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What Kind of Physician Will You Be? How Variation in Health Care Impacts Your Training

By Anita Arora, MD Geisel School of Medicine at Dartmouth’s Class of 2012, and Alicia True, Geisel School of Medicine at Dartmouth’s Class of 2015

When fourth-year medical students choose which residency programs to rank highly in the Residency Match, various factors play an important role: a hospital’s reputation, the training curriculum, and the student’s own geographical and lifestyle preferences. But there’s something else America’s next wave of doctors should consider: the differences in care provided by even the most elite teaching hospitals, and how these differences affect the way we will practice medicine.

During residency training, we learn by observing faculty who make decisions regarding how to treat chronically ill patients or whether to recommend elective surgeries. A new report from the Dartmouth Atlas Project, which examined the care provided by 23 top academic medical centers, found considerable variation in both the intensity of care provided to chronically ill patients at the end of life as well as the frequency with which patients undergo surgery when other treatment options are available. It also showed that quality, safety, and patient experience ratings did not increase with increased intensity of care. These variations in the way care is delivered are not trivial, and may very well affect the future practice of medicine.

For instance, complex patients are often cared for by multiple physicians, each having a specific set of recommendations. Primary care physicians and resident teams are frequently charged with the task of coordinating these instructions and organizing the patient’s care. This is a challenging responsibility, and can be difficult for both patients and providers to integrate the advice from so many physicians. Residents at hospitals where patients have multiple physicians will need to make a special effort to manage these recommendations to avoid potential consequences of fragmented or disorganized care.

Another example involves patient preferences for how they would like to spend their last six months of life. When asked, many patients prefer to be cared for in a home-like setting. However, data show that for many patients, it is not their preferences that determine how they spend the last few months of life, but the practice styles of the hospitals where they receive care. While it’s true that more time in the hospital and more physician visits provide residents with more information, longer and more frequent hospital stays have their own risks for patients and don’t always lead to a longer or better quality of life.
Hospitals providing higher intensity care are not necessarily providing higher quality or better patient experiences, and in turn, training at hospitals with less intensive utilization patterns may better prepare us to provide care that respects patient preferences.

Understanding these patterns of care is particularly important for future doctors, especially to practice successfully in the new environment created by health care reform. We encourage other physicians who are early along in their training to research programs that emphasize learning how to use health care resources wisely, provide high-quality care, and incorporate patient preferences into care plans.

Our choice of a residency program can shape the care we provide to patients for years to come. It can also present opportunities to lead improvements in health care by learning to provide the right care, in the right way, at the right time.

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