Category Archives: Medical students and residents
Improvements to Dermatology Curriculum and Residency Training Could Improve Patient Safety, Study Finds
Modifications to curricula, systems, and teacher development may be needed to bring down medical error rates among dermatology residents, according to a study published online by JAMA Dermatology.
The survey of 142 dermatology residents from 44 residency programs in the United States and Canada draws attention to several areas of concern. According to the survey:
- Just over 45 percent of the residents failed to report needle-stick injuries incurred during procedures;
- Nearly 83 percent reported cutting and pasting a previous author’s patient history information into a medical record without confirming its validity;
- Nearly 97 percent reported right-left body part mislabeling during examination or biopsy; and
- More than 29 percent reported not incorporating clinical photographs of lesions sampled for biopsy in the medical records at their institutions.
Also, nearly three in five residents reported working with at least one attending physician who intimidates them, reducing the likelihood of reporting safety issues. More than three-quarters of residents (78 percent) have witnessed attending physicians ignoring required safety steps.
For the fifth consecutive year, the number of U.S. medical school seniors choosing internal medicine residencies has increased, according to 2014 data released by the National Resident Matching Program. However, at 3,167, the number is well below the 3,884 medical school seniors who chose internal medicine three decades ago, the internist-focused American College of Physicians (ACP) pointed out in a news release.
“While the number of U.S. medical students choosing internal medicine residencies continues in an upward trend, the exorbitant cost of medical education with the resulting financial burden on medical students and residents, along with problematic payment models and administrative hassles, are barriers to a career in general internal medicine and primary care,” ACP’s senior vice president for medical education, Patrick Alguire, MD, FACP, said in the release. “General internists and other primary care physicians are the heart of a high-performing, accessible, and high-quality health care system.”
Improved patient safety and educational environments at academic medical centers were the goals of work-hour reforms adopted for first-year residents in 2011. A study published online by the Journal of Hospital Medicine shows that progress on the patient-safety front has been slow going.
Researchers examined data on patients discharged from the Johns Hopkins Hospital in Baltimore from 2008 to 2012 and analyzed safety outcomes for those seen by resident and non-resident hospitalists. The analysis revealed no significant differences—before and after the 2011 reforms that reduced the maximum length of residents’ on-duty shifts from 30 hours to 16—in areas including length of stay, 30-day readmission, inpatient mortality, ICU admission, and hospital-acquired-conditions.
The study concludes that, as noted by the Institute of Medicine, improving patient safety requires a significant focus on keeping residents’ caseloads manageable, ensuring adequate supervision of first-year residents, training residents on safe handoffs in care, and conducting ongoing evaluations of patient safety and any unintended consequences of work-hour reforms.
What’s on the minds of this year’s medical school graduates? Among top concerns for the country’s future physicians are uncertainty about health care reform, practice choices, and debt repayment, according to the 2013 Medical School Graduation Questionnaire administered by the Association of American Medical Colleges (AAMC). Overall, most medical students say they are satisfied with their education.
The 2013 graduates in the new survey report an average premedical education debt of $11,849, which is about eleven percent more than students reported in 2012. This ends a four-year trend in which the average premedical debt had been decreasing. In addition, the 2013 graduates report an average medical education debt of $135,084—an increase of two percent from 2012 graduates. Nearly two in five graduates this year (38.1%) say they plan to enter a loan-forgiveness program.
Fewer than 2 percent of 2013 graduates say they plan to go into full-time solo practice. Twenty percent have their sights set on a group practice of three or more. Nine percent expect to pursue hospital work.
With a primary care provider shortage looming, medical schools are trying a new approach to get physicians into the workforce quickly: condensing medical education from four years to three.
Mercer University (Georgia), Texas Tech University, and New York University offer three-year primary care programs, and will soon be joined by programs in Tennessee, Indiana, University of Wisconsin, East Carolina, and Kentucky, MedPage Today and Fierce Healthcare report.
Most of the schools are shortening or eliminating fourth-year clinical rotations to consolidate their programs, leaving the first three years—which often focus on medical science—untouched.
"We chose to do it on the clinical end rather than [the] basic science end because, as long as Step 1 is [and] as important as it is, our students need to be fully prepared for it,” Betsy Jones, EdD, vice chair of research in Texas Tech's Department of Family Medicine, told MedPage Today. “We didn't make any changes to the curriculum that would threaten our students' ability to do well on [the United States Medical Licensing Examination]. The changes are really at the fourth year level."
A three-year program also saves medical students tuition money, and allows them to earn money in the workforce sooner than in a conventional four-year program, according to Fierce Healthcare.
There have been some unusual cooks in the kitchen at the Johnson & Wales University culinary institute in Providence, R.I., lately: medical students.
Doctors-in-training from Tulane University have been cooking alongside Johnson & Wales students for several weeks, NPR reports, to learn about nutrition. This unique program, which debuted this year and was organized by Tulane’s Goldring Center for Culinary Medicine, aims to change the way medical students think about food and, ultimately, how they will talk to future patients about nutrition and healthy eating.
