Hidden Curriculum Shapes How Med Students Learn End-Of-Life Care

Attention medical students: When selecting your residency program, there's more than just geography and the hospital's reputation to consider.

The nation's 23 top academic medical centers also vary quite a bit in what researchers say is the intensity of care they provide patients at the end of life, according to an analysis from the Dartmouth Atlas Project.

More intense care can translate into worse, and more expensive, care at the end of life, according to the authors. So, the thinking goes, physicians who train at hospitals with better and more efficient care will be in better shape to become leaders in changing how health care is delivered.

The authors of the report call it the "hidden training curriculum."

"Learning how to use health care resources wisely, provide high-quality care, and incorporate patient preferences into a care plan is just as important as learning to work up a patient," said Alicia True, a co-author of the report and a med student at the Geisel School of Medicine at Dartmouth.

The report tracks variations in end of life care and chronic illness management, surgical procedures, and quality and patient experience using data from Medicare and published on the Hospital Compare website.

Take Johns Hopkins Hospital and Mount Sinai Medical Center, for example. They are both prestigious, but around 50 percent of patients at Johns Hopkins were enrolled in hospice in their last six months of life, compared to only 23 percent at Mount Sinai.

Residents at Mount Sinai "may therefore learn a higher threshold for referral of a patient to hospice or may decide to explore more aggressive treatment approaches first," according to the report, while Hopkins residents "may be better trained in having discussions with patients about their preferences for end-of-life care."

Patient safety training also varies widely. A patient at NYU Langone Medical Center is 47 times less likely to get an infection from a urinary catheter than a patient at the University of Michigan Health System.

"Medical students should be aware of the practice styles of residency programs they are considering ranking highly in the residency match," True added.

The report, "What Kind of Physician Will You Be," is intended as a guide for fourth-year medical students to help them select hospitals with the best practice patterns for training. The selection is particularly important "for tomorrow's doctors in order to practice successfully in the new environment created by health care reform," the authors write.

"These variations in the way care is delivered are not trivial, as they may very well affect the future practice of medicine. During their residency training, young physicians learn by observing faculty, making decisions on how aggressively to treat chronically ill patients at the end of life, and whether to recommend surgery when other treatment options exist," said Dr. John R. Lumpkin, director of the Health Care Group at the Robert Wood Johnson Foundation, which funds the Dartmouth Atlas Project.

The Dartmouth Atlas has been researching disparities in care using Medicare data to analyze trends about regional and local markets, but this is the first time the researchers have applied the findings to residency training. Dartmouth is working to get the word out to student medical groups and publications in the hopes that the report will help medical students make informed decisions when selecting their residency program.

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