In this paper, we use qualitative data from a factorial experiment of clinical decision making for diabetes to analyze the ways in which physicians describe their experience and how it influences their clinical decision making. We found that what physicians actually gain over time to constitute their experience is complex social, behavioral and intuitive wisdom. In practice, experience played out as typologies of past patients used to assess barriers to good outcomes.
Our results show that common measures of physician experience—age and years in clinical practice—are inadequate to the task of fully understanding what experience means to physicians, which skills they acquire over time, and how they implement those skills in their clinical work. While subconscious psychological processes are critical and certainly contribute to some aspects of observed variations in decision making, our findings show evidence of additional, conscious processing that has varied implications for treatment decisions. What physicians actually gain over time is complex social, behavioral and intuitive skills and knowledge about how to “read” social/behavioral cues, intuit signs beyond the patient’s words, and compare the present day patient against similar past patients. These active cognitive reasoning processes are essential components of a forward-looking research agenda in the area of physician experience and decision making.
The specific example of type 2 diabetes used in this study may limit the generalizability of our findings to clinical decision making involving chronic illnesses like metabolic and cardiovascular diseases. Such diseases require long-term management rather than the short-term treatment required for health problems such as infectious disease or injury. Long-term disease management requires the use of social skills and the marshaling of knowledge of the patient’s behavior in a much more involved and complex way than is necessary for referring, prescribing or treating an acute health problem. Further, type 2 diabetes requires more complex management on the part of the physician and more time and attention on the part of the patient than other chronic diseases such as heart disease or obesity. Thus, type 2 diabetes may represent an extreme example of physicians’ reliance on social skills and typologies in their practice.
Our work builds directly on previous efforts by researchers who have tried to understand mixed results wherein physician experience (as measured by age or years) is sometimes positively and sometimes negatively associated with high quality outcomes. For example, Choudhry and colleagues suggest that physicians who have been in practice longer may be less likely to adhere to practice guidelines due to cohort effects whereby older physicians may have less familiarity with disease management guidelines and are less accepting of them (Choudhry et al., 2005
). The inadequacy of continuing professional education in medicine has also been suggested as a potential culprit (Grimshaw, Shirran, Thomas, Mowatt, Fraser, Bero et al., 2001
). Copious and mercurial guidelines are often a source of frustration for clinicians who perceive them to be poorly conceived, unhelpful in the task of treating individual patients, and a superficial gauge of quality medical practice (Lutfey & Freese, 2007
; Samuels & Ropper, 2005
). Our findings add to this list by showing how increased experience translates into increasingly elaborate cognitive schemas for understanding types of patients, their health behaviors, and disease trajectories. Over time, the use of these typologies—while necessary for the practical completion of their everyday work—may contribute to increased cognitive rigidity and decreased ability (and perceived need) to incorporate new information such as guidelines. By comparison, less experienced physicians have a smaller store of these skills and may therefore be more readily able to integrate such information. These processes are not simply subconscious, invisible biases that affect physicians’ work without their knowledge, but are actively and consciously shaped, implemented, and refined over time. Furthermore, it is possible that physicians with greater years in practice have seen more iterations of guidelines, potentially increasing their frustration relative to physicians with fewer years in practice. Such frustration may stem from the fact that more experienced physicians already carry the information contained in guidelines in their heads, or from the fact that guidelines simply do not address the non-medical (e.g. social) issues of real and present concern to the physician (Gabbay & le May, 2009
In our study, the fact that physicians were easily able to make predictions about the diabetes management potential of a mock patient after viewing only a short vignette suggests that physician decision making may be heavily influenced by experience with prior patients, or as has been suggested previously, by heuristics, rules of thumb or “mindlines” (Andre et al., 2002
; Gabbay & le May, 2004
; Greenhalgh et al., 2008
). This conscious use of typologies and deductive reasoning is not captured in measures of physician age or years in clinical practice, yet it may contribute to some of the mixed results reviewed at the outset of our paper. On one hand, physicians gain powerful cognitive tools from experience with past patients, but on the other, they should remain wary of assumptions built into their reasoning that may discount an individual patient’s unique potential for behavior change. This type of imbalance between patient-specific information and epistemological priors has been discussed at length in literature on sources of variation in clinical decision making, typically with reference to overreliance on epidemiologic base rates at the expense of patients’ presenting symptoms (Balsa & McGuire, 2001
; Balsa, McGuire, & Meredith, 2005
; Elstein, 1999
; Klein, 2005
). In the present case, however, the prior that potentially biases decision making is not related to epidemiology or physiological
patterns of disease, but to social typologies
about patients and their predicted behavior and abilities. Understanding the content of these typologies may be one key to understanding observed multivalent variations in decision making by physician experience.
