Training program directors and patient advocates have voiced concerns for years that residents who toil for long shifts on-the-job could harm patients because fatigue increases the risk they will make errors of one sort or another.

A 6 year-old study by the Accreditation Council for Graduate Medical Education gave credence to their concerns by showing that the fatigued residents  caused more than half of all preventable adverse events.

In response, the ACGME recently proposed strict new guidelines which would, if adopted, curtail the duration of residents’ shifts and increase supervision requirements for those in charge of their care. The plan extends previous initiatives by the ACGME to limit the work hours of residents.

The new guidelines were published in the New England Journal of Medicine and are subject to a 45-day public comment period.

The fundamental components of the ACGME’s proposal are 16-hour shift limits for first-year residents and 24-hour limits for those in later years of training.  Current rules permit residents to work for as many as 30 consecutive hours.

Also included are instructions about the supervision of interns by residents, and beefed-up monitoring and enforcement of the guidelines including annual site visits of each program.

In a replay of what happened the last time ACGME addressed the subject, some physicians and patient advocacy groups said the new guidelines didn’t go far enough. These groups pointed out that the guidelines weren’t as far-reaching as the changes recommended by the Institute of Medicine in 2008.

Meanwhile, some physicians argued the new limitations would impede the educational process and result in more errors…the kind that occur during hand-offs in care at the ends of shifts. Hopefully, some well designed studies of the matter can add value to the debate once (and if) the new guidelines go into effect.

Sales of soda and other drinks have dropped sharply since 2004 in US secondary schools, according to a report by carried out by Keybridge Research on behalf of the American Beverage Association.

To reach this conclusion, Keybridge surveyed 12 bottlers responsible for nearly 90% of all drink shipments to schools on behalf of drink-makers Coke, Pepsi, and Dr Pepper Snapple Group.

Keybridge found overall beverage sales volume to schools has dropped 72% in the last 6 years. There was a 95% decline in sales for full-calorie soft drinks, and a 94% decline in sweetened juice drinks. Full-calorie soft drinks made up less than 7% of total beverage volume shipped to schools last fall. They comprised 40% of the product mix in 2004.

Overall, beverage calories shipped to schools fell 88% during the study period.

State and local regulations are responsible for some of the fall-off, but the beverage companies and their bottlers are to be commended for adopting voluntary guidelines in this regard in May, 2006.

Back then beverage makers and bottlers joined an alliance comprised of the American Heart Association and the William J. Clinton Foundation to fight childhood obesity. In that agreement, the companies pledged to completely eliminate sales of full-calorie sodas to schools by this year, and to ship lower-calorie options in smaller portion sizes instead.

At the beginning of this shool year, 99% of school districts were found to be in compliance with the guidelines, according to Keybridge.

The beverage industry has made “a very strong good faith effort to get full-calorie soft drinks out of schools” Margo Wootan, director of nutrition policy for the Center for Science in the Public Interest, told the Wall Street Journal.

Medical students begin losing empathy after their first year in school, and the decline accelerates after clinical rotations, according to a study in Academic Medicine.

To reach these conclusions, Bruce Newton and colleagues followed 419 medical students from four consecutive classes from freshman through senior year at the University of Arkansas for Medical Sciences.

Researchers assessed vicarious empathy, which is a person’s emotional response to the perceived emotional experiences of others. Using a 9-point scale, they asked students to agree or disagree with statements like, “I cannot feel much sorrow for those who are responsible for their own misery.”

The scientists found that student empathy scores dropped after the first year of medical school and then again after the third year. Female students turned in higher empathy scores than their male counterparts, and students entering primary care showed more empathy than those entering pathology, radiology and surgery.

They attributed the early decline in empathy to stress and anxiety associated with students’ competitiveness and worry about exam scores. The late decline was assumed to be caused by the intensity of hospital practice. Teaching on the wards was likely to have been rushed, and students may not have received as much mentoring or bedside teaching as they wanted.

