1. The health care utilization of the region (high-intensity or low-intensity) in which internal medicine residents train may predict how conservatively or aggressively they will practice in the future.

2. Residents that trained in a low intensity region were more likely to select the “appropriately conservative” and “appropriately aggressive” management answers on the American Board of Internal Medicine (ABIM) certifying exam.

Evidence Rating Level: 3 (Average)

Study Rundown: Physician practice patterns can be quite varied across the country. This variation is thought to be one of the contributors to rising health care costs. Since physicians serve as the stewards of medical resources, their ability to practice judiciously and conservatively can determine the cost of healthcare. This study examined whether the location of residency training, whether in a high-intensity or low-intensity health care utilization environment, is associated with internal medicine residents’ ability to identify appropriately conservative or appropriately aggressive management answers on their board examination. The results of the study suggest that there is an association between the practice environment in which residents train and their answer selections on management questions of the ABIM certifying exam. Residents that trained in a low intensity region were more likely to select the appropriately conservative and appropriately aggressive management answers on certifying exam.

One of the strengths of the study is that most of the internal medicine training programs were represented. Also, the investigators created an intensity of practice scale by accounting for the relative “health” of the region, so that “healthiness” of different regions did not bias the results. One major limitation of the study, however, is the assumption that the way in which trainees answer the certifying exams is the same way they will practice in their future careers. Furthermore, using the End-of-Life Visit Index may not be the appropriate index of intensity of health care utilization.

Click to read the study, published today in JAMA Internal Medicine

Relevant Reading: Physician board certification and the care and outcomes of elderly patients with acute myocardial infarction

In-Depth [cross-sectional study]: This study examined the results of the 2007 ABIM certifying exam of 6639 candidates from 357 programs in North- and Central-America. The intensity of the practice environment was determined by the End-of-Life Visit Index (EOL-VI), which is based on the mean number of physician visits for Medicare patients in the last six months of life. In order to define the outcome of the study, the investigators extracted the management-style questions from the exam, and classified the questions as “conservative” or “aggressive” and each of the answer choices for those questions were sub-classified as more or less aggressive than was appropriate for the question.

The results showed that the residents who trained in the lowest intensity residency environment scored the highest on the appropriately conservative (ACM) (P<0.001) and appropriately aggressive (AAM) management questions (P=0.004). For the ACM questions, there was a 0.96 percentile point decrease (95% CI, 0.87-1.06) for each unit increase in the EOL-VI in the training environment. Similarly, for the AAM questions, there was a 0.20 percentile point decrease (95% CI, 0.11-0.30) in the exam score for each unit increase in EOL-VI of the training environment.

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