In the mid-1990s, researching a book about the quality of medical care, I discovered how the profession had for years been ignoring evidence about the appalling death toll from preventable medical error. Though I’d never myself experienced an error, I became an activist.
Recently, however, a relative was a victim, and the frustrating persistence of error became personally painful.
Thanks to my relative being acutely aware of the need to be alert (and a bit of luck), no harm was caused by what could have been a serious medication mistake. That was the good news. The bad news is that even Famous Name Hospitals, like the one where my relative was treated, are rarely doing everything possible to forestall the impact of inevitable human fallibility.
September 17 was World Patient Safety Day, and the theme for the next 12 months is “Medication Without Harm.” That makes this an opportune time to examine more closely what the profession euphemistically calls a “medication misadventure.”
If you’re involved in medical education or residency selection, you know we’ve got problems.
And starting a couple of years ago, the corporations that govern much of those processes decided to start having meetings to consider solutions to those problems. One meeting begat another, bigger meeting, until last year, in the wake of the decision to report USMLE Step 1 scores as pass/fail, the Coalition for Physician Accountability convened a special committee to take on the undergraduate-to-graduate medical education transition. That committee – called the UME-to-GME Review Committee or UGRC – completed their work and released their final recommendations yesterday.
This isn’t the first time I’ve covered the UGRC’s work: back in April, I tallied up the winners and losers from their preliminary recommendations.
And if you haven’t read that post, you should. Many of my original criticisms still stand (e.g, on the lack of medical student representation, or the structural configuration that effectively gave corporate members veto power), but here I’m gonna try to turn over new ground as we break down the final recommendations, Winners & Losers style.
Among those in the field, it’s been referred to as the Covid Tour of Duty. Doctors, nurses, and support staff working around the clock on high alert, in many cases seeing the worst effects of our world-wide battle against the pandemic. Even those non-hospital workers, especially those in primary care, are being pushed to their limits with no definitive end in sight.
Long before the pandemic, the alarm bells were sounded due to an aging population, which by nature requires more healthcare. That population was being met with shortage of physicians and nurses. Couple that with the pandemic—which has claimed the lives of many healthcare workers, and burned out those that remain—and the shortage becomes the next industry crisis.
Patients with post-Covid sequelae will need ongoing care and may require more visits to their primary care for years to come. Without an adequate push for educating more doctors and nurses, the American population will be met with a continued shortage, now of massive proportion. Opening borders during a pandemic is equivalent to pouring gasoline on the fire, as the country is currently short pressed to take care of their own.
A survey from Mental Health America ( https://mhanational.org/ ) that surveyed healthcare workers from June through September 2020 showed that more than 75% were frustrated, exhausted or overwhelmed. In addition, 93% were experiencing symptoms related to stress. Those same workers are still going full-speed-ahead five months later.
In March of 2020, when we had limited knowledge on the infectivity and virulence of the virus that causes COVID-19, I joined a team of critical care nurses who were willing to risk their lives to care for those suffering from COVID-19. As a full-time PhD student in nursing, a new parent to my infant son, a primary caregiver to my 73-year-old mother, and as someone with a known history of severe asthma, I knew that I was embarking on a journey that could potentially cost me my professional and personal dreams and endanger those I care for the most in life: my family. My intentions to practice only part-time as a critical care nurse while pursuing full-time studies were halted after only two weeks of managing critically ill COVID-19 patients early in the pandemic. The countless code blues and unprecedented levels of patient deaths made it clear that we were in uncharted territory. After seeing the pain and fear on the faces of my nursing peers, I knew I could never leave them behind in this new battlefield. So, I stayed at bedside full-time for a year while also maintaining my full-time status as a PhD student. I had to. I could not turn my back on my practice oath, or my future professional goals as a nurse scientist. It is in this spirit that, on behalf of myself and my exhausted colleagues, I call on those with critical care experience who have stepped away from bedside to return, as they are able, and answer this same call to action.
