sometimes, he added, young, inexperienced doctors become overly wedded to guidelines and ignore the patient. "They're going to follow those guidelines and if somebody doesn't fit, damn it, they're going to make them fit," he said. "I see that all the time."
The perspective that accompanies clinical experience is critical, said cardiologist Stuart F. Seides. "I've seen a lot of new, big, greatest things in my time," said Seides, 57, associate director of cardiology at Washington Hospital Center. The reality, he said, is that in medicine, knowledge "is seldom revolutionary and much more likely to be evolutionary."
Staying abreast of new findings and ways of doing things, Choudhry and his colleagues suggest, will take more than recertification exams. One solution may be "academic detailing," a concept borrowed from drug companies' sales pitches, in which specially trained educators visit doctors in their offices and make them aware of recent advances. The concept, pioneered in Australia, has had some success there, he said.
Choudhry, who finished his residency training in 2000, said he regards competence-enhancing efforts as a boon.
"I already feel that it's hard to keep up," he said.