Category Archives: Medical students and residents
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.”
Human Capital News Roundup: RWJF’s 40th anniversary, graduate medical education, the New Mexico Hispanic Nurses Association, and more.
Around the country, print, broadcast and online media outlets are covering the groundbreaking work of Robert Wood Johnson Foundation (RWJF) leaders, scholars, fellows and grantees. Some recent examples:
The Philadelphia Inquirer reports on the Foundation’s 40th anniversary celebration last week, as well as some of its most notable accomplishments during its first four decades. Learn more about RWJF’s anniversary, and about the “Force Multipliers” it is saluting this year. The Foundation also announced ten winners of its first-ever RWJF Young Leader awards last week.
RWJF Physician Faculty Scholar Ruchi Gupta, MD, MPH, gave comments to Reuters about a study that finds babies are less likely to get eczema if their mothers take probiotics during pregnancy. Gupta, who was not involved in the research, calls the findings “fascinating.” Read a post Gupta wrote for the RWJF Human Capital Blog about her professional and personal experience with children’s food allergies.
Kristy Nichols, MS, an RWJF Community Health Leader, spoke to the Associated Press about cuts to Louisiana State University’s (LSU) hospital health care system, and proposed changes to the state’s graduate medical education training program.
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.”
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.
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.”
Many elite medical schools — Columbia, Cornell, Harvard, Johns Hopkins and Yale, among them — have no departments of family medicine to train students who want to specialize in primary care. Students interested in that field are instead trained to take care of seriously ill patients and are sometimes even discouraged by professors if they do not pursue a specialty, NPR reports.
But Mount Sinai School of Medicine in New York is making a “fundamental change” in its mission. Previously ranked among the bottom 20 medical schools in the country when it comes to the number of primary care doctors it graduates, Mount Sinai had neither a department nor any family physicians on staff until this June.
Now, thanks to a partnership with the Institute for Family Health, the school employs primary care doctors from the Institute’s community clinics to teach students during all four years of medical school, offering primary care students a chance to learn the skills they’ll need in practice.
"I want to spend my career keeping people healthy rather than trying to bring them back from a very serious illness," Mount Sinai student Demetri Blanas told NPR. "I think it is what society needs right now, and that is important to me."
Neil Calman, president and CEO of the Institute for Family Health, called the partnership “a natural marriage.”
"I think people are finally realizing that the country will be bankrupt if we continue to admit people and readmit people for conditions that could be prevented with good primary care," he told NPR.