My father, now in his third decade of practicing family medicine, is always willing to give me advice. But his greater joy seems to come from showing me how much I don\u2019t know. He leaves CME clippings from academic journals on my desk or the kitchen counter, to read when I\u2019m home for the holidays. The American Family Physician<\/i> journal\u2019s photo quiz is a favorite of his, and while I am frequently stumped, occasionally the answer actually is<\/i> chalazion. He, on the other hand, is quite adept, and I haven\u2019t seen him get one wrong.<\/p>\n
Considering my father\u2019s broad knowledge of all things primary care, I was surprised when we got into a discussion about aspirin over dinner at a restaurant known for its extensive salad bar.<\/p>\n
\u201cYou eat well and are health conscious,\u201d I said. \u201cBut given your age and our family history of MI, would you benefit from taking aspirin for prevention?\u201d<\/p>\n
His response was a negative: \u201cThere wouldn\u2019t be any benefit, and it would expose me to the risk of gastrointestinal bleeding.\u201d<\/p>\n
So I broke dinner etiquette and placed my smartphone on the table. I accessed the Agency for Healthcare Research and Quality\u2019s Electronic Preventive Services Selector (ePSS). The ePSS is a well-constructed application<\/a> that aggregates U.S. Preventive Services Task Force (USPSTF) recommendations so that they are relevant to the patient in front of you and easy to read on the spot.<\/p>\n I entered the few required variables \u2014 on age, sex, pregnancy status, tobacco use, and sexual activity \u2014 and showed him the level A recommendation: aspirin<\/i>. A helpful link to the NIH\u2019s cardiovascular disease risk calculator is also embedded in the application, and within a few moments we could determine that his expected benefit from taking aspirin outweighed his risk for bleeding.<\/p>\n Our dinner reminded me of the perplexing inverse relationship, which this Annals review article<\/a> seemed to detect, between increasing physician experience and a variety of performance measures.\u00a0If I use age less than 40 as a rough estimate for when things start going downhill, and assuming I work until age 65, I\u2019ll reach my professional peak as a doctor in 13 years, with the next two-thirds of my career spent in slow decline. Presumably, I\u2019ll start ordering prostate-specific antigen tests for all my male patients, tell my female patients to do routine self-breast exams<\/a> at home, and order MRI of the lumbar spine for anyone with back pain.<\/p>\n Could it be true that as my time away from medical school graduation increases, the likelihood of my adherence to standards of care decreases? One review article lists 293<\/a> potential barriers to adherence, broadly listed under categories of knowledge, attitude, and behavior. From a regulatory perspective, testing someone\u2019s knowledge is the easiest way to assess competence, and formal interactive CME sessions<\/a> have some evidence of improving physicians\u2019 performance.<\/p>\n But even if dwindling knowledge were to explain aging-related declines, the Institute of Medicine<\/a> and many others<\/a> nonetheless believe that the CME system is a very poor way to address the knowledge deficit. I wholeheartedly agreed with this when I examined various states\u2019 CME requirements<\/a> and realized I would be halfway done with certification in Arkansas after completing 10 AMA PRA Category 1 Credit\u2122<\/a> opportunities. My list:<\/p>\n It isn\u2019t entirely clear how my choices from this list would translate into better patient care, but I\u2019d certainly know more about physician employment agreements. So I find myself wondering whether CME will ever improve doctors\u2019 ability to care for patients. Suppose that we learn the most up-to-date<\/a> way to approach a medical condition upon first encounter, when we have no pre-formed mental heuristics, and that with increased exposure the need to consult the literature decreases. Bias begins to set in, and the benefit of future knowledge exposure diminishes.<\/p>\n Consider, instead, if the Centers for Medicare and Medicaid Services and insurance companies were empowered to detect deviant prescription and billing practices that indicate poor-quality care. This information could then be sent to each state\u2019s accrediting body, to determine whether a formal interactive class is appropriate. With this approach, behavior rather than knowledge is the trigger, which makes for a more targeted intervention.<\/p>\n Incidentally, my father still does not take aspirin. He refuses any medication and prides himself on not having used a pain reliever since 1975.<\/p>\n JOIN THE DISCUSSION<\/strong><\/p>\n Share your thoughts on the best way for doctors to remain on their game as they age.<\/b><\/p>\n","protected":false},"excerpt":{"rendered":" A medical student’s conversation with his physician father makes him wonder about the future of lifelong medical education.<\/p>\n","protected":false},"author":844,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[251,789,2101],"class_list":["post-41647","post","type-post","status-publish","format-standard","hentry","category-general","tag-aging","tag-cme","tag-continuing-medical-education"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/41647","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/844"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=41647"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/41647\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=41647"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=41647"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=41647"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}\n