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Original Investigation |

The Association Between Residency Training and Internists’ Ability to Practice Conservatively

Brenda E. Sirovich, MD, MS1,2; Rebecca S. Lipner, PhD3; Mary Johnston, MS4; Eric S. Holmboe, MD5
[+] Author Affiliations
1Outcomes Group, Veterans Affairs Medical Center, White River Junction, Vermont
2The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
3The American Board of Internal Medicine, Philadelphia, Pennsylvania
4Center for Assessment and Research Studies, James Madison University, Harrisonburg, Virginia
5The Accreditation Council for Graduate Medical Education, Philadelphia, Pennsylvania
JAMA Intern Med. 2014;174(10):1640-1648. doi:10.1001/jamainternmed.2014.3337.
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Importance  Growing concern about rising costs and potential harms of medical care has stimulated interest in assessing physicians’ ability to minimize the provision of unnecessary care.

Objective  To assess whether graduates of residency programs characterized by low-intensity practice patterns are more capable of managing patients’ care conservatively, when appropriate, and whether graduates of these programs are less capable of providing appropriately aggressive care.

Design, Setting, and Participants  Cross-sectional comparison of 6639 first-time takers of the 2007 American Board of Internal Medicine certifying examination, aggregated by residency program (n = 357).

Exposures  Intensity of practice, measured using the End-of-Life Visit Index, which is the mean number of physician visits within the last 6 months of life among Medicare beneficiaries 65 years and older in the residency program’s hospital referral region.

Main Outcomes and Measures  The mean score by program on the Appropriately Conservative Management (ACM) (and Appropriately Aggressive Management [AAM]) subscales, comprising all American Board of Internal Medicine certifying examination questions for which the correct response represented the least (or most, respectively) aggressive management strategy. Mean scores on the remainder of the examination were used to stratify programs into 4 knowledge tiers. Data were analyzed by linear regression of ACM (or AAM) scores on the End-of-Life Visit Index, stratified by knowledge tier.

Results  Within each knowledge tier, the lower the intensity of health care practice in the hospital referral region, the better residency program graduates scored on the ACM subscale (P < .001 for the linear trend in each tier). In knowledge tier 4 (poorest), for example, graduates of programs in the lowest-intensity regions had a mean ACM score in the 38th percentile compared with the 22nd percentile for programs in the highest-intensity regions; in tier 2, ACM scores ranged from the 75th to the 48th percentile in regions from lowest to highest intensity. Graduates of programs in low-intensity regions tended, more weakly, to score better on the AAM subscale (in 3 of 4 knowledge tiers).

Conclusions and Relevance  Regardless of overall medical knowledge, internists trained at programs in hospital referral regions with lower-intensity medical practice are more likely to recognize when conservative management is appropriate. These internists remain capable of choosing an aggressive approach when indicated.

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Figure 1.
Flow Diagram of the Identification and Coding of 2007 American Board of Internal Medicine (ABIM) Certifying Examination Questions for Subscale Inclusion

ACM indicates appropriate conservative management; AAM, appropriately aggressive management.

aMost usable management questions did not qualify for inclusion in the ACM or AAM subscale. Coding was performed by the investigators or by trained physician coders overseen by the investigators depending on the stage of the project.

Graphic Jump Location
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Figure 2.
Association Between Intensity of Practice in the Region of a Residency Program’s Primary Hospital and Resident Scores on the Appropriately Conservative Management (ACM) Subscale

A, Overall results. B, Results stratified by tier of residency program based on exam takers’ mean American Board of Internal Medicine certifying exam knowledge scores. Quintiles of regional practice intensity are based on the number of physician visits in the last 6 months of life (End-of-Life Visit Index). Regression coefficient is for the linear regression of the mean program ACM score (continuous) on the regional End-of-Life Visit Index (continuous).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.
Association Between Intensity of Practice in the Region of a Residency Program’s Primary Hospital and Resident Scores on the Appropriately Aggressive Management (AAM) Subscale

A, Overall results. B, Results stratified by tier of residency program based on exam takers’ mean American Board of Internal Medicine certifying exam knowledge scores. Quintiles of regional practice intensity are based on the number of physician visits in the last 6 months of life (End-of-Life Visit Index). Regression coefficient is for the linear regression of the mean program AAM score (continuous) on the regional End-of-Life Visit Index (continuous).

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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