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How residency programs are training doctors to waste money

Much of what doctors learn during residency is technical — how to take patient histories, wield scalpels, and administer drugs.

But there are also more subtle skills that doctors learn from their instructors. Doctors-in-training see their superiors decide whether to refer patients to specialists or order imaging scans. This is a grey area where there's no best practice. "These are not absolute rights and wrongs," says Fitzhugh Mullan, a professor of medicine and health policy at George Washington University.

Mullan's newest research, published today in the Journal of the American Medical Association, argues that those subtle instructions might be one of the reasons our health care system is so expensive. Residents who train in regions with high health care costs (that is, the places that err on the side of more scans and specialists) continue to practice expensive medicine decades beyond graduation — even if they move to low-cost parts of the country.

Researchers have long known about widespread variation in health care spending across the United States. A decades-long research project called the Dartmouth Atlas has found some parts of the country spend twice as much as others even though the people who live in the expensive parts of the country aren't sick enough to justify the difference.

This new paper suggests that at least part of the variation stems from how we train doctors: in residency, many pick up costly practice habits that take decades to reverse.

"Even eight to 15 years later, this is showing that some doctors' practice patterns are persistently expensive," says Elliot Fisher, who directs the Dartmouth Institute for Health Policy and Clinical Practice and was not affiliated with the study.

Doctors learn to bill Medicare for more

Mullan's new paper looks at just over 2,800 primary care doctors who finished their residencies between 1992 and 2010 and examines where they trained, whether it was an expensive region, like Boston, or low-cost area, like Billings, Montana.

The training seemed to matter a lot: doctors who were trained in high-cost parts of the country billed Medicare 7 percent more — an additional $522 annually, on average — than those trained in less expensive areas.

Doctors trained in higher-cost areas spent more regardless of whether they stayed in a high-cost area or moved to a place where other doctors spent less (the doctor who trains in Boston, for example, who moves to Billings).

And perhaps most notable is the fact that spending disparities are biggest among newly-minted residency graduates. In their first seven years of practice, doctors trained in high-cost areas spend 29 percent more than their counterparts educated in low-cost places.

The gap gets smaller over time. For doctors in practice between 8 and 15 years, there's a 7 percent spending difference. And for those who have worked more than 16 years, the gap disappears.

This suggests to Mullan that doctors' practice patterns can change, gradually, but that there's also something important about the initial training that "imprints" on the doctors and how they practice medicine.

"It suggests that the cost pattern of a physician's practice is related to the training he or she gets, not only the didactic training but also the nature of practice in that community," Mullan says.

Can reforming residencies save money?

The JAMA paper suggests a tantalizingly easy way to save money in American health care: train more residents in low-cost areas of the country. They would learn, from the get-go, to be more frugal physicians. If there was a way for the health care system to cut 7 percent of all spending just by training doctors differently, after all, you'd think we'd jump at it.

But, like most things in health policy, this is easier said than done. Many of the mammoth academic medical centers are in in the Northeast, which tends to have some of the highest health care costs in the region. Boston and New York are two cities in particular that have especially high health spending — and train lots of doctors. This chart shows the distribution of residencies in the United States by average per patient Medicare spending. And it shows that the most expensive parts of the country also have more residents.

jama chart

(Journal of the American Medical Association)

Getting the resources built in those large, urban centers out to less expensive areas of the country would be a pretty big lift.Change is hard — but the status quo, where we train expensive doctors and send them out across the country, isn't great either.

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