Residency Training Predicts Physicians’ Ability to Practice Conservatively

Doctors trained in locations with less intensive (and expensive) practice patterns appear to consistently be better at making clinical decisions that spare patients unnecessary and excessive medical care, according to a new study in JAMA Internal Medicine.

“Growing concern about the costs and harms of medical care has spurred interest in assessing physicians’ ability to avoid the provision of unnecessary care,” says lead author Brenda Sirovich of the VA Outcomes Group, The Dartmouth Institute for  Health Policy & Clinical Practice, and the Dept. of Community and Family Medicine at the Geisel School of Medicine at Dartmouth.

Sirovich and colleagues sought to evaluate whether residency training influences physicians’ capability of making good management decisions, even when those decisions require them to “forgo a wide array of costly medical interventions in favor of management strategies of less intensity, such as watchful waiting.” To do this, the investigators developed a measure based on existing questions from the American Board of Internal Medicine certifying exam. On the exam, some questions implicitly assess candidates’ ability to manage patients conservatively when such an approach is warranted – that is, questions for which a conservative management strategy was the “right answer.”

The authors found that independent of overall medical knowledge, internal medicine exam takers who had trained at programs characterized by lower intensity practice patterns consistently scored higher (better) on the Appropriately Conservative Management exam subscale. These same physicians did just as well, if not better, at recognizing when aggressive management was indicated – a finding that surprised Sirovich and her co-authors.

They conclude that “conservative training environments may promote more thoughtful clinical decision making at both ends – conservative and aggressive – of the spectrum of appropriate practice.”

The measure of health care intensity measure the researchers used was physician visits among a comparably ill cohort of patients, but they reported that their findings held for other intensity measures, including spending. Higher regional spending is not associated with better outcomes, satisfaction, or quality of care, and high spending itself leads to more rapid growth in spending, according to previous journal studies published by The Dartmouth Institute on variations in Medicare spending.

“While health care certainly offers important benefits to many, a growing body of evidence points to serious problems of overuse and harm,” Sirovich says. Understanding the factors contributing to higher health care utilization has, therefore, become an increasingly important national priority.

She concludes on a hopeful note: “… the possibility that high intensity training environments foster a practice style that may waste precious resources – and harm patients – through inappropriate interventions warrants attention. Reporting feedback to programs about residents’ performance on a prospectively designed appropriately conservative management certifying examination subscale might help address the problem of overuse and promote attention to value in medical practice in the United States.”

To view the abstract of the article in JAMA Internal Medicine, please go to

The Dartmouth Institute for Health Policy & Clinical Practice was founded in 1988 by Dr. John E. Wennberg as the Center for the Evaluative Clinical Sciences (CECS). Among its 25 years of accomplishments, it has established a new discipline and educational focus in the Evaluative Clinical Sciences, introduced and advanced the concept of shared decision-making for patients, demonstrated unwarranted variation in the practice and outcomes of medical treatment, developed the first comprehensive examination of US health care variations (The Dartmouth Atlas), and has shown that more health care is not necessarily better care.