Friday, September 21, 2007

Medical Residents Don't Understand Statistics

But they want to:

This is but one of many unsettling findings of an excellent article by Windish et al in the September 5th issue of JAMA.

Medical residents correctly answer only approximately 40% of questions pertaining to basic statistics related to clinical trials. Fellows and general medicine faculty with research training fared better statistically, but still have some work to do: they answered correctly approximately 70% of the questions.

An advanced degree in addition to a medical degree conferred only modest benefit: 50% answered correctly rather than 40%.

The solution to this apparent problem is therefore elusive. Even if we encouraged all residents to pursue advanced degrees or research training, we would still have vast room for improvement in the understanding of basic biomedical statistics. And this is not a realistic expectation (that they all pursue advanced degrees or research training).

While it would appear that directed training in medical statistics might have a beneficial effect on performance of this test, with work hours restrictions and the daunting amount of material they must already master for the practice of medicine, it seems unlikely that a few extra courses in statistics during residency is going to make a large and sustainable difference.

Moreover, we must remember that performance on this test is a surrogate outcome - what we're really interested in is how they practice medicine with whatever skills they have. My anecdotal experience is that few physicians are actually keeping abreast of the medical literature - few are actually reading the few journals that they subscribe to - so improving their medical evidence interpretation skills is going to have little impact on how they practice. (For example, few of my colleagues were aware of the Windish article itself, in spite of their practice in an academic center, its publication in a very high impact journal, and their considerable luxury of time compared to our colleagues in private practice.)

In some ways, the encouragement that the average physician critically evaluate the medical literature seems like a far-fetched and idyllic notion. This may be akin to expecting them to stay abreast of the latest technology for running serum specimens, PCR machines, or to the sensitivity and specificity of various assays for BNP - they just don't have the time or the training to bother with nuances such as these, which are better left to the experts in the clinical and research laboratories. Likewise, it may be asking too much in the current era of medicine to expect that the average physician will possess and maintain biostatistical and trial analysis skills, consistently apply them to emerging literature, and change practice promptly and accordingly. Empirical evidence suggests that this is not happening, and I don't think it has much to do with lack of statistical skills - it has to do with lack of time.

Perhaps what Windish et al have reinforced is support for the notion that individual physicians should not be expected to keep abreast of the medical literature, but should instead rely upon practice guidelines formulated by those experts properly equipped and compensated to appraise and make recommendations about the emerging evidence.

1 comment:

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