A paper from the National Bureau of Economic Research entitled, “Addressing the Opioid Epidemic: Is there a role for physician education?” by Schnell and Curry begins with this the question of how initial medical training varies with opioid prescriptions written and finds this provocative finding:
- “…physicians trained at the lowest ranked US medical schools prescribe nearly three times as many opioids per year as physicians trained at the top medical school. This striking inverse relationship reflects two factors: (1) physicians from lower ranked medical schools are more likely to write any opioid prescriptions; and (2) conditional on being an opioid prescriber, physicians for lower ranked medical schools write more opioid prescriptions on average. This prescribing gradient is particularly pronounced among GPs. 
Let’s unpack the study; the authors obtained data regarding prescriptions written from a dataset of physician level prescriptions filled at pharmacies. All good, except the primary weakness here (and acknowledged by the authors), is that we do not know the number of patients cared for or the strength and number of doses prescribed. The ranking of medical schools was taken from US News and World Report: Research Rankings. This classification emphasizes the school's reputation for research, not teaching. Moreover, a similar ranking based on primary care graduates rather than research was not used, and the rankings differ. 
Using a dataset of 742,297 physicians (for which all relevant data was available), they found that
- 2.16 billion opioid prescriptions were written between 2006 and 2014
- GPs made up 27.4% of physicians and prescribed 48.2% of all opioids
- 28.3% of physicians wrote no opioid prescriptions (for GPs the figure was 16.2%)
- Average physician wrote 221.7 opioid prescriptions in 2014 (for GPs the figure was 480.3)
- While GPs trained at Harvard write an average of 180.2 opioid prescriptions per year, GPs from the lowest ranked US medical schools write an average of nearly 550 opioid prescriptions per year
Now this last factoid is the basis for the 3-fold difference in prescribing behavior, but buried deep in the paper is this
“Taking into account differences in specialties and counties of practice across medical school rankings, doctors from the lowest ranked schools still write on average over 33 more opioid prescriptions per year than doctors from the highest ranked schools.”
Some quick math suggests that when even a gross measure of patient demographics is considered the difference goes from a 300% to an 18% increase.
There is another limitation to the study; it does not take into account training after medical school. And this is a significant limitation because most physicians learn prescribing behavior as interns and residents, not as medical students. Here their data tells a different story,
“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.”
And even setting this aside, here is what the authors say about medical school training in opioid prescriptions.
“A review of the curricula at all four medical schools in Massachusetts, for example, found that there was no standard in place to make sure that all students were taught safe and effective opioid-prescribing practices before graduation.”
And Harvard is one of those schools. I would agree that physician education “has a role to play in addressing the opioid epidemic.” But without knowing how many patients were treated by the doctor, without knowing the patient mix they cared for in terms of co-morbidities and presenting problems (e.g. back pain vs. colds) and without information on the strength and doses of opioids prescribed, these prescriptions written for opioids have no context. A deeper flaw is the belief, unsubstantiated by the authors or in fact by me, that training in opioid prescribing occurs in medical school; in fact, the authors own evidence suggests that training after medical school removes any impact of where a physician went to medical school on their prescribing. Having trained as a physician and having trained residents and fellows, I believe that my knowledge of prescribing is based on my surgical training, not my medical school  and what my patients taught me as I cared for them. Finally, how are the rankings of medical schools by research pertinent to their ranking as teachers? The data might have looked much different if the rankings by primary care (who after all are the big prescribers) were used.
 GPs are defined in this paper as general practitioners, family practice, and internal medicine physicians. While all three provide primary care, their training after medical school differs. I would suggest that the group is more heterogeneous than the authors believe.
 Harvard the poster child of research is ranked #1 in research and #16 in primary care; University of Washington #1 in primary care is #12 in research
 Disclosure of conflict of interest – I did not graduate from Harvard’s medical school or residency programs.