How do the characteristics of residency training influence the nature of a physician’s future practice? A recent study in JAMA investigated whether exposure to different practice and spending patterns during residency left an “imprint” detectable in practice after training.
The study evaluated data from 2,851 primary care physicians who provided care to 491,948 Medicare beneficiaries, and used Dartmouth Atlas Hospital Referral Region files to determine high- and low-spending regions.
Investigating how residents’ spending patterns could influence tomorrow’s health care environment is important because Medicare- and Medicaid-funded graduate medical education (GME) represents the largest public investment in health workforce development in the United States, the study said.
The results showed a strong association between residency training sites and future practice locations. More than one-half of physicians who trained in a low-cost region then practiced in a low-cost region, and nearly 70 percent of physicians who trained in a high-cost region ultimately practiced in one. For doctors who trained and practiced in high-spending regions, mean physician spending per beneficiary was $9,482—nearly $2,000 more per beneficiary annually compared with mean spending among physicians who trained in low-spending regions but practiced in high-spending ones.
The analysis also showed:
- Physicians who trained in higher-spending regions were more likely to be general internists, to be international medical graduates (IMG) or to have been practicing for longer periods of time.
- IMGs, male physicians and physicians spending more time working in a hospital setting had higher expenditures per patient.
- Physicians with more years of practice had overall lower mean patient expenditures.
The results showed an average difference of about 7 percent in spending between physicians trained in the highest- and lowest-spending training groups. However, this difference was as high as 29 percent for those within seven years of completing their residencies, and this difference appeared to decrease over time, to no statistically significant difference at 16 or more years after completing residency.
“These observations suggest an imprinting of care-related spending behaviors that might take place during residency,” the study said.
Currently, higher numbers of total GME residents are trained in higher-spending regions than in lower-spending ones: Nearly one-half of graduating residents in 2010 were trained in the top three deciles for average Medicare spending per beneficiary.
If physicians trained in lower-spending regions continued to practice in a less costly manner even when they moved to higher-spending regions, and vice versa, then national cost management strategies should take that into account, the study said. “For example, considerations might be given to prioritizing public investments in GME to institutions with learning environments in which trainees are exposed to less costly care,” it said.
