"There is no substitute for experience."
Jock Stein
In case you were wondering, Jock Stein was a soccer (football for all you old world types) coach (or manager for all you old world types) who won the European Cup in 1967.
His famous quote was undoubtedly in the context of the wily vet soccer players who, through hard won, first hand experience, knew what it would take to win a game. The intangible intangibles. The finer points. The inside baseball, so to speak.
It doesn't just apply to soccer or other sports; in fact, it probably applies to just about everything in life to varying degrees. It took me years to figure out my Weber grill: where were the hot spots, the cold spots, the right level of gas for each burner, etc. A grizzled mechanic might know that a particular extension will be needed for a particular wrench to loosen/tighten a particular bolt in a particular automobile. A wine expert might tell you about the Gros Frere "Musigni" which sits immediately adjacent to the "real" Musigny grand cru vineyard and tastes just as good but at a fraction of the price.
What is the value of these little tid bits of accumulated knowledge that we collect over years and decades? Perhaps we could measure it in dollars, or time saved, greater personal enjoyment, or improved efficiency. For me, I'd argue that in direct patient care, the value of experience cannot be calculated any more accurately than calculating the value of someone's life or well-being.
One of the more common questions I get from patients is, " how many of these have you done?" Obviously, they ascribe to the same value system; namely, if I have performed this procedure 500 times, I am, as a practitioner, more valuable to them than, say, one of my partners who has done 25. It's the old, "I want the gray haired doctor to do my procedure" trope.
Isn't it interesting that even though the patient (who is in the very best position to judge what "value" really means to them when contemplating undergoing a medical or surgical procedure) recognizes the value of experience, insurance companies, hospitals, universities, faculty practices, or medical schools don't? Should an insurance company pay me and one of my junior partners the same amount for the same procedure?
Admittedly, at many academic institutions, a full professor like me has a slightly higher salary than a clinical instructor or an assistant professor. But that doesn't address the insurance companies who don't distinguish at all. My junior colleagues and I are equivalent in the eyes of the Great Payor (ie Medicare) and its cronies.
10,000 hours, Malcolm Gladwell, deliberate practice, etc. Countless treatise in popular literature and scientific journals have shown that, when intentionally attained, experience in a procedural specialty leads to better outcomes. It stands to reason that better outcomes should lead to lower costs, better health, and presumably better compensation. After all, should a highly skilled surgeon with better outcomes be paid the same as a less skilled surgeon with more complications? Isn't the Great Payor clamoring for more accountability in health care?
Not that surgeons or proceduralists want more accountability. We (and I mean all of us who perform surgeries or procedures on patients that generate objective outcomes) are, as a group, loath to compare ourselves to each other. Despite the intense competitive nature that all of us have to varying degrees (and which probably helped get us into medical school, residency, etc), comparing outcomes is not an activity that many of us want to pursue once we are practicing physicians. To wit, if you're the most experienced surgeon in a group, you might get the toughest cases referred to you. Obviously your outcomes might be worse because your patients are sicker to begin with. But there are ways to adjust for this, like the Case Mix Index which calculates, objectively, how sick your patients are compared to others. But this isn't a tool for individual practitioners, for now at least.
What prompted this screed about the asymmetry of experience and reimbursement? I got this ridiculous email solicitation (of which I receive a few per month) offering me $45 for 10 minutes of my time to answer survey questions about treatment of a particular disease. But here's the thing: as "generous" as $45/10 minutes is, I know I'm worth a lot more. Don't get me wrong: I'm not pissing on the $45 as if it is below me. Rather, my argument is that my accumulated experience, attained over decades, amassed at the direct expense of my patients whether they suffered complications or had great outcomes, and pored over in my mind endlessly during sleepless nights, is worth a fuck of a lot more than $45. It is an insult to suggest otherwise.
I suppose Jock was mostly right: while there is no substitute for experience, there doesn't seem to be any objective value for experience either.