“We know that really good communication skills (helps) patients…to comply with the instructions of the physician,” said Newton. “A bond of trust is established, and if something unfortunately goes wrong, if you have this bond, you are less likely to be sued.”

“We start with students who are very caring but have no diagnostic skills and end up with physicians with great diagnostics skill but who don’t care,” summed up Richard Frankel a professor of medicine at Indiana University School of Medicine, for AMedNews.

Lincoln University, a historically black college located west of Philadelphia, requires that overweight students take a fitness course if they want to graduate, and that’s not sitting well with a number of students.

The rule was enacted 4 years ago. It requires that students get their body mass index checked, and those found to be obese—a BMI of 30 or higher—must take a class called “Fitness for Life,” which meets three hours per week.

The course involves physical activities including walking and weight training as well as information on nutrition and stress management.

James DeBoy, chairman of the Lincoln’s department of health said the school had become concerned about high rates of obesity and diabetes in the African-American community.

“We’re in the midst of an obesity epidemic,” he told MSNBC. “We have an obligation to address this head on.”

Protests bean last week when seniors—who are the first class affected by the new rule—began realizing they were running out of chances to meet the requirement.

Senior Tiana Lawson wrote in the student newspaper that she “didn’t come to Lincoln to be told that my weight is not in an acceptable range. I came here to get an education.” Lawson added that she has no problem with the general concept so long everyone must take the class.

As of this fall, about 80 seniors — 16% of the class — had neither had their BMI tested nor taken the class. At least some of them are expected to be cleared because they are not obese, officials said.

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UPDATE: After this post was written and scheduled for publication on Pizaazz, faculty at Lincoln decided to nix the idea of a required “fat course.” So obese students at Lincoln can now graduate without taking the class. 

In lieu of the requirement, the school will “suggest” to certain students that they enroll in a “Fitness for Life” class.

Comprehensive, school-based sex-education programs that teach teens about contraception and encourage them to delay sexual activity increase condom use and lower the risk of contracting sexually transmitted diseases including HIV, according to a panel appointed by the CDC.

But the panel concluded there isn’t enough evidence to endorse programs focused more narrowly on encouraging sexual abstinence until marriage.

The 15-member Task Force on Community Preventive Services reached these conclusions after reviewing 83 studies of such programs that were run between 1980 and 2007.

“Evidence and common sense have returned to public-health policy,” James Wagoner of Advocates for Youth told the Washington Post. “The report endorses a comprehensive approach to prevention that includes condoms and birth control. We should be spending taxpayer dollars only on evidence-based programs.”

Alas, 2 panelists, Irene Erickson of the Institute for Research and Evaluation and Danielle Ruedt of the Georgia Governor’s Office of Children and Families disputed these conclusions.

According to them, “the data indicated that many types of [comprehensive] programs do not work. Unfortunately, the report’s conclusion ignores these findings. This is misleading to policymakers who are seeking evidence-based programs, especially for schools.”

Answering these claims, panelist Randy Elder, who also works for the CDC, argued that the critics’ case was incorrect.

“Those points…reflect a misunderstanding of a systematic review process,” he said. “The whole point of what we are doing is to aggregate data from many studies that are critical to answering the question. What they were doing was chopping up the evidence into fine subsets to poke holes.”

More than a third of surgical residents think that regulations designed to limit their work schedules to a maximum of 80 hours per week represent a “significant barrier” to their training. And 43% of them want to work more hours than the regulations permit.

To reach these conclusions, Jacob Moalem and colleagues at the University of Rochester distributed a Web-based survey to all surgical residents and associate members of the American College of Surgeons.

Of the nearly 600 respondents, 41% said the rules were a “considerable or moderate barrier” to their training. Less than a third said the rules did not hinder their training. An additional 27% said the rules were a minimal barrier.

Senior residents were more likely to view work time restrictions as a barrier to their training, regardless of whether they trained at small, medium, or large programs.

The write-up appears in the Journal of the American College of Surgeons.

