Report: Variations in quality of care a ‘hidden’ curriculum for new doctors at teaching hospitals

Medical students have a lot to consider when deciding where to pursue a residency placement, including faculty credentials, hospitals’ financial stability, location, cost of living, and more. A new report from the Dartmouth Atlas Project suggests that they add another factor to the list: How do teaching hospitals stack up on quality of care?

The report looked at 23 teaching hospitals across the country and used Medicare data to compare them on metrics such as the frequency with which patients develop new infections during a hospital stay and how often patients at the end of life are referred for hospice care.

Wide variations point to a “hidden training curriculum” that can have a “profound effect” on how doctors are taught to treat patients, the report says.

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For more than two decades, the Dartmouth Atlas Project has been using Medicare records to evaluate health care quality. The new report is specifically designed as a tool for medical students. It gives each hospital a score judging the “intensity” of care for patients who are dying that accounts for days spent in the hospital and the number of doctor visits in the last two years of life.

Cedars-Sinai Medical Center had the highest score, three time that of hospitals at the low end. In this case, a low score is better.

“Hospitals providing a higher intensity of care are not necessarily providing higher quality care or better patient experiences,” co-author Dr. Anita Arora, a recent graduate of the Geisel School of Medicine at Dartmouth, said in a press release.

The report, which also examines surgical rates and patient satisfaction, includes some of the most popular training programs in the country, including Johns Hopkins Hospital, Vanderbilt University Medical Center, and the Cleveland Clinic. Scores for Massachusetts General and Brigham and Women’s hospitals generally were in line with national averages.

The list demonstrates that even hospitals with excellent reputations may fall short in certain quality measures, said Dr. David Goodman, a principal investigator on the Atlas project director of the Center for Health Policy Research at the Dartmouth Institute.

“Medical students should consider these differences when they select their training programs,” he said. “Teaching hospitals need to continue to improve the quality of care and not be complacent about the care that they’re providing.”

Dr. Joanne Conroy, chief health care officer for the Association of American Medical Colleges, said some of the results seemed contradictory. Mount Sinai Medical Center in Chicago, for example, is home to leaders in end-of-life care but is noted as having a low percentage of patients enrolled in hospice care, she said.

Conroy said she thinks the report may be a good conversation starter for leaders within the teaching hospitals, but not a definitive tool for students. “There aren’t ultimate answers in it,” she said.

This is not the first report to point to hospital culture and performance as a “hidden” aspect of doctor training. Conroy said the term is “loaded” and one she avoids. But some scholars in medical education have popularized it in recent years, often using it to describe how doctors in training can be affected by team dynamics and mentors’ bedside manner.

Research in recent years has tied hospital culture to quality of care and medical training. Though she has concerns about the Dartmouth report, Conroy said the issue is an important one that should be studied.

Her organization is considering starting a project with Kaiser Permanente in California to examine whether physicians trained within the California health care system practice differently than doctors trained elsewhere, even when they move on to other hospitals.