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Should Insurers Contribute To Graduate Medical Education Funding?

Graduate Medical Education has for the most part escaped big budget cuts in the past, mainly because powerful lawmakers have aligned to protect funding for teaching hospitals in their own states and districts. Plus, the Association of American Medical Colleges, the American College of Physicians, hospital organizations, and many others long have made funding for GME a top legislative priority.

GME, though, could be on the chopping block as Congress’s new “Super Committee” comes up with recommendations to reduce the deficit by at least $1.2 trillion over the next decade. A report from the Congressional Budget Office of options to reduce the deficit to suggests that $69.4 billion could be saved over the next decade by consolidating and reducing GME payments. Earlier this year, the bipartisan Fiscal Commission on Fiscal Responsibility and Reform also proposed trimming GME payments.

How then should those who believe that GME is a public good respond? One way is to circle the wagons and just fight like heck to stop the cuts. But that raises a basic question: is GME so sacrosanct that there shouldn’t be any discussion of its value and whether the current financing structure is effective and sustainable?

Another approach, the one taken by the ACP in a position paper released last week, is to Read more »

*This blog post was originally published at The ACP Advocate Blog by Bob Doherty*

Emergency Medicine Residency Doesn’t Prepare Docs For The Real World

Emergency Medicine News:
February 2010 – Volume 32 – Issue 2 – p 5, 24, 25, 26

Residents training in large urban centers typically see more than 200 patients a day. They have access to all subspecialty care, typically available 24 hours a day. Residents have around-the-clock access to angioplasty, interventional radiology, hand surgeons, neurosurgeons, and plastic surgeons. Most practice emergency medicine with cardiologists and neurologists in the building or a short phone call away. Decision-making is shared, and occurs with a relative surplus of information and opinions and in a milieu of shared risk.

In reality, though, these very large and highly-specialized EDs with Level I trauma comprise less than five percent of U.S. EDs, according to the American College of Surgeons. Read more »

*This blog post was originally published at GruntDoc*

When Incompetence Kills

Some things make me feel so powerless (yes, even i can be powerless in the face of incompetence).

I have previously mentioned a thing or two about my opinion of where medical training is going in this country. Basically the powers that be are not-so-gradually degrading the degree. To them somehow it seems like a good idea. Ideas I suppose can easily seem good when you are safely hidden away in your nice air conditioned office far from the reality of the consequences of essentially negligent doctors released into the community. Well I get to see the consequences up close.

He was referred from an outlying hospital on a Friday. The peripheral hospitals so like to empty their wards for the weekend. After all there is some good fishing in these parts. Thank goodness for good fishing. Otherwise many more would die unnecessarily. Read more »

*This blog post was originally published at other things amanzi*

Physician Burnout Is The Biggest Threat To Healthcare Reform

It was supposed to be delayed gratification.

After all, that’s the American way: work hard, put your nose to the grindstone, get good grades, be obsessively perfectionistic, then you’ll be rewarded if you just stay with it long enough. It’s the myth that perpetuated through medical school, residency and fellowship, and our poor residents, purposefully shielded from the workload they’re about to inherit, march on.

But then they graduate and find that just as the population is aging, chronic and infectious diseases are becoming more challenging, health advances and potential are exploding. Just then, we decide to launch a full scale attack on physicians and their patients with increased documentation requirements, call hours, larger geographic coverage of their specialties, reduced ancillary workforce, and shorter patient vists.

Physicians get it – burn out and dissatisfaction are higher now than ever before. This is probably the greatest real threat to the doctor-patient relationship and health care reform discussions don’t even put it this on the table.

At the same time that we expect our doctors to be devoted, available, enthusiastic, meticulous and at the top of their game with perfect “quality” and “perfect performance,” while simultaneously cutting their pay, increasing documentation reqirements and oversight, limiting independence, questioning their professional judgment, and extending their working hours. We must become more efficient!

Deal?

*This blog post was originally published at Dr. Wes*

Work Hour Restrictions Protect Patients From Sleepy Surgeons

Surgery Residency, Massachusetts General Hospital and Work Limits – Health Blog – WSJ

It’s not surprising that newly minted doctors at one of the most prestigious hospitals in the country, and in a specialty with a particularly demanding residency, have been violating national limits on work hours.

But the Boston Globe’s report that Massachusetts General Hospital must rein in surgical residents’ hours is a reminder that the work limits put in place several years ago remain unpopular with many residents and senior doctors.

