Greater risk seen with older doctors

A provocative study from Harvard Medical School suggests that, as a group, older doctors know less, provide lower-quality care, and may expose patients to greater risks than physicians recently out of medical school, a conclusion that an accompanying editorial declares should be ''a wake-up call to the medical profession."

Older doctors were less likely to know or follow current treatment standards on everything from surgery to treating children's fevers, the Harvard team found in their analysis of nearly 40 years of research into factors that shape healthcare quality. One study found that heart attack patients were 10 percent more likely to die in the care of a doctor 20 years out of medical school compared with a recent graduate.

The earlier studies included age as one factor in the quality of care, but the Harvard paper is the most comprehensive look at the importance of age and years since medical school in determining physicians' skills.

Senior doctors, as well as the Harvard researchers themselves, were quick to emphasize that doctors may improve over time in harder-to-measure ways such as earning the patient's trust, and they agreed that age is just one factor for patients to consider. But older doctors generally agreed that the rapid increase in new medical knowledge can be a challenge to keep pace with, especially as doctors already are pressed for time to see all their patients.

''You store a lot of factual knowledge during school, and then . . . you're expected to, on your own, keep up with what is an enormous flood of facts," said Dr. Donald Berwick, 58, president of the Institute for Healthcare Improvement in Boston and a 1972 medical school graduate. ''Someone said that if a doctor started reading one randomized trial a day, he'd be 10,000 trials behind by the end of the first year."

The problem is not just the volume of new information or people's tendency to forget facts over time, said Niteesh K. Choudhry, 33, the lead author of the study in today's Annals of Internal Medicine. The basic philosophy of medicine has shifted over the past 30 years from one in which doctors relied heavily on their own experience to make decisions to a new paradigm in which doctors depend more on research published in medical journals. Doctors who were not trained in ''evidence-based medicine" may be slower both to adopt new approaches and to abandon outdated ones, he suggested.

Officials from two leading organizations that provide continuing education for doctors said that they were ''initially surprised" at the Harvard findings, but that the sheer number and variety of studies linking older physicians to lower-quality care persuaded them. In an accompanying editorial, officials from the American College of Physicians and American Board of Internal Medicine conclude that doctors should be required to undergo more rigorous training to maintain certification, the seal of approval given by boards representing medical specialties.

''Practice does not make perfect, but it must be accompanied by ongoing active effort to maintain competence and quality of care," wrote Dr. Steven Weinberger of the college of physicians and Drs. F. Daniel Duffy and Christine Cassel of the internal medicine board.

Dr. Alan C. Woodward, president of the Massachusetts Medical Society and a 1977 medical school graduate, said the trend toward tougher requirements for certification has already begun, noting that in his field, emergency medicine, doctors for the past two years have been required to take an annual online exam to remain board-certified. Because such measures are so new, ''You haven't seen the impacts yet" on the quality of medicine, he said.

The Harvard study did not trigger an immediate generational battle; younger and older doctors alike agreed that newly-minted physicians have the advantage of being freshly trained in the latest techniques. However, young doctors such as Jonathan Winickoff, a 34-year-old pediatrician at Massachusetts General Hospital, stressed that the real issue is not age itself, but the willingness to keep up with research.

''My gut feeling is that the very best doctors are the ones who both have the experience and make a commitment to keep up with guidelines," he said. ''They have the best of both worlds."

Dr. Talia Herman, 55, an internal medicine specialist at Harvard Vanguard Medical Associates in Boston, agreed, saying computers have made keeping up with research much easier for doctors who make the commitment. But computers have also made patients more knowledgeable, she added, so ''if I'm not current, I'm getting e-mails from my patients because they have had the time to read" the latest studies.

The Harvard study is a review of other people's research, bringing together the findings of 59 papers since 1966 that looked at physicians' age or years out of medical school when measuring knowledge or the quality of patient care. Most of the studies weren't delving only into age-related issues, but Choudhry and his co-researchers for the first time brought all the studies together and focused exclusively on age as a factor in physician knowledge or quality of care.

Forty-five of the 59 studies found that age or years since medical school graduation had a negative effect on performance for everything from following proper cancer-screening techniques to diagnosing depression to prescribing aspirin to angina patients. At the same time, only two of the studies found that the doctors' performance improved over time: on advising patients to exercise and on referring diabetic patients for eye tests.

Perhaps most striking, a 2000 study by the American Board of Internal Medicine found that a patient was less likely to die after a heart attack if his or her doctor was a recent medical school graduate.

The study, which looked at patients treated by more than 4,500 family practitioners, internists, and cardiologists in Pennsylvania, found that patient mortality increased by half of 1 percent for every year since the doctor graduated from medical school.

Of course, it would be absurd to conclude patients should avoid experienced doctors, said Rebecca Lipner, coauthor of that study, and statistical findings such as hers should not be used to select individual doctors anyway. Moreover, other factors, such as whether the physicians are board-certified in their specialties, appear to be stronger indicators of the doctors' ability, Lipner said.

Still, ''it does consistently seem like the older physicians are not necessarily doing as well on the medical knowledge or the patient outcomes," said Lipner, associate vice president of psychometrics at the Philadelphia-based board, which has been at the forefront of efforts to toughen standards for certification.

Most boards that give specialty certification, however, either require no renewal of certification, have limited requirements for renewal, or waive the requirements entirely for older doctors, said Berwick, of the Institute for Healthcare Improvement. What's more, certification is voluntary, meaning that even doctors who fail to achieve renewal can continue to practice medicine.

In Massachusetts, where 75 percent of licensed physicians are over 40, doctors must get credit for 100 hours of continuing education every two years to renew their license to practice medicine. However, only 40 percent of that time has to be in programs that meet American Medical Association quality standards; the rest can be self-instruction, attending lectures, or taking part in hospital case reviews.

Nancy Achin Audesse, executive director of the Board of Registration in Medicine, which licenses doctors, contends that Massachusetts should establish a training and testing center where doctors can learn new techniques in hands-on simulations and be tested periodically to make sure their skills are up to date. Currently, there are five such centers nationally. Achin Audesse said the board has been lobbying medical groups in Massachusetts to support a training and testing center, but she acknowledges that doctors have mixed feelings.

''Everyone likes the opportunity to learn new skills," she said. ''Very few people are excited to be the first ones to be tested."

Scott Allen can be reached by e-mail at allen@globe.com.