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Tag: Residency

Stay Out of my Wellness

By VA WEST HAVEN COE CLINIC

On a sunny New England morning at a secluded guest house with a perfectly manicured lawn, medical residents, each with their own brightly colored yoga mat, were getting ready to assume the downward dog position. They were on an annual retreat organized by their residency program to promote wellness. One embraced the opportunity with delight, smiling through every pose.  Another grimaced  as his back spasmed. And yet another wandered off towards a lake to find his own kind of respite.

Physician wellness has become something of a buzzword in recent years, and rightfully so considering that the rates of burnout and suicide within medicine are rising. Individual residency programs have found burnout rates between 55% and 76%. Such burnout erodes well-being over time and may be contributing to suicide, which is now the second leading cause of death among residents nationwide. In 2014, the suicides of two medical interns in New York prompted the American College of Graduate Medical Education to take action. A series of initiatives to combat burnout were rolled out, including the consideration of wellness in its review of residency programs during site visits. In 2017, emergency medicine physicians convened the first Residency Wellness Consensus Summit to devise a module-based curriculum on wellness. Hospital systems have attempted to respond as well, through the hiring of chief wellness officers.

It is unsurprising that the medical community has taken such an analytical approach towards diagnosing burnout, much as we do with other diseases, in search for a cure. But perhaps such a prescriptive approach fails to capture the highly individualized and somewhat abstract concept of wellness. The reasons for resident burnout are personal and vast. Decreased wellness has been attributed to the lack of time for self-care, inadequate sleep, social isolation, negative work environments, excessive paperwork, long work hours, poor relationships with colleagues, and insufficient mentorship, among others in a lengthy list. Any attempt to standardize the definition of wellness should be met with caution.

So how do we as a society go forward in ensuring our resident physicians are well?Continue reading…

Has Med School Changed For the Better?

karan chhabraEvery third-year has heard it.

…When I was in your position, I was taking 24-hour calls every other night. If my resident was there, I was there….

We’re regaled about the glory days, without shelf exams, without phlebotomists, and—by god—without those work-hour restrictions. The days when medical students wouldn’t dare ask their residents for help, or residents their chiefs, or chiefs their attendings, and so on. I hear a bit of romance: the heroism of providing total patient care, exactly when the patient needed it, unfettered by handoffs or outside interference. I envy the skill required to practice medicine almost-literally in one’s sleep.

As the veteran doc continues his (yes, usually his) soliloquy, he may admit that it wasn’t the safest model for patients, or the most humane for trainees. He may today be a better doctor for it, but he’s a bit ambivalent about whether it should remain exactly the same today. Presumably he wasn’t alone, because since the good ol’ days, the third year of medical school has morphed into something barely recognizable.

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Growing Up in the Era of Work-Hour Restrictions

Danielle Jones

In 2008, the IOM study on resident work hours came out and in the years that followed the Accreditation Council for Graduate Medical Education (ACGME) subsequently implemented a gamut of “recommendations.”

As a medical student, I remember thinking it was a much needed change – why wouldn’t it be a good idea to improve patient safety and decrease resident fatigue?

Alas, as a newly minted intern growing up in the era of work-hour regulations, it’s become apparent that many of these changes may actually make life harder without achieving their main goal of improving patient care.

The 80-hour work week cap is fine; it’s been in effect on its own since 2003 and overall it seems to have made residency more humane. Most programs have found reasonable ways to limit work hours to this full-time-times-two amount, at least when hours are averaged over four-week periods.

However, the additional bullet point “recommendations” from 2010 seem to play out very differently in real life than they do on paper. Many of them seem to be arbitrary lines drawn in political sands hiding behind a facade of patient safety, but that’s another blog for another time.

So, what do the bullet point regulations look like in the hospital?

They look like: Interns can’t work 24-hour shifts. 

So, what used to be a two-and-a-half shift weekend turns into a four shift weekend. At a four intern/year program like mine, that means instead of two people splitting the weekends and having a post-call day after 24 hours on, one intern is committed to night-float six nights/week for a month while the remaining three interns take the three leftover weekend shifts.

The result: Fewer hours at a time in the hospital, but more working days in a row and more days/month away from your family.

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Why You Should Care about the New Accreditation Agreement for Osteopaths

More than a century of American medical history was turned on its ear last week by the announcement that the groups that accredit medical residencies will unify their standards. Don’t be too hard on yourself if you failed to understand the significance (or notice at all).

But this should be viewed as good news across the land. As someone who trains doctors from both ‘traditions,’ I certainly welcome a more level playing field.

