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Dr. Christopher Boes, Mayo Clinic
Dr. Christopher Boes, a neurology specialist, speaks with residents at St. Mary's Hospital. Mayo was praised in the Dartmouth report for taking a less-intensive approach to end-of-life care than many of its peers.

Elevating variation

Dartmouth Atlas says its hospital report has valuable info for med students


By Andis Robeznieks
Posted: November 3, 2012 - 12:01 am ET
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The Dartmouth Atlas Project and the nation's teaching hospitals have had their differences before, but a new report issued by the group made those differences a little more personal.

The report—titled What Kind of Physician Will You Be?—suggests that medical students weighing options for residency programs should think about how an institution's practice variations reflect its culture and how that may affect the rest of their professional careers.

The researchers reviewed variations in care according to Medicare statistics from 23 of the top U.S. teaching hospitals. At institutions where more patients have knee replacements, for example, physicians are quick to perform surgery, the report concluded, and they are more likely to discuss treatment options such as physical therapy and analgesics at institutions that perform fewer knee-replacement procedures.

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As a sign of high-intensity treatments at the end of life, the report noted that 66.6% of patients in their last six months of life at NYU Langone Medical Center in New York saw 10 or more doctors, but that figure was only 42.5% at Scott & White Memorial Hospital in Temple, Texas.

“At NYU, a patient's care will be heavily dictated by specialists' opinions,” the report concluded. “In contrast, residents at Scott & White may be more likely to develop experience managing complex chronic illnesses, as fewer patients see multiple specialists.”

In packaging this information as a guide to students selecting a training program, the report also discusses how academic medical centers often have a “hidden curriculum” where trainees are told one thing in the classroom and shown another in clinical settings. This includes “how aggressively physicians at each hospital treat chronically ill patients at the end of life, and the frequency with which patients undergo surgery when other treatment options are available,” according to the report.

Dr. Joanne Conroy, chief healthcare officer with the Association of American Medical Colleges, said she was surprised by the use of the expression “hidden curriculum,” which she described as a “loaded term” because it implies that residents are being purposely misled. Conroy also said that the Dartmouth Atlas report is more of a “snapshot” in time because it only shows an institution's placement at the moment and doesn't note whether its performance is trending up or down.

The report was released hours before superstorm Sandy hit New York. And while the report's statistics highlighted NYU Langone's high intensity tendencies, Conroy noted how it didn't measure the staff's “high heroics” evacuating patients down darkened stairwells after power was lost. “They are truly remarkable people—not just the doctors and nurses, but the techs and everyone in the hospital,” she said.

Dr. Glenn Braunstein, vice president for clinical innovation at Cedars Sinai Medical Center in Los Angeles, argued that the report paints his institution as a high-intensity provider for patients at the end of life without noting that the care being provided has lowered mortality rates.

“We've had a long-time dialogue with the Dartmouth Atlas people about their methodology,” Braunstein said, adding that physicians don't know in advance if the care they are providing will be futile. Still, he said, the report does provide some motivation. “We see this data and it re-stimulates us to reduce variation even more.”

Ultimately, Conroy said, the report may be “another data point” medical students use when evaluating their residency options, but “I don't actually believe that a student who is applying for a position at one of these coveted institutions will bring it up.”

Elizabeth Wiley, president of the American Medical Student Association, however, is just starting on the “interview trail” and said she thinks the report “will be incredibly helpful.” Wiley said she expects to go on about 20 interviews in the next three months seeking a primary-care residency position, and the report essentially says “this is the culture of an institution and these are the outcomes.”

“It's great to have a more holistic way to assess the performance of an institution,” Wiley said, noting that some hospitals with strong reputations don't necessarily appear to perform as well as one might expect.

Dr. Robert Pendleton, chief medical quality officer for University of Utah Health Care, said he thought reaction to the report has been quiet, but its importance could grow in the next three to five years as more attention gets focused on regional and institutional variations in care. “The challenge is, what does define unjustified variation?” Pendleton said. “I certainly hope we are preparing medical students well enough to ask questions like this.”

Pendleton said data used in the study “is far from definitive,” and people may be drawing unwarranted conclusions from the statistics, but he added that its importance may be in how it illustrates the need to engage residents and to incorporate “system think” into classroom and clinical settings. He said this means integrating issues such as patient safety, quality improvement, cost and shared decisionmaking with patients into physician training.

The Mayo Clinic-affiliated teaching institution, St. Mary's Hospital in Rochester, Minn., showed lower intensity rates for end-of-life care and high scores in the report's patient safety, quality and patient-satisfaction measures. Mayo Clinic Health System CEO Dr. Robert Nesse credited his organization's integrated practice model that starts with organized primary care and extends to palliative care at the end of life. In between, there is a network of coordinated providers with an aligned financial system and aligned purpose receiving timely feedback on how to improve.

The Dartmouth Atlas report, Nesse said, serves as a reminder of the variations in practice that exist and will help stimulate change—in part because it's bringing students and residents into the process. “I think it's always exciting when people who are just entering their training are discussing this.”



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