Patients of doctors further from medical school graduation have poorer outcomes John J Norcini, John R Boulet, Amy Opalek & W Dale Dauphinee CONTEXT There is an apparent contradic- tion between the findings of studies indicating that patient outcomes are better when physi- cians have a greater volume of practice and those that find outcomes to be worse with increased time since training, which implies greater volume. OBJECTIVES This study was designed to esti- mate the adjusted relationships between physi- cians’ characteristics, including recent practice volume and time since medical school gradua- tion, and patient outcomes. METHODS This is a retrospective observa- tional study based on all Pennsylvania hospitali- sations over 7 years for acute myocardial infarction, congestive heart failure, gastroin- testinal haemorrhage, hip fracture and pneu- monia. It refers to 694 020 hospitalisations in 184 hospitals attended by 5280 internists and family physicians. Patient severity of illness at admission and in-hospital mortality, hospital location and volume, and the physician’s recent practice volume, time since medical school graduation, board certification, and citizenship or medical school location were analysed. RESULTS After adjustment, recent practice volume did not have a statistically significant association with in-hospital mortality for all of the conditions combined. By contrast, each decade since graduation from medical school was associated with a 4.5% increase in relative risk for patient mortality. CONCLUSIONS Recent practice volume does not mitigate the increase in patient mortality associated with physicians’ time since medical school graduation. These findings underscore the need to finds ways to support and encour- age learning. Medical Education 2017: 51: 480–489 doi: 10.1111/medu.13276 Foundation for Advancement of International Medical Education and Research (FAIMER), Philadelphia, Pennsylvania, USA Correspondence: John J Norcini, Foundation for Advancement of International Medical Education and Research (FAIMER), 3624 Market Street, 4th Floor, Philadelphia, Pennsylvania 19104, USA. Tel: 00 1 215 823 2170; E-mail: jnorcini@faimer.org 480 ª 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education; MEDICAL EDUCATION 2017 51: 480–489 clinician training