#KeyLIMEPodcast 80: Does educational geography = professional destiny?

The International Clinician Educators blog achieved a milestone this week. It’s not big enough (obviously) to register on this timeline of SoMe.

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However, we did manage to pass the 2k subscriber mark. The editorial board is proud of the work profiled here and grateful for the support of our audience.

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Ok – onto the post for today.

The Key Literature in Medical Education abstract today is going to stir up  controversy. This commentary summarizes a series of studies conducted by the author group that shows the profound influence of (residency/GME training) culture on future practice.

Here’s the punch line: even when controlling for the influence of selection (e.g. “top” programs recruit “top” trainees) a residency program influences practice decades after graduation. In other words, your complication rate in practice can be correlated to where you trained. These findings are a powerful. Controversial? They are also a reminder of the value of our day-to-day work as CEs to improve the delivery of health professions education.

For more details on “education imprinting” check out the abstract below. For an even better take on this paper, listen to the podcast.

– Jonathan

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KeyLIME Session 80 – Article under review:

Fri post_Ken Harris

Listen to the podcast

View/download the abstract here.

Asch DA, Nicholson S, Srinivas SK, Herrin J, Epstein AJ. How Do You Deliver a Good Obstetrician? Outcome-Based Evaluation of Medical Education. Academic Medicine, Jan 2014; 89 (1):24-6

Reviewer: Jason Frank

Background
As educators in the health professions, we all want to think that our dedication to preparing the next generation of competent physicians has an impact. But just how big is that impact? Do we as teachers and curriculum designers really shape future practice patterns? Put another way, how much does the location of training impact future patient outcomes? Isn’t this really the “holy grail” of the art, science, and enterprise that is medical education? Previous work by meded researchers like Tamblyn and Norcini have suggested that “geography is destiny”, or where you train predicts your future practice.

Purpose
David Asch and colleagues set out test the implications of the “geography is destiny” hypothesis by looking for associations between training experiences and various patient outcomes and practice patterns for US Obstetricians.

Furthermore, this group wanted to explore what medical education can learn by examining large data sets on physician practice patterns.

Type of paper
Review: Narrative overview of a series of observational administrative database studies by this group

Key Points on the Methods
This paper is a narrative overview, a tour-de-force synthesis of a series of studies by Asch et al.

The research comprises administrative database studies looking at maternal outcomes as a surrogate marker of competence or performance in practice. The authors looked at all hospital-based deliveries in the states of Florida and New York across decades (from 1992-2007). To be included, obstetricians had to be licensed, trained in the US, and contribute at least 100 deliveries to the dataset. This data was cross-tabbed to compare programs who trained at least 10 of the physicians in the sample. 4.9 million deliveries performed by 4,124 physicians from 107 residency training programs in the US. The residency program sample represents 43% of American programs. They tried to control for differences in maternal health and type of delivery.

For further details, have a look at the original works in a variety of journals:

1. Asch DA, Nicholson S, Srinivas S, Herrin J, Epstein AJ. Evaluating obstetrical residency programs using patient outcomes. JAMA. 2009;302:1277–1283.

2. Epstein AJ, Srinivas SK, Nicholson S, Herrin J, Asch DA. Association between physicians’ experience after training and maternal obstetrical outcomes: Cohort study. BMJ. 2013;346:f1596.

Key Conclusions
The authors conclude that residency training is associated with a major and pervasive impact on practice performance.

Spare Keys – other take home points for clinician educators
1. This is a synthesis of landmark studies that suggest “Geography is Destiny”, and where you trained impacts your career practice patterns. This suggests that residency education is a critical enterprise deserving major attention.

2. This is part of the educational theory of “imprinting” teachers’ practice patterns on trainees.

3. It demonstrates that “true” outcome-based education must take into account these downstream effects of training sites.

Listen to the podcast here