The extent of the critical care nursing shortage we are currently experiencing is alarming to me and almost beyond my comprehension. This shortage has forced critical care nurses who have been at bedside since March of last year to remain at bedside even as several of us have reached the breaking point of psychological exhaustion. Our desperate outcry for backup from our fellow critical care nurse colleagues seems to have yielded no outcome. It is obvious that addressing this shortage would require a solution with immediate implementation as we do not have time for the training of more critical care nurses. Thus, an immediate call to all nurse anesthesia students to return to bedside should be a part of any strategy geared towards quickly addressing issues of this critical care nursing shortage.
At a time when the role of critical care registered nurses is most needed, several nurse anesthesia programs continue with their regular admission cycle protocol: pulling critical care nurses away from bedside. At my current hospital, we lost nearly a dozen critical care nurse colleagues to nurse anesthesia programs between March and May of 2020 at the peak of the pandemic. Since the nurse anesthesia program requirements stipulate a minimum of one year of critical care nursing experience, all program applicants possess highly specialized clinical skills needed for the care of critically ill COVID-19 patients. While there are unarguable reasons as to why some nurse anesthesia students have yet to answer this urgent call to duty, we as a profession, and as a society must do what we can to incentivize them to return to bedside to help relieve the suffering of patients and exhausted nurses who have fought tirelessly at the frontlines since the onset of the pandemic – many of whom have lost their lives as a result.
As a physician and writer on the topic of medical careers, I’ve noticed extensive interest in nonclinical career options for physicians. These include jobs in health care administration, management consulting, pharmaceuticals, health care financing, and medical writing, to name a few. This anecdotal evidence is supported by survey data. Of over 17,000 physicians surveyed in the 2016 Survey of America’s Physicians: Practice Patterns and Perspectives, 13.5% indicated that they planned to seek a nonclinical job within the subsequent one to three years, which was an increase from less than 10% in a similar survey fielded in 2012.
The causes of this mounting interest in nonclinical work have not been adequately investigated. Speculated reasons tend to be related to burnout, such as increasing demands placed on physicians in clinical practice, loss of autonomy, barriers created by insurance companies, and administrative burdens. However, attributing interest in nonclinical careers to burnout is misguided and unjustified.
Physicians are needed now – more than ever – to take on nonclinical roles in a variety of industries, sectors, and organizational types. By assuming that physicians interested in such roles are simply burned out and by focusing efforts on trying to retain them in clinical practice, we miss an opportunity promote the medical profession and improve the public’s health.
Supporting medical students and physicians in learning about and pursuing nonclinical career options can assist them in being prepared for their job responsibilities and more effectively using their medical training and experience to assist various types of organizations in carrying out missions as they relate to health and health care.
By PRANAV PURI, PUNEET KAUR, and MARCUS WIGGINS, MBA
As current medical students, the ongoing COVID-19 pandemic represents the most significant healthcare crisis of our lifetimes. COVID-19 has upended nearly every element of healthcare in the United States, including medical education. The pandemic has exposed shortcomings in healthcare delivery ranging from the care of nursing home residents to the lack of interoperable health data. However, the pandemic has also exposed shortcomings in the residency match process.
Consider the United States Medical Licensing Examination (USMLE) Step 1. A 2018 survey of residency program directors cited USMLE Step 1 scores as the most important factor in selecting candidates to interview. Moreover, program directors frequently apply numerical Step 1 score cutoffs to screen applicants for interviews. As such, there are marked variations in mean Step 1 scores across clinical specialties. For example, in 2018, US medical graduates who matched into neurosurgery had a mean Step 1 scores of 245, while those matching into neurology had a mean Step 1 score of 231.
