Category Archives: Medical students and residents
The news media has recently covered some innovative programs that are influencing the choices and attitudes of the next generation of doctors.
American Medical News reports on the Buddy Program, which pairs first-year medical students with early-stage Alzheimer’s patients and their caregivers. The program empowers patients, and also serves as a valuable learning tool for the students, heightening “their sensitivity and empathy toward people with the disease.” The program was developed at the Northwestern University Alzheimer’s Disease Center in Chicago; Boston University, Dartmouth College, and Washington University have replicated it.
NPR reports on a program at the University of Missouri School of Medicine that is encouraging more young doctors to pursue primary care in rural areas. During the summers, the school has been sending medical students to work alongside country doctors. While school officials caution they can’t be sure about the reasons, they have discovered that students who took part in the summer program were more likely to become primary care doctors who practice family medicine. Some 46 percent of participants are choosing to work in the country after completing their medical training.
The U.S. Department of Health & Human Services (HSS) last week announced that it will support twice as many primary care residencies during the 2013-2014 academic year as it supported last year, thanks to $12 million in funding from the Affordable Care Act. The new funds will support more than 300 residents at community-based Teaching Health Center programs across the country.
“Teaching Health Centers help attract students who are committed to serving communities of need and prepare them to practice in these communities,” HHS Secretary Kathleen Sebelius said in a news release. “Students exposed to training opportunities in health center settings are more likely to stay in these communities and continue to contribute to the care of their residents.”
Residents will be trained in family and internal medicine, pediatrics, obstetrics and gynecology, psychiatry, and general and pediatric dentistry.
First-year surgical interns are getting less experience performing or assisting with surgeries as a result of the 16-hour workday cap enacted in July 2011 by the Accreditation Council for Graduate Medical Education, according to a study in JAMA Surgery.
In a review of 10 West Coast general surgery residency programs, researchers found 2011-2012 interns recorded a 25.8 percent decrease in total operative cases as compared with the preceding four years before the cap was enacted. There was also a 31.8 percent decrease in cases performed primary by the interns, under faculty supervision, and a 46.3 percent decrease in cases in which the interns assisted a faculty member.
“The decline in operative case volume in our present study is in some respects surprising given that the new duty-hour changes did not mandate a reduction in an overall 80-hour work week for interns,” the researchers write. “Thus, interns were presumably working the same number of total hours.” The program directors surveyed in the study reported that their predominant solution to the 16-hour rule was to expand the “night-float” system, meaning interns are increasingly working overnight when there are fewer intern-level, elective surgeries taking place.
Graduate Medical Education Funding Is Not Helping Solve Primary Care, Rural Provider Shortages, Study Finds
From 2006 to 2008, 158 of the country’s 759 residency sponsoring institutions and teaching sites did not produce any primary care graduates, according to a study published online last week by Academic Medicine. Less than one-quarter of medical school graduates entered primary care during those years.
The study also found that physician shortages in rural and underserved areas persist; only 4.8 percent of 2006-2008 graduates practice in rural areas. Nearly 200 institutions produced no rural physicians, more than half produced no Health Service Corps graduates, and 283 produced no physicians practicing at Federally Qualified Health Centers or Rural Health Clinics.
Graduate medical education (GME) distribution is uneven, the researchers found, and provides more support to subspecialty programs than to primary care programs. The top 20 primary care producing institutions (where 41 percent of graduates were in primary care) received $292 million in total Medicare GME payments, while the bottom 20 (where only 6.4 percent of graduates were in primary care) received $842 million in these funds.
Italo M. Brown, MPH, is a third year medical student at Meharry Medical College. He holds a BS from Morehouse College, and an MPH in epidemiology and social and behavioral sciences from Boston University, School of Public Health. He is a Health Policy Scholar at the Robert Wood Johnson Foundation Center for Health Policy at Meharry Medical College.
In an ad-hoc poll among classmates, I recently inquired about the most important date (in 2013) to a second year medical student. The overwhelming majority of respondents cited their respective STEP 1 exam dates as most important, followed closely by the season finales of ABC’s Scandal and Grey’s Anatomy. While the top three responses are noteworthy, the one date that should bear the most gravity in the minds of medical students across cohorts is October 1st.
This October marks the launch of open enrollment for health insurance exchanges, a much-anticipated provision of the Affordable Care Act (ACA). The ACA seeks to reduce the number of nonelderly uninsured Americans by half; in other words, a projected 20 million new patients will enter the health care system over the next 18 months.
