Medical students should consider hospitals’ end-of-life care when applying to residency programs, according to a recent study.
A recent report issued by the Dartmouth Atlas of Health Care shows teaching hospitals throughout the country have major differences in their end-of-life care policies, which is the treatment given to patients suffering from terminal or incurable diseases. The differences may stem from the variation in institutional policies at different hospitals. Using data collected from Medicare, researchers compared the care statistics for 23 highly ranked teaching hospitals, including the Duke University Medical Center. The study suggests that such data on the effectiveness of hospital care ought to be more widely available to students deciding between residency programs.
To compare the overall treatment of chronically ill patients, the report calculated a hospital care intensity index that combined the average number of days these patients spent in the hospital in the last two years of their life and the average number of physician visits in the same period. Duke performed below the national average on this index: Patients near the end of life at Cedars-Sinai Medical Center in Los Angeles saw physicians more than twice as frequently as those receiving care at Duke’s medical center.
“Choosing where you go to do your residency after medical school is a major decision in your life, and the more information that you can have to make that decision the better,” said Alicia True, a second-year student at Dartmouth’s Geisel School of Medicine and co-author of the study. “Being aware of practice patterns in places that you’re applying is pretty important.”
But such information is not always easily accessible, or given the weight that some believe it deserves, said Dr. David Goodman, professor of pediatrics at the Geisel School.
“Intensity of care is not a marker of reputation or the breadth of research being done or the array of tertiary services that are available at a hospital,” Goodman said. “The problem is that medical students have very little information, generally, about the quality of the program or the type of care provided by the hospital. There’s not much out there, and there’s not a lot of incentive for teaching hospitals to pull back the veil that hides the important differences between them.”
Of course, not all such statistics can be purely quantitative. Patient satisfaction rates only generally correlate with empirically determined quality of care statistics, and different rationales may exist for different kinds of treatment and care, said Dr. Anthony Galanos, director of palliative care at Duke University Hospital.
“We generally want to do stuff for you, not to you,” Gallanos said in regards to end-of-life care.
According to the study, this offers one possible explanation for such variance in percent of deaths occurring in hospitals, which ranges from a national high of 44.8 percent at Cedars-Sinai to lower values such as Duke’s 30.7 percent for terminal patients.
“People generally prefer to spend their last days at home or in a comfortable setting that is not like a hospital bed,” Gallanos said, adding that Duke is fortunate to have its own hospice for end-of-life care.
The report provides more information than was already available to recent medical school graduates, but there are many variables and rationales behind the statistics that are currently unaccounted for. Goodman noted that there is still much to be done in the field.
“This is an effort in the direction of improving the kind of information that [prospective residents] have. What we need in the future is a fuller set of metrics that are developed to more completely characterize training programs at teaching hospitals so that decision-making of medical students can improve further,” he said.
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