Long working hours that cause fatigue, sleepiness, burnout and depression are a threat to the personal safety of medical residents, according to a Mayo Clinic study published this month. Working conditions associated with these characteristics are linked to motor vehicle crashes and near crashes, and may contribute to exposure to blood and body fluids on the job.

In the survey of 340 internal medicine residents in training at the Mayo Clinic, 168 respondents (56%) reported a motor vehicle incident during their training. Of those incidents, 34 were motor vehicle crashes, and 130 were near misses. Sixty residents reported falling asleep while driving, and 53 reported falling asleep while stopped in traffic. Residents attribute these incidents to diminished quality of life, exhaustion and depression, and fatigue and sleepiness, the study finds.

Residents also reported exposure to blood and body fluid during their training, some of which was attributed to fatigue. The researchers call the rates “reassuringly low,” but caution that “it is not possible to definitively rule out associations of distress with [blood and body fluid] exposure.”

“These findings indicate that resident distress is related not only to patient safety and quality of care but to residents’ personal safety as well,” the study says. “In addition to ongoing efforts to limit physician fatigue and sleepiness, interventions to promote well-being and reduce distress among physicians are needed to improve both patient and resident safety.”

Read the study.

Two new studies show the nation’s younger primary care physicians may find it hard to recover from their medical school debt.

Primary care physicians who graduate with a median amount of debt and have a salary that is typical for the field can pay off their debt within 10 years, even if they live in a high cost residential area, according to a study from researchers at Boston University and the American Association of Medical Colleges, published in Academic Medicine. But young primary care doctors with debt that is above average—$200,000 or more—may have to employ “trade-offs and compromises” to support their repayment. These may include: extended repayment plans, increasing the interest repaid and the number of repayment years, living in a lower-cost area, or joining a federal loan forgiveness program that requires a service obligation such as practicing in a medically underserved area.

There are more sobering statistics for primary care doctors: a study in the Journal of the American Medical Association finds their earnings have grown more slowly than the salaries of other health care professionals. From 1987 to 2010, the average doctor’s earnings grew 9.6 percent; pharmacists’ earnings increased by 44 percent, and dentists earnings grew by 23 percent.

“It is possible that there are some specialties that have done extremely well in the past 10 or 15 years,” Amitabh Chandra, PhD, study co-author and Robert Wood Johnson Foundation Health & Society Scholars program faculty member at Harvard University, told Reuters Health. The slow growth for doctors—compared to other medical professions—is most likely due to lagging salaries of primary care physicians, he said. "If as a country we want more people to go into primary care, this anemic, jaundiced earnings growth is not going to be a motivator to get people to join primary care.”

What do you think? Should more be done to help medical students who go into primary care lower or repay their debt? Are slow-growing salaries a deterrent for medical students to enter this field? Register below to leave a comment.

Read the study in Academic Medicine.
Read the study in the Journal of the American Medical Association.

Michael D. Cohen, PhD, is the recipient of a Robert Wood Johnson Foundation (RWJF) Investigator Award in Health Policy Research, and the William D. Hamilton Professor of Complex Systems, Information and Public Policy at the University of Michigan School of Information.

Handoffs are a critical link in maintaining continuity of care during a hospital stay. Whenever there is a shift change, or when a patient moves between departments (such as from an Emergency Room to an inpatient unit), there should be communication between the personnel who have been caring for the patient, and those who are to assume responsibility. These handoffs have to be done effectively. Root cause analyses of sentinel events find communication breakdowns to be major contributing factors nearly two-thirds of the time, and a large fraction of those problems occur during handoffs.

It seems logical that nurses and doctors should receive some training in how to conduct these vital conversations, but in interviews during my research on handoffs, it has been rare to find a practitioner who learned anything in nursing or medical school about how to hand off effectively.

The United States will need 52,000 additional primary care physicians by 2025 to meet demand that is growing due to three trends: population growth, population aging and insurance expansion. That is a key finding from a study published in the November/December issue of the Annals of Family Medicine. The researchers estimate that population growth will account for the majority of the needed increase in primary care doctors.

Given the current number of visits to primary care physicians and an expected population increase of 15.2 percent, the researchers predict that office visits to primary care physicians will increase from 462 million in 2008 to 565 million in 2025. This trend will be especially evident among people 65 and older, a segment of the population that is expected to grow by 60 percent. Population growth will require an additional 33,000 physicians, the study says, and aging another 10,000.

Insurance expansion under the Affordable Care Act will also require additional physicians, the researchers find. Eight thousand physicians will be needed to meet that growth.

The 52,000 additional primary care physicians would represent a 3 percent increase in the workforce.

Read the study.

A report from the consulting firm Accenture finds a significant drop in physicians who practice independently, from 57 percent in 2000 to 39 percent in 2012. Business costs and expenses were the top concerns influencing physicians’ decision to seek employment (cited by 87 percent of survey respondents).

For those who remain independent, alternative business models are becoming more common. Accenture estimates that one-third of independent physicians will adopt subscription-based care models, like high-end concierge medicine and direct pay models.

“Doctors who convert to subscription-based models that shift the focus away from service volume will not only access greater financial rewards, but will also gain the flexibility to get back to the basics of patient care,” the report says. “Patients could also reap the rewards by gaining enhanced access to care at a service level they can afford.”

Accenture estimates that only 36 percent of physicians will be practicing independently by the end of 2013.  The survey of 204 physicians who represented an equal split of primary care and specialty physicians was conducted in May.

Read the report.

