Practice Perfect 808
How Important Is Experience?
Part 1 - Does It Really Matter?

When I was a more advanced trainee, as I reached my later stages of residency training, I saw that some of my preceptors were not as great as I thought they were. Some were not as knowledgeable, didn’t make the best clinical decisions, and weren’t as technically proficient as I previously thought they were when I had first started residency. On the other hand, some of my teachers were fabulous, doing so many things right, clearly founts of knowledge, wisdom, and experience. To some degree, this moment of realization was painful. Some of my idols just weren’t as special as I originally thought. But it also created a more realistic view of the power of experience. Clearly, there was more to being good at the job – being a true “expert” - than simply how long someone has been in a profession. 

Today, as I’ve assumed the role of the more experienced person – with my 17 years of clinical practice surrounded by trainees, I’m the “expert” – I often feel less than adequate for the job. As a result, I typically try to point out my own failings and where I need to learn more. It’s important to get rid of the ego. Now, to be clear, I believe experience is important – medicine is more than just reading the literature and doing what the book says…or what your attending says – but to what degree is experience important? Is being an effective physician simply a matter of years or is there something more each of us needs to do to improve and become true experts in our field? In today’s editorial we’ll examine the question, Is experience the “end-all-be-all” some say it is?

Let’s first start with knowledge and clinical skills in the nonsurgical arena. Choudhry and colleagues performed a systematic review of studies between 1966 and 20041 looking to see how strong the relationship was between physician age and knowledge-based outcomes. Of 62 published studies they found 32 (52%) of the studies reported decreasing performance outcomes with age. Only one of the studies found an improvement of performance with age.

Before those of you “seasoned” podiatrists start writing angry emails, I’ll point out some issues pertaining to generalizability. First, none of these studies included podiatric medicine. In fact, I was not able to find a study about this topic in the podiatric literature. Second, this paper examined studies published all the way back to 1966, and it’s fair to say undergraduate and postgraduate training, as well as clinical practice itself, have changed to a large degree over this time. Hence, we should be cautious about interpreting this study, and we should not throw out the experienced babies with the metaphorical bathwater. 

What about surgery? Again, nothing exists specific to podiatrists, so we have to extrapolate a bit. Duclos, et al performed a cross sectional, prospective, multicenter study comparing surgeon experience and outcomes in thyroid surgery.2 Their study examined 28 surgeons who performed 3574 thyroid surgeries and found the rates of postoperative laryngeal nerve palsy and hypoparathyroidism (two well-known complications of thyroid surgery) to be 2.8% and 2.69%, respectively. Their analysis found that being in practice more than 20 years increased the probability of these complications, with an odds ratio of 3.06 for laryngeal nerve palsy and 7.56 for hypoparathyroidism. Importantly, though, when they looked at specific age groups, they found a concave association with length of experience. Surgeons aged 35-50 years-old had better outcomes than those younger and older. Interestingly, a number of similar studies in various specialties from spine surgery to general orthopedics found the same outcome distribution.

My interpretation of these studies is that this is a little more nuanced than simply “get older equals less knowledge and worse outcomes.” Obviously, for the very young physician, the quality of training and their exposure to a wide variety of disorders is important. If they received a lot of high-quality training experiences, they would likely handle early clinical practice well, while those with poor training or little experience would not have a strong foundation from which to work. This is also true with how much thought process the residency teaches. I have always believed that we need to train our residents to think for themselves with a logical and organized approach so they can make clear decisions, especially in those instances that may be different from their initial training. 

For the older physician, how strong their knowledge base and decision-making capacity remain, is strongly correlated with whether or not they continued to learn and grow during their years of practice. For example, I know an educator who started practice before internal fixation was common in podiatry and began training residents at about the same time. Today, after more than 40 years in practice, this surgeon incorporates modern internal fixation methods and remains current. On the other hand, an early trainee of this person never learned modern fixation techniques. One obtained further education as their career proceeded while the other did not. I’ll also mention for completeness’ sake, that physical changes with age may limit a physician or surgeon’s career. For example, loss of eyesight may make it very difficult to do surgery. 


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Without tipping my hand too much in regard to next week’s Part 2, I will say that the answer to the question “Is experience important?” is a definitive yes, but knowledge and skills must be maintained in a very specific manner. It’s more complex than the number of years in practice and related more to the manner in which we maintain mastery. There is something to the idea of being a lifelong learner. In next week’s issue we’ll discuss what that method looks like. 

Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
jarrod@podiatry.com

References
  1. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Inter Med. 2005 Feb 15;142(4):260-273.
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  2. Duclos A, Peix JL, Colin C, Kraimps JL, Menegaux F, Pattou F, Sebag F, Touzet S, Bourdy S, Voirin N, Lifante JC. Influence of experience on performance of individual surgeons in thyroid surgery: prospective cross sectional multicentre study. BMI. 2012 Jan 10;344.
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