As health care becomes increasingly transparent, and the calls to improve care delivery grow louder by the day, more and more groups will find new and different ways to slice and dice hospital data. Even those who have been doing it for eons will find new stories to tell.
Consider the latest entry from the Dartmouth Atlas Project. Early this morning, Dartmouth researchers released a report that attempts to shine a light on what they call the "hidden training curriculum" at some of the nation's most elite and highly-regarded academic medical centers (don't think of "hidden" in dubious terms though; the researchers aren't accusing these teaching hospitals of some nefarious plot…read on).
As you know, the Dartmouth Atlas Project has for nearly two decades been studying and publicizing the problem of variation that exists within the delivery system. This morning's report, "What Kind of Physician Will You Be? Variation in Health Care and Its Importance for Residency Training," not only delves into the variation between 23 different teaching hospitals, but attempts to link that to the training of doctors-to-be.
The report, researchers said during a press call yesterday, is an effort to show med students, and current residents, that how they are taught to care for patients is as important as where and what they are taught. Based on various Medicare data stretching from 2008 to 2010, the report identified significant swings in the "intensity of care" provided at the end-of-life, surgical procedure rates, patient experience and safety and quality.
For instance, the lead researchers — one a med student, the other a resident — found that nearly 70 percent of chronically ill patients at NYU Langone Medical Center saw 10 or more different physicians during the last six months of life. Compare that to Scott & White Memorial Hospital in Texas, where 43 percent of patients saw 10 or more docs. This suggests that residents at Scott & White are more likely to develop the skills needed to manage patients with complex chronic conditions, rather than referring them to a specialist, said report co-author Alicia True, a first-year student at the Geisel School of Medicine at Dartmouth.
Or this example: "Knee replacements are performed in Salt Lake City at a rate that is more than two times that in Manhattan." This led researchers to make the following assumption: "An orthopedic resident trained in Salt Lake City is likely to learn a treatment style for osteoarthritis of the knee where surgery is more probable than a resident in New York City, who more readily prescribe physical therapy or analgesics."
During the press call, True and her co-reseacher, Anita Arora, M.D., a resident at Yale School of Medicine and recent Dartmouth graduate, acknowledged that they didn't interview residents or medical center officials to assess how or what the residents are actually taught.
"I really only know the training that I am getting," Arora said. "It is difficult for me to understand what it would be like to train at another institution, but the data shows that there is variation."
Joanne Conroy, M.D., chief health care officer at the Association of American Medical Colleges, says that the report and data don't pick up on some key things, like the culture within the institution or market dynamics. For instance, there could be other factors leading to the high number of knee surgeries in Salt Lake City, not the least of which are those giant hills that people ski down. Or, she said, consider Cedars-Sinai, which has one of the most highly regarded palliative care programs in the country, but scores low in the Dartmouth report for the number of patients in hospice.
Importantly, Conroy told me during an interview, the report does highlight the need for greater attention to having open dialogue with patients. "That is the enduring lesson from this," she said. That and creating an environment of team-based care.
"The strength of integrated health care involved with medical education is that it provides the daily mentoring of how patient-centered care works best," said Jim Rohack, M.D., director of the Center for Healthcare Policy at Scott & White Healthcare and immediate past president of the AMA. Sharing medical records, improving communication between physicians, discussing cases, creating a true team environment, he said, will help avoid duplication and unnecessary expenses.
Both of those ideas — patient-centered and team-based care — were things that True and Arora reiterated time and time again on the press call.
"If I train in residency and I get use to having conversations on the patient's goals and desires, if I am good at those discussions, I will carry that forward and that will stick with me," Arora said.