Not surprising in the least.  I’m actually astonished that there’s anybody with the chutzpah to defend extended work hours for residents.   I did my residency largely in the pre-hour-restriction era — there were hour restrictions on months in the ER, but effectively none for the off-service rotations — and it was a terrible way to deliver care.  I did my time of q3 call in the units and q2 call on surgical services.  This includes a memorable time when I was the sole intern on the pediatric surgical service and was on duty for ten days straight without leaving the hospital.  That gives a new meaning to being a “resident physician!”  (Actually, that’s the original meaning, if you must get picky about it.)

The care provided was just scary.  I prided myself on being a machine and able to get through 36 hours of uninterrupted work without cracking; I used to run marathons and endurance was my forte.  And I did get through it better than most.  But after 24 hours with no down time (and there was never meaningful down time), you get stupid, and you make mistakes.  I remember once, in the medical ICU I was surprised in morning rounds to find that one of my patients had had a swann-ganz catheter placed overnight.  Caught flat-footed by this in front of the attending, I asked the nurse who had put in a swann without telling me, only to be informed that I had done the procedure! Apparently I was too sleep-addled to recall that I had done it!  Fortunately, I had apparently done it right, because a swann involves threading a catheter through the heart into the pulmonary vessels and can be Very Bad [tm] if you screw it up.   But I apparently did it by reflex without actually achieving a state of full wakefulness.  This sort of thing was fairly routine, and I also remember well the overnight residents being excoriated in morning rounds for the errors and misjudgments they had made overnight.  Great training, but not so great for the patients who were the victims of the mistakes.

It seems to me that the defenders of the status quo have donned their rose-colored glasses.  They fondly remember the camaraderie and the pride in accomplishment that their residencies evoked, while conveniently forgetting the mistakes and omissions, while neglecting the depression and divorces and other personal costs of such an abusive training environment.  And there’s the faux toughness: “I got through it, they can, too if they’re not too weak.”  And the old guard romanticize the qualities of the “true physician” in their dedication to their patients above all else: “These younger doctors just don’t care enough.”

What a load of crap.

Look, it’s with damn good cause that other professions in which errors can hurt people have work time restrictions (truck drivers, airline pilots, etc), and it’s stupid and arrogant to think that we physicians are so awesome that we are immune to the human factors of fatigue and circadian rhythms that contribute to errors.  When it’s inexperienced trainees working the ridiculous hours with minimal supervision (in many cases), the potential for fatigue-related errors is compounded.

I also question the motivations of some of those who defend the status quo.  It seems strangely self-serving that residency directors who would otherwise have to find attending physicians or PAs to perform the work that residents do on the government’s dime are the ones to insist that the situation is just fine, or that “the evidence of benefit is lacking.”  How cool is it that they can ignore reams of research on human factors, take the a priori position that the system is fine as it is, and demand formal evidence on “efficacy, safety and cost” before making any changes?  That’s balls!  It’s also fairly blatant obstructionism and should not be given any credence.

Dr Bob of Medrants has some thoughtful comments on the matter, mostly pleading for flexibility in the new rules. I would mostly agree, excepting that flexibility is best given to those who have proven themselves trustworthy, and residency directors (especially but not exclusively of surgical training programs) have repeatedly and flagrantly flouted the rules thus far imposed.   Flexibility is fine, but accountability should also be demanded.

I would also take issue with Dr Bob’s comment that this “training system that has served our profession well for many years.”  I look at the statistics on physician burnout, substance abuse, divorce, depression and suicide.  They are terribly concerning.  I would not lay all of this at the feet of residency, but I would say that the abusive (I’m sorry, “rigorous”) environment of residency training sets the tone for the culture of machismo that harms physicians as much as it harms patients.  Nobody is well-served by the current system.

It is true that change might be painful.  Reducing hours might mean reducing patient contacts and reducing the training opportunities for physicians.  This might require academic centers to revalue the time of physicians in training, by which I mean that residents might no longer be used as free menial laborers.  Maybe it doesn’t make sense to have a surgical resident “running the book” — many surgical residents never see the inside of the OR till their second and third years.  The universities might have to hire PAs or NPs for the “scut work” instead of using MDs in training as glorified secretaries (what a waste of time and money).

I’m glad the Institue of Medicine and the ACGME seem to be on the right path with the recommendations.  The reactionary response from the change-resistant academic centers will take some time and political will to overcome. I remember when they first imposed the rules, they followed it up by decertifying the Internal Medicine program at Hopkins for violating the rules.  That effected the desired change, I can tell you!   Hopefully, as the restrictions evolve, there will be accountability and enforcement until the culture starts to shift.

*This blog post was originally published at Movin' Meat*

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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