As Clinician Educators, we must remain mindful of the profound and persistent influence of the culture of residency training on future practice.
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Chen C1, Petterson S2, Phillips R3, Bazemore A2, Mullan F1. Spending patterns in region of residency training and subsequent expenditures for care provided by practicing physicians for Medicare beneficiaries. JAMA 2014, 312 (22):2385-93
Reviewer: Jason Frank
Previously on KeyLIME, we reviewed Asch’s paper that suggested that “geography is destiny”, and where you train a health professional can determine their lifelong competence trajectory. This remains a controversial premise today, and further data is needed. Enter Chen et al in the JAMA 2014 Med Ed theme issue, who looked at the connection between training site and health resource spending. Studies have shown that practice can vary by as much as 60% in terms of resource allocation, so this is a critical aspect to examine.
Chen et al set out to look at the relationship between Medicare spending patterns in the region of a primary care physician’s residency training and their subsequent Medicare resource allocation patterns in practice. Essentially, they asked: “If you train in a place that spends more, will you spend more in practice?”
Type of paper
Research: Observational administrative database study
Key Points on the Methods
In this clever Medicare database study, Chen & co selected a random, weighted, representative, national sample of physicians in Family Medicine & Internal Medicine who trained between 1992-2010 in the US. Inclusion criteria also included having at least 40 Medicare patients in their practice in 2011. MDs were excluded if they were considered to primarily teach or do research, were hospitalists, were not primary care, or had little Medicare activity.
They classified training geography using the Dartmouth Atlas Hospital Referral Region taxonomy. Medicare spending was defined as low, average, or high. The primary outcome measure was mean MD Medicare spending per patient. They included data from 2851 physicians caring for 491 948 patients. They tried to control for physician and patient characteristics. They standardized Medicare spending by year to account for overall growth over time.
The authors conclude that residency training is associated with an impact on practice resource allocation patterns, particularly for younger MDs.
Spare Keys – other take home points for clinician educators
- This is yet another paper that suggests “Geography is Destiny”, and where you trained impacts your career practice patterns. This suggests that residency education is a critical enterprise deserving major attention. This is part of the educational theory of “imprinting” teachers’ practice patterns on trainees.
- Cost-effectiveness should be part of residency education.
- JAMA’s annual medical education theme issue is usually excellent, and should be part of your reading as a clinician-educator.
- The Dartmouth Atlas project is another example of a project that enables educators to look for practice patterns and attempt to correlate these with aspects of training.
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