The valence of physicians’ prognoses in our study varied from optimistic and positive to pessimistic bordering on fatalistic (e.g., “diabetes always wins”) and subjectively varied by physician. We know that physicians experience feelings of frustration and failure associated with diseases that resist therapy (Groopman, 2007
) and by extension, with their sickest patients (Hall et al., 1993
), as well as with patients who themselves resist therapy (O’Dowd, 1988
); it follows that physicians may have a similar reaction to managing patients with chronic disease requiring behavior change, as they will inevitably encounter non-compliance. Frustration associated with behavioral noncompliance may be even stronger than frustration associated with diseases that resist therapy, for in the former scenario, patients have the agency to undertake behavioral change, but physicians do not have the agency to make them do so. Feelings of fatigue or frustration associated with noncompliant past patients may extend to new patients who are similar to past patients through the use of typologies, and to subsequent encounters with past patients. Further research is needed to determine whether physician frustration and other affective responses to chronic disease management are associated with poorer quality of care or outcomes.
More generally, these results build on other studies concerned with the ways in which clinical guidelines systematically overlook the importance of social information in clinical decision making and neglect to supply providers with structured guidance for how to interpret these aspects of their work (Gabbay & le May, 2009
; Lutfey et al., 2008
; Lutfey & Freese, 2007
). While this problem is not specific to physician experience, this may be yet another instance in which clinical guidelines measure one type of (physiological) outcome that may not capture the whole picture. As a result, key components of physician experience (e.g., social typologies or intuition) are not measured by the standard outcomes or clinical guidelines that traditionally define “quality care”. This mismatch between assumptions about what is gained with experience and the reality of physicians’ descriptions may provide further explanation of why “experience” is not consistently associated with higher quality of care; as they are currently devised, clinical guidelines, which take into account process and outcomes measures, do not constitute an appropriate yardstick for measuring physicians’ success in relation to their experience.
Process measures (e.g. sending a patient for a foot or eye exam) function as a more proximate measure of a physician’s success at encouraging patient adherence, while outcome measures (e.g. HbA1c or LDL) may be a more distal reflection of physician success; however, both kinds of measures incompletely appraise physician success in relation to their experience and are systematically biased. Consider the example of a non-adherent “problem patient” in a less- and more-experienced physician’s practice: the “more experienced” physician, who has honed her social skills and ability to interact with difficult patients succeeds in convincing the “problem patient” to show up to his appointments. This “more experienced” physician hopes that, if the patient continues to prioritize his medical appointments, over time he will show improvements in adherence. Meanwhile, the “less experienced” physician fails to “make a connection” with a comparable “problem patient”, and as a result, this patient does not even show up to his appointment. This scenario unjustly results in better outcomes for the “less experienced” physician, whose performance on process and outcome measures of diabetes control elides the scores of the non-adherent patient. Furthermore, patients may have higher satisfaction with physicians who have gained social skills through experience, and increased satisfaction may lead to increased adherence to medical recommendations. Alternatively, these other aspects of experience may lead doctors to be more cost- and time- effective because they are readily able to identify types of cases, even if they do not take specific actions as dictated by guidelines. These examples demonstrate that, if they are to be a true measure of the influence of physician experience on clinical decision making, process measures should be revised to capture the social, behavioral, and intuitive skills gained with experience that help physicians overcome the ongoing challenges of chronic disease management. In short, guideline-based process and outcome measures, accompanied by underdeveloped age- and years-based definitions of experience, may prematurely conclude that more experienced physicians are providing deficient care while overlooking the ways in which they are providing more and better care than their less experienced counterparts.