“Surgeons are expressing a desire and a need to learn more in a compact time frame,”  Moalem told BurrillReport. “Senior surgery residents should be given the chance to control their own schedules as they continue to refine their technical skills and transition into independent practice.”

The regulations had been implemented to address resident burn-out and improve patient safety. It had been the norm for surgical residents to log 100+ hours per week before the change.

The regulations have been shown to increase the number of hours residents sleep each week, and there have been anecdotal reports that their personal lives have improved, but their effect on caseload, academic performance, and board scores is not well understood.

Beyond this, some studies have suggested that the shorter work-weeks have led to more communication errors caused by more frequent patient handoffs, according to the scientists.

There once was a time when college students asked classmates or TAs for help when it came time to prepare for exams.

Now it seems, these tried and true resources have been replaced by Web sites which offer answers to textbook problems, copies of old exams, lecture notes, and on-line help from paid experts among other things.

“Many professors won’t tell you how you got (something) wrong — just that it’s wrong. This way you complete the feedback process, which is essential to learning,” Columbia sophomore Chris O’Connor explained to the New York Times.

On Course Hero for example, students can access 3 million student-submitted items from 400,000 courses at more than 3,500 schools, including study guides, lecture notes, lab results, presentations, essays, research papers, and homework assignments.

Those who submit the goods can navigate Course Hero for free. Everyone else forks over a monthly fee. The site has several hundred thousand users.

On Cramster, 500,000 visitors have sought answers to science and math textbook problems. Answers to odd-numbered problems are free, but for those particularly tricky even-numbered problems, students must pay $9.95 per month.

Advocates for the Web sites, which include some professors, argue that many documents housed on the sites have been accessible to fraternity and sorority members since Animal House.

David Sachs, an associate dean at Pace University who has joined Cramster’s advisory panel, argues that “if Cramster and all these companies disappeared tomorrow, you could still do a Google search and find what you’re looking for in 5 minutes.”

And William Kinney, a Physics professor at SUNY Buffalo believes the system is “self-policing.” “If the students just copy down answers to the homework, they will not do well on the exam,” he told the Times.

With the dentist shortage nearing crisis proportions in Maine, 2 of the state’s primary care residencies have begun to train physicians how to do simple dental procedures like lancing abscesses and pulling teeth.

The Pine Tree state has 4 times more physicians than dentists and that means there’s  only one dentist for every 2,300 people.

The national average is a dentist per 1,600 people.

“Doctors typically say, ‘say aah,’ take a look at the back of the throat and are done,” William Alto told the New York Times.  Alto is a physician at the Maine Dartmouth Family Practice Residency in Fairfield, home to one of Maine’s dental clinics for medical residents.

Maine is a largely rural state and dental school grads are even less prone to opt for such practice settings than their med school brethren. It doesn’t help that the state has no dental schools; the closest ones are in Boston, an hours’ drive with a tailwind from the state’s southernmost point.

Since Maine’s dental training programs began in 2005, 2/3 of residents graduating from these particular programs have set up shop in rural or remote areas.

“I see dental complaints all the time,” Andrew Fletcher confirmed for the Times. Fletcher learned some dentistry during his medical residency and now works up near the Canadian border.

“It’s mostly Medicaid patients who don’t have money to see dentists,” he added.

The Maine Dental Association supports the program but would rather recruit real dentists to the state. Said executive director Frances Miliano, “medical residents are only going to be doing this in dire circumstances. It’s not a total solution by any means.”

Four years ago a Harvard Medical School student smelled a rat when his pharmacology lecturer waxed on and on about the benefits of cholesterol busting drugs and then came on a bit too strong towards a classmate who had queried about their side effects.

Matt Zerden did a little snooping and it turned out the professor was bankrolled by 10 drug companies including 5 that made cholesterol drugs.

One thing led to another and now 200 HMS students and a handful of sympathetic faculty are on a mission to expose and limit industry influence in the classroom and who knows, maybe the labs and HMS’ 17 teaching hospitals as well.

