“Practice Makes Perfect” … Or Does It?

The current public focus on health care quality is mobilizing payers and regulatory bodies alike to measure quality of care and to link quality with physician reimbursement through “pay for performance” (1). For the medical profession to address the public's concern and improve its care of patients, it must understand the determinants of quality so that physicians can model and emulate predictors of good quality and recognize and remedy predictors of poor quality.

To address one potential predictor of quality, in this issue Choudhry and colleagues (2) systematically reviewed data relating experience and age to physician performance. Surprisingly, 70% of studies demonstrated a negative association between length of time in practice and several measures of good physician performance. Although the magnitude of the association varied, this general relationship held for medical knowledge, adherence to nationally accepted guidelines and standards, and patient outcomes. The negative association between experience and measures of quality initially surprised us, but its consistency across specialties (including internal medicine), across measures of performance, and across many studies spanning several decades sends a wake-up call to the medical profession. Choudhry and colleagues acknowledge that attributes not evaluated in the studies, such as humanism and judgment, might improve with experience. However, even if these traits improve with experience, the most caring and wise physicians, regardless of their age, would be even better with current information about accepted clinical practice and systems of care that support such practices. …