In 2011, the Accreditation Council for Graduate Medical Education (ACGME) limited shifts for first-year medical residents, or interns, to 16 hours, in an effort to improve their well-being. But two studies published online this week in the Journal of the American Medical Association (JAMA) find that these regulations may not be improving resident well-being—and that they may be decreasing both the quality of care they provide and their educational opportunities.
Although interns worked fewer hours after implementation of the shift length restriction in 2011, researchers found no change in their sleep duration or symptoms of depression. That study, led by Srijan Sen, MD, PhD, of the University of Michigan in Ann Arbor, also found an increase in self-reported medical errors among interns (from 20% in 2009 to 23% in 2011). The researchers hypothesize that the increase in errors may be due, in part, to interns having to perform more handoffs—where medical errors are known to occur—and to a lack of additional clinical staff that may mean “residents [are] expected to complete the same amount of work as previous cohorts but in less time.”
Another study, led by Sanjay V. Desai, MD, of Johns Hopkins University, also found “unintended consequences” of duty hour regulations. Although that study found more consistent sleep patterns for interns, it also found that nurses, as well as the interns themselves, believed the quality of patient care suffered. Desai’s research team found a concerning balance between the interns’ workload and their time spent on educational activities. “Concerns have been raised about the competency achievable with less hospital experience during any fixed duration of training,” they write. “Opportunities were reduced with restricted shifts, many of which occur solely during evening hours, precluding participation in traditional core educational components of medicine residency programs, such as noontime conference and morning rounds.”
More U.S. medical students “matched” to primary care residency positions this year than in 2012, according to data from the National Resident Matching Program (NRMP). Almost 400 more students chose primary care fields— internal medicine, family medicine, and pediatrics—than last year. NRMP is a private, non-profit organization established in 1952 to provide a mechanism for matching the preferences of applicants for U.S. residency positions with the preferences of residency program directors.
Of the 17, 487 graduating seniors who participated in Match Day 2013, 3,135 matched to internal medicine—a 6.6 percent increase from last year. The number of seniors who matched to pediatrics (1,837) represents a 105 percent increase over last year.
This year’s Main Residency Match was the largest in NRMP history, with more than 40,000 student and independent registrants. NRMP attributes the increase to three new medical schools graduating their first classes, and expanded enrollment in existing medical schools.
Conducted annually by the NRMP, The Match uses a computerized mathematical algorithm to align the preferences of applicants with the preferences of residency program directors in order to fill the training positions available at U.S. teaching hospitals.
A report from the Association of American Medical Colleges (AAMC) documents an overall trend toward increased diversity among students applying to medical school.
AAMC’s Diversity in Medical Education: Facts and Figures 2012 finds that nearly half of the applicants to U.S. medical schools in 2011 were non-White. Whites were the largest group of applicants, followed by Asians. “Compared with 2010, in 2011 the percentage of Hispanic or Latino applicants increased by 5.7 percent and the number of Black or African American applicants grew by 5 percent,” the report says.
But only 2.5 percent of medical school applicants in 2011 were Black men. Twice as many Black women as men applied to medical school that year, creating the biggest gender gap in medical school applicants among all racial or ethnic groups.
“We have a major, major problem in this country,” Marc Nivet, EdD, AAMC’s chief diversity officer, told American Medical News. “There is just simply an enormous amount of indisputable evidence that we’re not intervening as effectively as we’d like as a society to increase the talent pool of African-Americans who are capable of taking advantage of the science curricula available up and down the pipeline.”
Two newly published studies examining different aspects of physician workforce trends suggest that the long-expected shortfall in primary care physicians could be averted or lessened.
A study in Pediatrics finds pediatric residents are more likely to consider primary care or hospital practice––rather than a subspecialty that requires additional training––if they have more educational debt. The researchers found that residents with at least $51,000 in debt were about 50 percent more likely to be planning a primary care or hospitalist career than residents who owed less or no money, Reuters reports. They also found that educational debt rose 34 percent from 2006 to 2010 for pediatric residents.
While an unintended consequence of student loan debt may be that it helps relieve the primary care shortage, another recent study in Health Affairs casts some doubt on the severity of that shortage. Most existing estimates of the primary care physician shortage are based on a simple ratio of one physician for every 2,500 patients, the study says, which does not take into account changing patient demographics and alternative care-delivery methods. The researchers found that the use of health care teams and non-physicians, as well as improved information technology and data-sharing have “the potential to offset completely the increase in demand for physician services while improving access to care, thereby averting a primary care physician shortage.”
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.”