New data from the Association of American Medical Colleges (AAMC) finds a 3.1 percent increase in the number of students applying to medical school this year. First-time applicants also increased (3.4 percent), which helped bring first-time enrollment at the nation’s medical schools up to an all-time high.

AAMC’s enrollment and applicant data also finds that this year’s entering class of medical students is more diverse than last year. There was an increase in applications and enrollees in all major racial and ethnic groups, and record high numbers for African American and Latino students.

If this year’s trends continue, medical schools are on track to increase total enrollment 30 percent by 2016, AAMC says.

“Medicine continues to be a very attractive career choice for our nation’s best and brightest,” Darrell G. Kirch, MD, AAMC president and CEO, said in a news release. “Given the urgent need our nation has for more doctors to care for our growing and aging population, we are extremely pleased with the continued growth in size and diversity of this year’s entering class of medical students.”

Read the news release.
See the data.

Large population centers like Las Vegas and Detroit are feeling the effects of the nation’s physician shortage, Bloomberg News reports, which is no longer limited to rural areas. Patients in populous urban areas are waiting weeks—or even months—or traveling to find the care they need.

Many factors are contributing to the shortage, including an aging physician workforce that is reaching retirement, and not enough new doctors in the pipeline to replace them and care for an influx of patients with increasingly complex health care needs.

Doctors also tend to stay near where they train, the story reports, creating poor distribution in states like Nevada that don’t have large medical schools or training hospitals. Census Bureau data shows that Nevada has the fifth-lowest ratio of doctors to patients in the country, behind Wyoming, Mississippi, Oklahoma and Idaho.

One possible solution: other health care professionals. “In a bid to address the shortage, the medical community has embraced the greater use of nurse practitioners and physician assistants, who can prescribe medicines and diagnose and treat many illnesses,” the story reports.

What do you think? What steps will convince physicians to practice in underserved areas? Register below to leave a comment.

Read the Bloomberg News story.

Every year, fourth-year medical students anxiously await “Match Day,” when they learn where they will complete their residencies. But long before they receive their sealed envelopes, an algorithm is at work matching them with schools based on their own rankings and those of the institutions to which they are applying. This week, two men responsible for that algorithm were recognized with the Nobel Prize in Economic Sciences.

In the 1950s and 60s, Lloyd Shapley, PhD, helped create the main concept of “pairwise matching,” or how individuals can be paired up if they have different views regarding who would be the best match. His model was the basis for the National Resident Matching Program (NRMP).

Alvin Roth, who worked independently of Shapley but had closely studied the algorithm as well as other countries’ medical markets, helped redesign the NRMP in 1995 to take into account married couples searching for residencies in the same region or at the same hospital, and to eliminate the system’s bias for hospitals over students.

The new system is still used today, and helps match more than 20,000 positions a year. The scholars’ work is also used to match students to high schools and to match up kidney donors.

Read a press release about the prize.
Read more about Roth and Shapley’s work.
Read a New York Times story about Roth and Shapley.

In the next one to three years, more than half of the nation’s physicians plan to retire, cut back on the number of patients they see, work reduced hours or take other steps that would reduce patient access to care, a survey from The Physicians Foundation finds. According to A Survey of America’s Physicians, which polled more than 13,000 physicians, a continuation of this trend could mean the loss of 44,250 physicians from the workforce in the next four years.

The survey finds that physicians are seeing fewer patients per day than they did in 2008, and 26 percent of physicians have closed their practices to Medicaid patients. Fifty-two percent have already or are planning to limit Medicare patient access to their practices.

More than three-quarters (77.4 percent) of the physicians surveyed are somewhat or very pessimistic about the future of the medical profession, and more than 84 percent agree that “the medical profession is in decline.” However, younger physicians, female physicians, employed physicians (as compared to those who own practices) and primary care physicians are generally more positive about their profession.

“The survey was conducted in the context of one of the most transformative eras in the history of modern healthcare,” the introduction to the study notes. “Physicians are at the vortex of these changes… It is a challenging and uncertain time to be a doctor. The results of the survey reflect this uncertainty and should be taken in the context of current events. As the course of healthcare reform becomes clearer, attitudes and perspectives may change. However, we believe the survey reveals what doctors are thinking today and is relevant to healthcare professionals, policy makers, media members, and to anyone who has been seen by a physician or who will be.”

Read the survey.

Feeling financial pressure to pay back student loans, medical students are choosing higher-paying specialties over primary care to secure higher incomes, according to a study published in Medical Education. In the 18-year-long study, researchers found that 31 percent of medical students who originally aspired to enter primary care had switched to a higher paying specialty by graduation.

The study, which followed more than 2,500 medical students at New York Medical College and the Brody School of Medicine at East Carolina University, asked students about their debt, income and career choices. Students were asked during their first year of medical school, and again in their fourth, to estimate their debt and anticipated income. They also rated how important income was to them, in terms of living comfortably, providing for their families and having an “adequate financial reward for the years of training required.”

The researchers found that students intending to pursue specialties anticipated higher debt, placed a greater importance value on income, and anticipated higher earnings after graduation than their primary care counterparts. They note that students interested in primary care were not altogether without income concerns, but those who did not switch before graduation may have rationalized their choice “by convincing themselves that income is less important than they originally believed.”

“Although many factors influence career choice, money is a significant concern,” the study says. “Medical students in the USA are graduating with increasing levels of debt and debt load appears to be pushing students toward higher-paying careers… Long-term legislative solutions may have to include more substantial corrections of specialty-specific income expectations and forgiveness of debts for those entering [primary care] careers.”

Read the study abstract.