One would assume that, at a minimum, Step 1 scores are a standardized, objective measure to statistically distinguish applicants. Unfortunately, this does not hold true. In its score interpretation guidelines, the National Board of Medical Examiners (NBME) provides Step 1’s standard error of difference (SED) as an index to determine whether the difference between two scores is statistically meaningful. The NBME reports a SED of 8 for Step 1. Assuming Step 1 scores are normally distributed, the 95% confidence interval of a Step 1 score can thus be estimated as the score plus or minus 1.96 times the standard error (Figure 1). For example, consider Student A who is interested in pursuing neurosurgery and scores 231. The 95% confidence interval of this score would span from 215 to 247. Now consider Student B who is also interested in neurosurgery and scores 245. The 95% interval of this score would span from 229 to 261. The confidence intervals of these two scores clearly overlap, and therefore, there is no statistically significant difference between Student A and Student B’s exam performance. If these exam scores represented the results of a clinical trial, we would describe the results as null and dismiss the difference in scores as mere chance.
The United States Medical Licensing Examination (USMLE) Step
1, a test co-sponsored by the Federation of State Medical Boards (FSMB) and the
National Board of Medical Examiners (NBME), has been the exam that people love
to hate. For many years, blogs, Twitter feeds, and opinion pieces have been
accumulating urging the presidents of the FSMB/NBME to stop reporting a 3-digit
score and instead report a pass/fail score. This animosity towards the Step 1
exam originates from the reality that medical schools have increasingly focused
their curriculum on teaching what the Step 1 wants you to learn – medical
trivia that almost always has no bearing on how to approach a clinical problem.
This “Step 1 Madness” is unhealthy. The reasons for its
existence are many: residency and fellowship programs allow it to exist by
idolizing higher scores, some believe it is a metric that can predict future
quality of care, board pass rates, etc. And some are naïve enough to think that
what is tested on the Step 1 is actually useful medical knowledge! It may be
due to a combination of the above that the Step 1 has found itself in such a
peculiar spot. However, the emphasis on the Step 1 score means that medical
students’ fate is being determined by a single test. Nobody wants their fate to
be so unmalleable.
Surely every resident has had the experience of trying to explain to a patient or family what, exactly, a resident is. “Yes, I’m a real doctor… I just can’t do real doctor things by myself.”
In many ways, it’s a strange system we have. How come you can call yourself a doctor after medical school, but you can’t actually work as a physician until after residency? How – and why – did this system get started?
These are fundamental questions – and as we answer them, it will become apparent why some problems in the medical school-to-residency transition have been so difficult to fix.
In the beginning…
Go back to the 18th or 19th century, and medical training in the United States looked very different. Medical school graduates were not required to complete a residency – and in fact, most didn’t. The average doctor just picked up his diploma one day, and started his practice the next.
But that’s because the average doctor was a generalist. He made house calls and took care of patients in the community. In the parlance of the day, the average doctor was undistinguished. A physician who wanted to distinguish himself as being elite typically obtained some postdoctoral education abroad in Paris, Edinburgh, Vienna, or Germany.
Many patients make this or similar requests, especially in January it seems.
This phenomenon has its roots in two things. The first is the common misconception that random blood test abnormalities are more likely early warning signs of disease than statistical or biochemical aberrances and false alarms. The other is the perverse policy of many insurance companies to cover physicals and screening tests with zero copay but to apply deductibles and copays for people who need tests or services because they are sick.
It is crazy to financially penalize a person with chest pain for going to the emergency room and having it end up being acid reflux and not a heart attack while at the same time providing free blood counts, chemistry profiles and lipid tests every year for people without health problems or previous laboratory abnormalities.
A lot of people don’t know or remember that what we call normal is the range that 95% of healthy people fall within, and that goes for thyroid or blood sugar values, white blood cell counts, height and weight – anything you can measure. If a number falls outside the “normal” range you need to see if other parameters hint at the same possible diagnosis, because 5% of perfectly healthy people will have an abnormal result for any given test we order. So on a 20 item blood panel, you can pretty much expect to have one abnormal result even if you are perfectly healthy.