Jishnu Das writes about research on physician training in low-resource countries. His disheartening conclusion is that the training has very little impact on improving quality of care.

The research was as follows:

Our approach has been to try and decompose the quality of medical advice into two components—what doctors know and what doctors do. What doctors know—measured by testing doctors—represents the maximum care that a doctor could provide. What doctors do—measured by watching doctors—represents the care they actually provide to real patients. We call the first “competence” and the second “practice quality”.

And the depressing conclusion:

In Tanzania we find that two additional years of school and three additional years of medical school buys an increase of only 1 point in the percentage of essential tasks completed. Results are similar for other countries.

Training doctors has been a standard way to improve the quality of health care for years. It’s a major shock to discover this minimal impact. I wonder if the quality of training make a difference? Perhaps competency based training would make a difference.

While this is depressing research, it’s not necessarily telling us things we didn’t already know. If you want to change a physician’s behavior, you don’t just give her training. You change the system she is part of. Good projects health projects recognize that, and so do American HMOs.

Lesson: Don’t try to change individuals, try to change the system they are part of.