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For Med Students, How To Define ‘Best’ Residencies

By Jenny Gold

October 30th, 2012, 12:08 AM

Attention medical students: When selecting your residency program, there’s more than just geography and the hospital’s reputation to consider.

The nation’s 23 top academic medical centers also vary drastically in what researchers are calling “the intensity” of care they provide patients at the end of life, according to a new report from the Dartmouth Atlas Project.

And more intense care can translate into worse and more expensive care at the end of life, according to the authors. The thinking is that physicians who train at hospitals with better and more efficient care will be better-prepared to become leaders in changing how health care is delivered in this country.

The authors call this phenomenon the “hidden training curriculum.”

“Learning how to use health care resources wisely, provide high-quality care, and incorporate patient preferences into a care plan is just as important as learning to work up a patient,” said Alicia True, report co-author and medical student at the Geisel School of Medicine at Dartmouth.

The report tracks variations in end of life care and chronic illness management, surgical procedures, and quality and patient experience using data from Medicare and published on the Hospital Compare website.

Take Johns Hopkins Hospital and Mount Sinai Medical Center, for example. They are both prestigious, but around 50 percent of patients at Johns Hopkins were enrolled in hospice in their last six months of life, compared to only 23 percent at Mount Sinai.   Residents at Mount Sinai “may therefore learn a higher threshold for referral of a patient to hospice or may decide to explore more aggressive treatment approaches first,” according to the report, while Hopkins residents “may be better trained in having discussions with patients about their preferences for end-of-life care.”

Patient safety training also varies widely. A patient at NYU Langone Medical Center is 47 times less likely to get an infection from a urinary catheter than a patient at the University of Michigan Health System.

“Medical students should be aware of the practice styles of residency programs they are considering ranking highly in the Residency Match,” report co-author True added.

The report, “What Kind of Physician Will You Be,” is intended as a guide for fourth-year medical students to help them select hospitals with the best practice patterns for training.  The selection is particularly important “for tomorrow’s doctors in order to practice successfully in the new environment created by health care reform,” the authors write.

“These variations in the way care is delivered are not trivial, as they may very well affect the future practice of medicine. During their residency training, young physicians learn by observing faculty, making decisions on how aggressively to treat chronically ill patients at the end of life, and whether to recommend surgery when other treatment options exist,” added Dr. John R. Lumpkin, director of the Health Care Group at the Robert Wood Johnson Foundation, which funds the Dartmouth Atlas Project.

The Dartmouth Atlas has been researching disparities in care using Medicare data to analyze trends about regional and local markets, but this is the first time they have applied the findings to residency training. Dartmouth is working to get the word out to student medical groups and publications in the hopes that the report will help medical students make informed decisions when selecting their residency program.

6 Responses to “For Med Students, How To Define ‘Best’ Residencies”

  1. John Rohe, RN says:

    You have to separate true physician care outcomes with nursing controlled outcomes. Urinary tract infection is a nursing function as RNs put most in and take most out as well as care for them when in place. As for hospice enrollment, although a physician order, where are the nurses in advocacy for the patient? A high quality nursing staff impacts on the quality of the resident and the reverse is also true. Lousy nursing produces lousy doctors.

  2. John Riggs says:

    Interesting comment, but ultimately irrelevant. Nursing culture seems to be conserved at hospitals – good nursing begets good nursing – and, for the purpose of this article, gets wrapped up into the idea of variations in quality of care/efficiency in care/safety of environment.

    Which is not to deny the importance of nursing on the professional and academic development of residents.

  3. Med Student says:

    It seems like a very specific suggestion to say that medical students should pick a residency program where hospice referral rates are high and UTI rates are low, above location and reputation. Really? Am I missing something? What’s the bigger picture? Picking a residency based on these specific statistics seems even less justified than going by a map or the US News rankings. None of these seem ideal, and as an applicant I’m going by the experience of current residents and the needs of my family.

  4. marjorie pound arnp says:

    Options must be presented to the patient/ family, then whatever they choose should be the course of action. The new doctor should try to explore what quality indicators are used when making these end of life decisions and how previous patients/families felt as far as if their wishes were followed. This type of decision making requires extra time with patients and family by the physician so that they are well educated on the options and the possible outcomes of their decision. The new resident should consider that this would be a part of the treatment plan and that they may be expected to devote some of their time to this type of care.

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