Q: What Scares Doctors? A: Being the Patient

What insiders know about our health-care system that the rest of us need to learn

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The reforms made intuitive sense; but the unintended result, older doctors warn, is a 9-to-5 mentality that detaches the doctor from the patient. They fear that young doctors don't get the experience they need or build the instincts and muscle memory from performing procedures so many times that they can do them in their sleep. Even the residents may agree: in a 2006 study in the American Journal of Medicine, both residents and attending physicians reported that they thought the risk of bad things happening because of fragmentation of care was greater than the risk from fatigue due to excess work hours. Other residents say that while they may feel more rested, they sense that they are not learning as much or as fast as they need to.

"I know that I will not like it 20 years from now when I'm 68 and having to be taken care of by these guys," says Dr. Paul Shekelle, a professor of medicine at UCLA. "It's all shift work now. When 5 o'clock comes, whatever it is they're doing, they just sign it all out to the 5 o'clock person. It's eroding the sense of duty, or commitment to being the person responsible for a patient's care."

But younger physicians may have other advantages--like a fresher sense of the latest standards of care. Many doctors have concluded that there is something of a sweet spot on the age-education-experience continuum. They seek out clinicians who are no more than 10 years out of residency, old enough to have some mileage, young enough to be up to speed. There is actually some hard data for this rule. A review published last year in the Annals of Internal Medicine examined the connection between a doctor's years in practice and the quality of care he or she provided. To the surprise of everyone--including the review's author, Harvard Medical School's Dr. Niteesh Choudhry--more than half the studies found decreasing performance with increasing years in practice for all outcomes assessed; only 4% found increasing performance with increasing age for some or all outcomes. One study found that for heart-attack patients, mortality increased 0.5% for every year the physician had been out of medical school.


We think of hospitals as cathedrals of science, yet doctors walk around with their pockets stuffed with 3-by-5 cards on which they write patient information; when they sign off for the day they read from the card to the doctor coming on duty. "My pizza parlor is more thoroughly computerized than most of health care," says Berwick. It's easy to see the advantage of giving everyone easy access to a patient's history and test results. But getting there can be painful. Enter a hospital when it is in the process of introducing more computers, they say, and you can hear the sound of nurses growling. Doctors using laptops sometimes have to wrestle with incompatible systems, manually retyping lab results from one computer into another.

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