First, a little background:

Osteopathic physicians (those with a D.O., or Doctor of Osteopathy degree) have a history dating back to the 1800s. They comprise slightly more than 10% of practicing doctors in the United States. Currently, there are 35 osteopathic medical schools, compared with 135 ‘allopathic’ institutions, the kind that confer the M.D. (Doctor of Medicine) degree.

Though historically the two educational paths varied in principles and practice, there aren’t many remaining differences. Both disciplines now use biomedical science as their core.

Originally, osteopathy relied on manipulation of bones and joints to diagnose and treat illness.

This tradition, known as Osteopathic Manipulative Treatment (OMT), lives on in the osteopathic curriculum, though it’s now mostly used as an adjunct for treatment of chronic musculoskeletal conditions. Today, most D.O.s leave OMT behind after they finish their training.

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The Real Problem with Board Exams-and How to Solve It

This week there’s been a debate brewing about why so many young doctors are failing their board exams. On one side John Schumann writes that young clinicians may not have the time or study habits to engage in lifelong learning, so they default to “lifelong googling.” On the other, David Shaywitz blames the tests themselves as being outmoded rites of passage administered by guild-like medical societies. He poses the question: Are young doctors failing their boards, or are we failing them?

The answer is: (C) All of the above.

I can say this with high confidence because as a young doctor-in-training who just completed my second year of medical school, I’ve become pretty good at answering test questions. Well before our White Coat Ceremonies, medical students have been honed into lean, mean, test-taking machines by a series of now-distant acronyms: AP, SAT, ACT, MCAT. Looming ahead are even more acronyms, only these are slightly longer and significantly more expensive: NBME, COMLEX, USMLE, ABIM. Even though their letters and demographics differ, what each of these acronyms share is the ability to ideologically divide a room in less time than Limbaugh.

This controversy directly results from the clear dichotomy* between the theory behind the exams and their practical consequences. In theory these exams do serve necessary and even agreeable purposes, including:

1)     Ensuring a minimum body of knowledge or skill before advancing a student to the next level in her education,

2)     Providing an “objective” measure to compare applicants in situations where demand for positions exceeds supply.

So apart from the common, albeit inconvenient, side effects that students experience (fatigue, irritability, proctalgia), what are the problems with these tests in practice? These are five of the core issues that are cited as the basis for reformations to our current examination model:

1)     Lack of objectivity. Tests are created by humans and thus are inherently biased. While they aim to assess a broad base of knowledge or skills, performance can be underestimated not due to a lack of this base but due to issues with the testing format, such as duration, question types, and scoring procedure (e.g. the SAT penalizes guessers, whereas the ACT does not). Just as our current model of clinical trial testing is antithetical to personalized medicine (What is a standard dose? Or, more puzzlingly, a standard patient?), our current model of testing does not take into account these individual differences.

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Are Young Doctors Failing Their Boards? Or Are We Failing Them?

A short piece in The Health Care Blog  reveals (albeit unintentionally) why so many outside of healthcare think the medical establishment still doesn’t get it.

The post, written by a general internist and residency program director, asked why an increasing number of internal medicine doctors are failing their internal medicine board exams.  The pass rate has reportedly declined over the last several years from 90% to 84%.  (Disclosure: I passed this required test about a decade ago.)

His differential included two possibilities:

(1)    The test is getting harder – The testing agency said this wasn’t the case.

(2)    Millennials lack the study habits of their elders, and have become great “looker-upers.” – The author suggested this was a key factor, and several commentators enthusiastically agreed.

The basic thesis here that in the Days of Giants, doctors worked harder, learned more, and were better.  Nowadays, doctors are relatively complacent, less invested, less informed, and are generally worse – which is what’s reflected on the board exams.

Let me suggest a third possibility – perhaps today’s doctors are providing better care to patients than their predecessors were a generation ago.  Maybe today’s doctors have figured out that in our information age, your ability to regurgitate information is less important than your ability to access data and intelligently process it.  Maybe what makes you a truly effective doctor isn’t your ability to assert dominance by the sheer number of facts you’ve amassed, but rather how well you are able to lead a care team, and ensure each patient receives the best care possible.

In other words, what if the problem isn’t the doctors, who are appropriately adapting, but rather the tests (and the medical establishment), which may not be?

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The Patient Explanatory Model

In The Birth of the Clinic, Foucault describes the “clinical gaze,” which is when the physician perceives the patient as a body experiencing symptoms, instead of as a person experiencing illness. Even in the era of the biopsyschosocial model, the physician’s perspective is largely through a biomedical lens where biology and behavior cause disease.

In contrast, what I hear from patients is that health and illness are not merely the end results of individual biology and behavior. What people believe and experience when they are ill is usually something far more complex, deeply interconnected with their daily lives. And research shows the way people think about health influences whether they are receptive to health information, willing to change health behaviors or take medications, and even whether or not their health improves. But how are physicians, who are able to spend less and less time with patients, supposed to expand their clinical gaze to include the patient’s health beliefs and perspectives?