This hasn’t phased HMS dean Jeffrey Flier who actually agrees things need to be tightened up a bit. He just tasked a committee to look at the school’s conflict-of-interest policies.

Flier had received a research grant for half a mil from Bristol-Myers Squibb and had consulted to 3 Cambridge biotech firms before accepting his new position 17 months ago. He unclipped those links before signing on as dean and hasn’t forged any new ones since.

According to the New York Times, that’s in contrast to his predecessor Joe Martin, who sat on Baxter International’s board for 5 years while he was in at dean for HMS.

For his efforts, Martin received up to nearly $200K a year from Baxter, piled nice and high on top of his HMS salary.

The activist HMS students have already secured passage of a blanket policy requiring that lecturers disclose industry ties in class, but this is an uphill battle.

For example, 1,600 HMS lecturers have told the dean either they or a family member have financial ties to a business related to their patient care, teaching or research.

And then there are the industry-endowed chairs, faculty prizes in the name of drug companies, Big Pharma-subsidized training programs taught by faculty on the take from…Big Pharma, and so on.

People who want to go to medical school take note.

A quarter of 2008 US medical school graduates have accumulated debt of $200,000 or more. And although only a third entered medical school with some degree of debt, 87% were in debt when they graduated, according a report by the Association of American Medical Colleges.

Annual medical school costs including tuition and living expenses exceed $62,000 per year. The number is $44,000 for those attending public medical schools.

Med students received $2.5 billion in financial assistance between 2006 and 2007, but only 20% was in the form of grants and scholarships, including assistance based on need and that which requires service payback, such as the National Health Service Corps and the military. 

The rest of it was in the form of loans.

Some medical schools recently bucked the trend by announcing scholarships. Yale Medical School for example no longer requires payment from students whose annual family income is less than $100,000.

But few schools have resources to support programs like this, and it hasn’t helped that the Great Economic Crisis of ’08-’09 has pummeled university endowments. 

Can the situation continue like this forever? In 2008, US medical schools enrolled over 18,000 students, which is more than ever. And twice that many applied.

But the prospect of enormous debt dissuades some from applying and more often than not it’s people from low-income families that back off.

As Robert Steinbrook noted in the New England Journal of Medicine, economic diversity in medical school is morally just and believed to improve patient care and access down the road.

But even now more than 50% of US med students come from families with incomes in the top 20%.

Medical and surgical residents aren’t stocking up on flannel pajamas just yet, but if an expert panel commissioned by the Institute of Medicine has its way, they will be working no more than 16 consecutive hours before qualifying for 5 hours of rack time.

In commenting on the shift-length reductions for the Washington Post, panel chief Michael M. E. Johns said “our overarching conclusion is that the science clearly shows that fatigue increases the chances of (medical) errors.”

Excessive fatigue has direct negative effects on residents as well, increasing the risk of depression and auto accidents for example.

In 2003 the Accreditation Council for Graduate Medical Education announced it would allow shifts of up to 30 consecutive hours while setting at 80 hours an upper limit on the work week.

The IOM panel did not suggest reducing the 80 hour work week because the replacement manpower simply isn’t there and if it were, putting all those new people to work would cost billions.

Meanwhile, flaunting ACGME rules has become an art form. That first year after the rules went into effect for example, 43% of interns claimed they worked more than 80 hours per week on a regular basis.

A more recent study from Vanderbilt found that 85% of residents had violated the 30-hour shift maximum during in the last year.

The expert panel acknowledged that shift limit manipulations have complex effects on the quality of care. In particular, reductions in errors caused by fatigue might be offset by increases in errors that transpire during patient “handoffs” at the change of shift.

And the news wasn’t all good for residents. The panel also wants to reduce allowable moonlighting hours meaning some won’t pay off their school loans until they’re old enough to qualify for social security.

The Institute for Healthcare Improvement’s long awaited National Network Day is today. The event will feature dozens of collaborative learning opportunities and will offer participants a chance to celebrate progress towards some laudable goals.

