• Brenda E Sirovich, Rebecca S Lipner, Mary Johnston, and Eric S Holmboe.
• Outcomes Group, Veterans Affairs Medical Center, White River Junction, Vermont2The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire.
• JAMA Intern Med. 2014 Oct 1;174(10):1640-8.

ImportanceGrowing concern about rising costs and potential harms of medical care has stimulated interest in assessing physicians' ability to minimize the provision of unnecessary care.ObjectiveTo assess whether graduates of residency programs characterized by low-intensity practice patterns are more capable of managing patients' care conservatively, when appropriate, and whether graduates of these programs are less capable of providing appropriately aggressive care.Design, Setting, And ParticipantsCross-sectional comparison of 6639 first-time takers of the 2007 American Board of Internal Medicine certifying examination, aggregated by residency program (n = 357).ExposuresIntensity of practice, measured using the End-of-Life Visit Index, which is the mean number of physician visits within the last 6 months of life among Medicare beneficiaries 65 years and older in the residency program's hospital referral region.Main Outcomes And MeasuresThe mean score by program on the Appropriately Conservative Management (ACM) (and Appropriately Aggressive Management [AAM]) subscales, comprising all American Board of Internal Medicine certifying examination questions for which the correct response represented the least (or most, respectively) aggressive management strategy. Mean scores on the remainder of the examination were used to stratify programs into 4 knowledge tiers. Data were analyzed by linear regression of ACM (or AAM) scores on the End-of-Life Visit Index, stratified by knowledge tier.ResultsWithin each knowledge tier, the lower the intensity of health care practice in the hospital referral region, the better residency program graduates scored on the ACM subscale (P < .001 for the linear trend in each tier). In knowledge tier 4 (poorest), for example, graduates of programs in the lowest-intensity regions had a mean ACM score in the 38th percentile compared with the 22nd percentile for programs in the highest-intensity regions; in tier 2, ACM scores ranged from the 75th to the 48th percentile in regions from lowest to highest intensity. Graduates of programs in low-intensity regions tended, more weakly, to score better on the AAM subscale (in 3 of 4 knowledge tiers).Conclusions And RelevanceRegardless of overall medical knowledge, internists trained at programs in hospital referral regions with lower-intensity medical practice are more likely to recognize when conservative management is appropriate. These internists remain capable of choosing an aggressive approach when indicated.

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