I doubt that any of the postulated mechanisms operate here. This does not appear to be an issue of knowledge vs. judgments (experience, wisdom) although the main assumption of the paper is that there is a relationship between decision-making and outcomes.
Even one assumes a perfectly balanced groups (always a problem for non-RCTs studies), and a well done statistical analysis (which appears to be a questionable here as the authors did not appear to have applied the hierarchical models to take account of dependency in the co-variates between the team members) the major hypothesis addressed by the paper is that the senior, attending physicians (in charge of HIERARCHICALLY organized teams that consist of 5 junior doctors) is responsible for all hundred decisions that are being made when his/her team takes care of patients. While attending physicians are morally and legally responsible for what happens to the patients, in actuality the decisions (and procedures) are all done by the junior doctors. But, the style among attending physicians dramatically vary- some are very hands-off and reluctant to micro-manage while others are very engaged, wishing to exert as maximum control on decision-making process as possible. So, even if I believe that this is a well done and analyzed study, the way I interpret the results is that the outcomes in patients taking care by the junior doctors who had the oversight by more senior attending physicians were inferior to those who were overseen by less senior attending physicians.
I wonder what were educational experience (satisfaction) of these two groups of the junior doctors?
Ben Djulbegovic
Sent from my iPad
On Jul 29, 2011, at 5:13 PM, "Jim Walker" <[log in to unmask]> wrote:
> I'm not an expert, but I believe the literature in cognitive psychology demonstrates beyond serious question that humans don't learn when they are tired, and especially when they don't get sleep. For that reason, one of the critical factors to try to correct for in studies like the one we're discussing and in any plan for addressing the problem (that goes beyond exhorting people to be life-long students) would be to understand how work hours and sleep affect physician performance long-term.
>
> Jim
>
> James M. Walker, MD, FACP
> Chief Health Information Officer
> Geisinger Health System
>
>
>>>> "Kalliainen, Loree K" <[log in to unmask]> 7/29/2011 4:15 PM >>>
> Stephen;
> Sad and possibly true. I remember being told ad nauseum during training that physicians are life-long students and that what we learned in med school would inevitably change. Looks like not all of us learned this, remembered it or took it to heart. Being a student is challenging, and changing established practice patterns even moreso. it will be interesting to watch how (if) the necessity to maintain board certification to retain hospital privileges affects the ability of physicians to be life-long learners, and, by extension, allows patient outcomes to be consistent no matter the age of the physician. One could hope that, with the addition of wisdom, outcomes could improve with the duration in practice!
> Loree K. Kalliainen, MD, FACS
> St. Paul, MN
> (9 yrs in training, 11 in practice)
>
> -----Original Message-----
> From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Stephen Senn
> Sent: Friday, July 29, 2011 3:00 PM
> To: [log in to unmask]
> Subject: Re: Patients worse off with more-experienced docs? In a study that flies in the face of common sense, sicker patients turned out to fare worse under the care of seasoned doctors than when newcomers to medicine looked after them.
>
> It may not be true but if true I think that there is a simple explanation. Medics don't learn by interacting with patients because the feedback is not quick enough. To learn would require them to make extensive notes and regularly analyse and compare. The last time they had a chance to learn was in med school, hence the younger the more up to date.
> Stephen
>
>
> Stephen Senn
>
> Professor of Statistics
> School of Mathematics and Statistics
> Direct line: +44 (0)141 330 5141
> Fax: +44 (0)141 330 4814
> Private Webpage: http://www.senns.demon.co.uk/home.html
>
> University of Glasgow
> 15 University Gardens
> Glasgow G12 8QW
>
> The University of Glasgow, charity number SC004401
> ________________________________________
> From: Evidence based health (EBH) [[log in to unmask]] On Behalf Of Paul Elias [[log in to unmask]]
> Sent: 28 July 2011 21:13
> To: [log in to unmask]
> Subject: Patients worse off with more-experienced docs? In a study that flies in the face of common sense, sicker patients turned out to fare worse under the care of seasoned doctors than when newcomers to medicine looked after them.
>
> http://www.reuters.com/article/2011/07/15/us-patients-worse-off-idUSTRE76E62T20110715
>
>
>
> According to findings in the American Journal of Medicine, patients whose
> doctors had practiced for at least 20 years stayed longer in the hospital and
> were more likely to die compared to those whose doctors got their medical
> license in the past five years.
>
> no doubt this raises serious questions and supports the evidence based approach
> and the need for doctors to remain seasoned and in touch with not just the needs
> of the patient but the updated science.
>
>
>
>
>
> Best,
>
> Paul E. Alexander
>
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