Why is this variation relevant to a medical student or resident?
Residents' training will be influenced by the intensity of care provided by their teaching hospital. The findings about the care of chronically ill patients near the end of life reflect a number of factors:
Organization of care and reliance on specialists: Complex patients are often cared for by multiple physicians, each having a specific set of recommendations. Primary care physicians and resident teams are frequently charged with the task of coordinating these instructions and organizing the patient's care. This is a challenging responsibility. Consider that, at NYU Langone Medical Center, almost 70 percent of chronically ill patients saw 10 or more different physicians during their last six months of life. It is difficult for both patients and providers to integrate the advice from so many physicians. Residents at hospitals where patients have multiple physicians will need to make a special effort to manage these recommendations to avoid potential consequences of fragmented or disorganized care.
The care provided at hospitals with a high percentage of patients seeing 10 or more physicians during the last six months of life is also particularly reliant on specialists. A resident at NYU Langone Medical Center will interact more frequently with specialists than a resident at Scott & White Memorial Hospital, where only 43 percent of patients saw 10 or more physicians. At NYU, a patient's care will be heavily dictated by specialists' opinions. In contrast, residents at Scott & White may be more likely to develop experience managing complex chronic illnesses, as fewer patients see multiple specialists.
Utilization of resources at end of life: When asked how they would like to spend their last six months of life, many patients prefer to be cared for in a home-like setting. However, the Dartmouth Atlas data show that, for many patients, it is not their preferences that determine how they spend the last few months of life, but the practice styles of the hospitals where they happen to receive care.
For example, patients at Cedars-Sinai Medical Center saw physicians 73 times in their last six months of life, compared to patients at University of Utah Health Care, who saw physicians 20 times during that same time period. Similarly, patients at New York-Presbyterian Hospital spent, on average, 20 days in the hospital during their last six months of life, compared to 10 days at the Mayo Clinic. These data show that Cedars-Sinai and New York-Presbyterian provide more aggressive care. It is true that more time in the hospital and more physician visits provide residents with more information, allowing a resident to be more certain about a diagnosis, treatment plan, or the stability of a patient prior to discharge. However, longer and more frequent hospital stays have their own risks of iatrogenic illness (for example, acquiring a nosocomial infection), increased financial burden, and uncoordinated care. Most importantly, for many patients with chronic illness, more hospital days do not lead to a longer or better quality of life.
Use of ICUs and reliance on hospice: Many heroic and life-saving measures occur in ICUs, where aggressive efforts are made to resuscitate patients and keep them alive. There are times, however, when these measures are more harmful than heroic—and they may be unwanted by the patient.
The percent of deaths associated with an ICU admission at Ronald Reagan UCLA Medical Center was more than three times what it was at University of Michigan Medical Center for patients dying in 2010. Days spent in an ICU are resource-intensive and often unpleasant for patients and their families. It is difficult to predict for which patients an ICU stay will be life-saving and for which patients it will be harmful. Physicians should consider and discuss with all patients, especially elderly patients, whether the possible benefits of an ICU stay outweigh the disadvantages. Some patients would prefer to be managed at home, perhaps under hospice care. In hospitals where a high percentage of deaths occur in the hospital and in the ICU, there is less emphasis on hospice care. Approximately 50 percent of patients treated at the Johns Hopkins Hospital were enrolled in hospice in their last six months of life, compared to only 23 percent of patients treated at Mount Sinai Medical Center in New York City. A Mount Sinai resident may therefore learn a higher threshold for referral of a patient to hospice or may decide to explore more aggressive treatment approaches first. Meanwhile, a Johns Hopkins resident may be better trained in having discussions with patients about their preferences for end-of-life care.