IHI describes the event as an interactive series of web-based virtual learning sessions that will highlight some of the best and most innovative quality improvement and patient safety work in extant. National leaders will share successful strategies to reduce patient falls, hospital infections, complications due to anticoagulant therapy and readmissions. There will also be sessions aimed at refining the business case for quality.

National Network Day runs from 11:30AM to 5:30PM EST. Pre-registration is not required. Interested parties can access the event through WebEx (found here).

The event is one of many initiatives spawned by the IHI’s 5 Million Lives Campaign, whose aim is to support the improvement of medical care in the US and in particular to reduce morbidity and mortality in US hospitals.

As part of the Campaign, the IHI challenged hospitals to prevent 5 million incidents of medical harm over a 2-year period. The IHI estimates there are 15 million such incidents each year.
 
The 5 Million Lives Campaign is an expansion of an earlier initiative, the 100,000 lives campaign. In that effort, the IHI and partner organizations worked with 3,100 facilities and saved, according to IHI, “an estimated 122,000 lives in 18 months.” 

It should be a great event. Good luck to the speakers!

Congratulations to the Robert Wood Johnson Foundation which this week celebrated the 25th anniversary of one of its most successful initiatives, the Harold Amos Medical Faculty Development Program (AMFDP).

Harold Amos, PhD

AMFDP is designed to increase “the number of individuals from historically underrepresented groups who achieve senior-level rank in academic medicine.”  It is based at Indiana University. Each year, AMFDP awards up to twelve 4-year postdoctoral research grants to physicians from disadvantaged backgrounds who want to establish careers in academic medicine.  Scholars receive an annual stipend of $75,000, and another $30,000 goes to their medical school.

AMFDP has graduated 181 scholars to date. More than 80% remain in academic medicine, including 35 professors. Recently, Harold Amos Scholar Dr. Lisa Cooper received a Genius Award from the MacArthur Foundation for her efforts to improve communication between patients and physicians.

The Robert Wood Johnson Foundation has invested more than $110 million in the project since its inception in 1983. The Foundation renamed the project 5 years ago to honor Harold Amos, PhD, the first African American chair of a department at Harvard Medical School and a founding advisor for the program.

More information on AMFDP can be found here.

Ever since surgical resident workweeks started getting shaved (it’s now 80 hours), there has been debate about how the change impacts quality in teaching hospitals. Proponents of the shorter workweek believe less fatigued residents make less errors. Skeptics fear that frequent shift changes increase the risk of errors in information transfer.

To date, studies of the matter have failed to silence the debate one way or the other.

The same can be said of the latest study of laporoscopic cholecystectomy in the era of the 80 hour workweek. The problem isn’t its finding that quality improved after the workweek became shorter, but that it’s not possible to attribute the improvement to residents sleeping more.

Using a retrospective trial design, the investigators compared complication rates at their hospital before and after the change to an 80 hour workweek. After accounting for age, gender and presence of acute cholecystitis, they found that the incidence of bile duct injury and total complications was lower after the rule change.

But why?  It may be that rested residents make all the difference. But it also could be that attending physician supervisors got more involved for whatever reason, or that the manpower alteration caused risky patients (where complications are most likely) to get procedures other than laporoscopic cholecystectomy.

Twenty years ago, we were aware that US medical school graduates tended to enter disciplines having the highest earning potential. Since then, income disparity between specialists and primary care physicians has widened, and medical student debt has ballooned to an astounding median of $140,000 per graduating senior.

So there is no reason to be surprised by the results of a recently published survey of graduating students from 11 US medical schools. Only 2% of respondents to this survey indicated that they planned to work in primary care internal medicine. That’s down from 9% in 1990. This year, 2,600 fewer US doctors enrolled in primary care training programs than did so just 6 years ago. 

The survey revealed that low income is just one reason why US medical students steer clear of general internal medicine. They are turned off by heavy workloads, continuous hassling with insurance companies and inadequate ancillary support as well.

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