Psychiatrist and anthropologist Arthur Kleinman’s theory of explanatory models (EMs) proposes that individuals and groups can have vastly different notions of health and disease. Kleinman proposed that instead of simply asking patients, “Where does it hurt,” the physicians should focus on eliciting the patient’s answers to “Why,” “When,” “How,” and “What Next.”

Kleinman suggests the following questions to learn how your patient sees his or her illness:

1.         What do you think caused your problem?

2.         Why do you think it started when it did?

3.         What do you think your sickness does to you?

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The Bedside Manifesto

“Most of us went into medicine because we love spending time with patients,” said Johns Hopkins Hospital’s Leonard Feldman, MD.

Dr. Feldman is co-author of an article published April 18 in the Journal of General Internal Medicine which reveals that medical interns spend only 12% of their time examining and talking with patients, and more than 40% of their time on computer tasks. 

“Our systems have squeezed [patient contact] out of medical training,” said Dr. Feldman.“ All of us think that interns spend too much time behind the computer. It’s not an easy problem to solve.”

For three weeks a year ago, investigators observed 29 interns at two Johns Hopkins University internal medicine residency programs for a total of 873 hours. Direct patient care accounted for only 12.3% of interns’ time, and computer use for 40%. The paucity of direct interaction may explain previous studies’ findings that only 10% of hospitalized patients know which resident physicians are responsible for their care. “I think we can do better,” said Dr. Feldman.

He’s right. Unless we want healthcare to devolve ultimately into a system of vending machines, we need to restore its traditional personal intimacy. But medical sages have been chanting that mantra since the 1920s. What holds it up?
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No Resident Left Behind

Yesterday at the faculty meeting, we learned that the first year residents in anesthesia will now have to take AND PASS a written exam at the end of their first year.  They will have a certain number of tries and if a resident can’t pass it by the third try they’re either out of the program or held back in some way.  Now, it used to be when I was a baby resident that the first year residents took the certification exam that the third years took, and it was graded on a curve based on year.  You didn’t have to pass it or get a certain grade; it was sort of a reality check, to see how you were doing.  I don’t know who’s brilliant idea this new test was, other than the people who administer and charge for the test.  It might be a solution in search of a problem, I have no idea.

Here’s the thing.  Testing freaks residents out.  They have been taking high-stakes tests their whole entire lives.  In high school they had to get As and score a 1400 on the SAT.  In college they still had to get As, but also had to ace the MCAT.  In med school the tests might have been pass/fail but USMLE Steps 1 and 2, both of which are taken during med school, certainly weren’t.  Results of those had bearing on what residency you got into.  The result of all this standardized testing is that every resident has PTSD about tests, and every resident has had years to figure out how he or she can most quickly cram in the amount of information necessary to do well on the test.  Residents are masters of this.  There is absolutely no reason to read the textbook, which is likely 8 years out of date anyway, when you can go straight to the review books and practice exams online.  Especially if the threat of expulsion or repetition, both of which are disasters on multiple foreign and domestic fronts, is held over their heads.

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Will Your Health Insurer Pay to Train Your Doctor?

Lost in the weeds of President Obama’s budget proposal is a 10-year, $11 billion reduction in Medicare funding for graduate medical education (GME). GME is the “residency” part of medical training, in which medical school graduates (newly minted MDs and DOs) spend 3-7 years learning the ropes of their specialties in teaching hospitals across the country.

Medicare currently spends almost $10 billion annually on GME. One-third of that is for “Direct Medical Education” (DME), which pays teaching hospitals so that they in turn can provide salaries and benefits to residents (current salaries average around $50,000/year, regardless of specialty; there are variances by region). No problem there.

The proposed cuts come from the Medicare portion known as “Indirect Medical Education” (IME) payments. Though IME accounts for two-thirds of the Medicare GME pie, it’s not easy for hospitals to itemize what exactly it is they provide for this significant amount of funding. Instead, hospitals bill Medicare based on a complex algorithm that includes the ‘resident-to-bed’ ratio, among other variables.

A 2009 Rand Corporation study commissioned by Medicare to evaluate aspects of residency training called on the government to tie IME payments directly to improvements in educational and hospital quality, lest the money be perceived to be going down a series of non-specific sinkholes. That idea has caught on, and legislators in both parties now see the healthy IME slice of Medicare education funding as a plum target for cost-cutting, as the direct benefits are difficult to enumerate, let alone quantify.

This has medical educators very worried that we will have to do more with much less (disclosure: I am one).

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