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Does clinical experience make up for failure to keep up to date?
  1. Geoffrey R Norman, PhD,
  2. Kevin W Eva, PhD
  1. McMaster University, Hamilton, Ontario, Canada

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    You have just moved to a new town to open up your internal medicine practice, and now must find a doctor for your own young family. Two doctors are accepting new patients:

    Jane completed residency 2 years ago, and scored in the top 2% of her class on the certification exams.Susan completed residency 10 years ago, and scored in the top 25% of her class on the certification exams.

    Who do you choose?

    When this question has been posed to large clinical audiences over the past few years, only half a dozen people ever choose Jane over Susan. Why? Most people would accept that not only did Susan start off worse in formal knowledge, but also that it is very likely that her knowledge and application of current recommended care is likely to have fallen off further, as Choudhry et al have shown in a recent systematic review.1 Why, then, do audiences so unanimously choose the more experienced practitioner?

    Perhaps for just that reason—experience. The practice of medicine, like many other areas of human endeavour, requires considerable “hands on” experience to achieve mastery. Most physicians, when asked, indicate that they did not really feel competent for several years after they entered practice, which tallies with estimates from other domains that suggest 10 years or 10 000 hours are required to become a virtuoso.2 But what is gained from experience?

    Unfortunately, if you believe the conclusions of Choudhry et al, the answer is that nothing is gained and much is lost. They claim to have identified several studies where increasing years in practice are associated with increased mortality. But on closer scrutiny, the differences, when present, are small. The paper states that, in the best study of outcome,3 every year since graduation resulted in an increase of …

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