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physician’s propensity to prescribe opioids could be affected by a range of factors relating to background and clinical experiences. But new research shows one variable may be especially influential: where the doctor went to medical school.

A paper published Monday by economics professors at Princeton University determined that physicians who studied at lower-ranked medical schools prescribe nearly three times as many opioids per year as those who attended top-tier institutions.

The finding, published by the National Bureau of Economic Research, suggests that education plays an influential role in prescribing practices that are under a microscope amid a drug abuse epidemic fueled by increased access to legal opioids. “Since variations in opioid prescribing have contributed to deaths due to the current opioid epidemic, training aimed at reducing prescribing rates among the most liberal prescribers … could possibly have large public health benefits,” wrote the paper’s authors, Molly Schnell and Janet Currie.

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The researchers found that the link between education and the amount of opioids prescribed persisted across regions and specialties — and even within hospitals — making it unlikely that differences in the patients seen by doctors from low- and high-ranked schools accounted for the variation in their practices.

 

Schnell said the research was sparked by a desire to examine physicians’ role in opioid crisis. “There’s been a lot more focus on the pharmaceutical companies and on the consumer side,” she said. “But If we’re going to try to decrease the number of prescriptions and get them into the right hands, we’re going to have to start looking at physicians. And this was a first step in that process.”

The study used data on all opioid prescriptions written in the U.S. between 2006 and 2014. The researchers used a composite ranking of medical schools from U.S. News and World Report — based on data from several years — to examine the link between physicians’ prescribing practices and where they attended medical school.

On average, the researchers found, physicians who attended Harvard wrote fewer than 100 opioid prescriptions per year, while physicians trained at the lowest-ranked schools wrote about 300 per year.

In addition, the study found striking differences related to the training of general practitioners, who, during the study period, accounted for nearly half of all the opioids prescribed. General practitioners trained at Harvard wrote an average of 180.2 opioid prescriptions per year; doctors from the lowest-ranked schools averaged 550 prescriptions per year.

Despite Harvard’s stronger performance, even some its students have been displeased with their educations on opioids and have organized their own trainings on how to use the medications more effectively and treat addiction.

The clinical use of opioids has quadrupled in the United States since 1999. Meanwhile, drug overdoses involving opioids shot up by 200 percent, raising alarms about the role physicians have played in fueling the crisis.

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Policymakers have instituted an array of measures to try to change prescribing practices, including requiring physicians to check prescription drug databases for signs of abuse before providing access to opioids. In recent years, the overall number of opioid prescriptions has dipped, but the drugs are still regularly doled out in clinical practice. In 2014, the average physician wrote 221.7 opioid prescriptions.

Prompted by government regulators, medical schools have begun enhancing their training on opioids. About 60 medical schools nationwide said they would accede to a request from the Obama administration that they include in the curricula opioid prescribing guidelines published by the Centers for Disease Control and Prevention.

Given the apparent connection between education and prescribing, the Princeton researchers concluded that if the CDC training is shown to be effective, “then policy makers might consider offering stronger inducements for medical schools to incorporate these guidelines.”

Schnell said she hopes that, if the research gets attention, she and others could start to examine variations in education and training on a more granular level. “One thing we would love is to start working with medical schools to maybe know what they’ve been teaching and see if we can pinpoint which strategies are most effective,” she said.

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  • There appear to be several issues with this study that cannot be explained by the data presented. The most obvious issue is that one would expect that residency training would influence and refine post-training practice far more than medical school. It would seem unlikely that a Harvard graduate and a student from a lower-tier school would attend the same residency program, yet have wildly disparate prescribing practices, giving their advanced clinical skills were refined at the same institution. In fact, the data presented strongly support that medical school attended, per se, is NOT the primary contributing factor to post-training prescription practices. It was observed that “For pain medicine, physical medicine and rehabilitation, and anesthesiology—the specialties where all practitioners could be expected to receive specific training in the use of opioids—we see virtually no relationship between initial medical school rank and opioid prescribing, as hypothesized above.” That observation would appear to strongly suggest (if not confirm) that medical school ranking is NOT the primary contributing factor to opioid prescription practices, which frankly, seems obvious. That seems obvious, considering that medical school training is not terribly disparate between those students that will eventually attend specialty training in areas that write almost no opioid prescriptions (pathology, radiology) and those who later train in primary care. With that in mind, this article appears to be a massive (though very detailed) exercise in futility suggesting that their primary hypothesis was flawed, as the mostly likely influence on practitioners’ prescribing practices–residency and/or fellowship training– is unstudied. Perhaps repeating the study looking at the ranking of the residency or fellowship programs would reveal more useful data. Sorry, guys– you blew it.

    • You explained away opioid prescription practices for certain specialties. Now, can you explain why there is a correlation between graduating school and opioid prescription practice for primary care MDs?

    • The correlation may between where they trained when they finished medical school. It’s difficult to believe that a medical student would develop clinical practices that became so ensconced they wouldn’t be later refined in residency training. This is especially true at Harvard, where the article accompanying the study suggested medical students at Harvard felt they were being inadequately trained in medical school and took it upon themselves to organize further study on the subject. From the article:
      “Despite Harvard’s stronger performance, even some its students have been displeased with their educations on opioids and have organized their own trainings on how to use the medications more effectively and treat addiction.”

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