Wednesday, February 16, 2005

Do older physicians not use guidelines? Are Internal Medicine Residents not taught ventilator use?

In the Feb.15, 2005 issue of the Annals of Internal Medicine, one article paints a worrisome picture of older physicians while another article is quoted in a pulmonary disease review showing that internal medicine trainees do not seem to know much about ventilator use.
The paper (The Relationship between Clinical Experience and Quality of Health Care,Choudhry et al) casting a bad light on older doctors does not appear to represent the highest level of evidence. It is a review article of many articles whose methods and metrics differ widely and at least two of which are too old to have much current relevance.(These are two articles from the 1970s that show older doctors prescibed more chloromycetin than younger doctors). Many of the articles used questionnaires with variable response rates. While some of the articles reviewed used a "general knowledge assessment", many of the negative-to-older-doctors papers claimed older docs adhered to guidelines less frequently than younger one . Should quality be equated with adhering to guidelines? The accompanying editorial, rather than offering a scholarly critique of the methods, accepts all at face value and states "The profession cannot ignore this striking finding and its implications" More commonly an editorial would state the obvious need for more data and analyze the data critically rather than adopting a "its time to do something about it" attitude. I believe the editorial is overreaching-the article itself is more cautious in its conclusions- and since two of the authors are members of the American Board of Internal Medicine should it be considered self serving as the ABIM would have justification for more action items (testing re-certification etc) if in fact a problem exists with older internists. The editorial states "The message is clear for certifying boards." The "Summaries for Patients" section takes a much more cautious view saying in part " these findings do not apply to all older doctors and must be confirmed by more specific research" .
More solid was the data quoted in the "Update in Pulmonary Diseases" section. 259 residents in internal medicine took a 19 item question examinations. Almost half did not know how to set the tidal volume in ARDS. And only 46% of program directors thought residents had adequate knowledge of ventilators. If the ABIM is worried about what it should do about older doctors, they should be at least as concerned about current trainee's apparent knowledge gaps over which they exert more control .


Blogger james gaulte said...

Another blog ( hcrenewal) expresses the same thoughts.You would think in this era of emphasis on methodologic vigor that the editors of the Annals would have been more circumspect in even publishing this paper.Further you would have expected to have seen some letters to the editors criticizing what appears to be rather shoddy work.I agree with with both blogers that the editorial certaintly "went beyond the data".

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