Many health problems and diseases—like obesity and diabetes—could be prevented by lifestyle changes such as better eating habits.
"We basically learn how to take care of patients when things go wrong,” Neha Solanki, a fourth-year Tulane medical student, told NPR. “I think that we need to learn how to be able to make nutritious meals and to discuss diet in an educated manner."
In addition to the collaboration with Johnson & Wales, Tulane’s Goldring Center for Culinary Medicine has built relationships in its own community. Medical students help with an “edible schoolyard” program at local schools, and host hands-on cooking and nutrition education classes for community members at the nation’s first teaching kitchen affiliated with a medical school.
The Accreditation Council for Graduate Medical Education’s decision to limit the working hours of medical residents has not increased patient mortality rates, but it has decreased the time residents spend on direct patient care, according to two studies published in the August issue of the Journal of General Internal Medicine.
Researchers from the University of Pennsylvania studied 13.7 million Medicare patients admitted to hospitals between 2000 and 2008. In the first three years after the Accreditation Council enacted an 80-hour work week for residents in 2003, the researchers found no significant changes in patient mortality within 30 days of admission.
“We can reassure the public that patients did not appear to be harmed by the initial duty hour reform of 2003,” senior study author Jeffrey Silber, MD, PhD, told American Medical News. “We have published many papers prior to this looking at other outcomes [including prolonged length of stay following 2003 duty hour reform], and we have found similar results.”
A second change in resident hours came in 2011, when the Accreditation Council limited residents’ maximum shift length to 16 hours, down from 30. Researchers at Johns Hopkins University and the University of Maryland found that this change contributed to a reduction in the amount of time residents spent on direct patient care. Studies conducted in 1989 and 1993 found an average of 18 to 22 percent of residents’ time was spent on direct patient care; the new study finds residents only spent 12 percent of their time on direct patient care—or about eight minutes per patient, per day—in 2012.
Residents spent most of their time (64 percent) on indirect patient care tasks, such as talking with other health professionals, reviewing charts, and handoffs, the study concluded. Lead author Lauren Block, MD, MPH, told American Medical News that while residents aren’t spending as much time eating and sleeping at hospitals, “that time is not being made up spending time with patients, because they spend that time instead working at their computer stations.”
Richard Rieselbach, MD, is an alumnus of the Robert Wood Johnson Foundation Health Policy Fellows program and a professor emeritus and health policy consultant for the University of Wisconsin Medical Foundation.
In the last decade, the nation’s community health centers (CHCs) have doubled their capacity. They now provide care for more than 22 million underserved children and adults in every state. But they’re going to need to do it again. By 2019, some 40 million patients will be in need of care.
The United States does not have enough primary care providers to serve these new patients, and our public investment in health professions education—graduate medical education (GME)—is failing to produce the pipeline we need. Medical students are choosing specialties over primary care at an alarming rate, and a policy vacuum keeps the GME program from being held accountable.
An initiative was launched in 2011 that I think holds great promise: the Teaching Health Center Graduate Medical Education initiative. This five-year, $230 million program was funded by the Affordable Care Act and created to increase the number of primary care graduates trained in community settings.
My colleagues and I have proposed a modified and expanded version of this initiative, called “CHAMP” Teaching Health Centers (CHAMP THCs). Our teaching model would pair CHCs with academic medical centers to develop a THC track that would encourage students to graduate in primary care and practice in urban and rural underserved areas.
Human Capital News Roundup: The cost of overtriaging, ‘medical students’ disease,’ the demographics of new Medicaid enrollees, 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, alumni, and grantees. Some recent examples:
People who will be newly eligible for Medicaid after expansion under the Affordable Care Act will be younger and healthier than those currently enrolled in the program, according to a study by RWJF Clinical Scholars alumna Tammy Chang, MD, MPH, and program site co-director Matthew Davis, MD, MAPP. The researchers found that the new Medicaid enrollees will also be less likely to be obese or to suffer from depression, although more of them will be smokers and drinkers. Among the outlets to report on the findings: Reuters, Kaiser Health News, NBC News, NPR’s Shots blog, and Medpage Today.
Medpage Today reports on a study led by RWJF Physician Faculty Scholars alumnus Craig Newgard, MD, MPH, finding that nearly one-third of patients sent to major trauma centers by first responders did not need that level of care and could have been sent elsewhere for diagnosis and treatment. This “overtriaging" raises per-patient health care costs by as much as 40 percent, the study finds. Read more about it.
While in Australia for a conference on reforming health care systems to meet the challenges of aging populations, RWJF Harold Amos Medical Faculty Development Program alumna Alicia Arbaje, MD, MPH, sat down for two interviews—one with The Australian Financial Review on how stereotypes about aging are changing, and one with Australian Broadcasting Corporation Radio about transitional care and reducing readmissions among older adults after they leave hospitals. Read a post Arbaje wrote for the RWJF Human Capital Blog about navigating care across settings and the role of caregivers.
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.