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STUDY: Does Capping Residency Hours Hamper Physician Training?

STUDY: Does Capping Residency Hours Hamper Physician Training?

When new rules capped training hours for medical residents at 80 hours per week in 2003, critics worried that the change would leave physicians-in-training unprepared for the challenges of independent practice.

Now, new research published July 11 in BMJ and led by scientists in the Department of Health Care Policy in the Blavatnik Institute at Harvard Medical School, shows that these dire warnings were largely unjustified.

The analysis — believed to be the first national study examining the impact of reduced hours on physician performance — found no evidence that reduced training hours had any impact on the quality of care delivered by new physicians.

Following a series of high-profile patient injuries and deaths believed to stem from clinical errors caused by fatigue, medical accreditation agencies initiated a series of sweeping changes to the regulations governing resident hours and other aspects of training. These efforts culminated in 2003 with the U.S. Accreditation Council for Graduate Medical Education capping the training of medical residents at 80 hours per week.

“This is probably the most hotly debated topic in medical education among physicians,” said Anupam Jena, the HMS Ruth L. Newhouse Associate Professor of Health Care Policy in the Blavatnik Institute, a physician in the department of medicine at Massachusetts General Hospital and lead author of the study. “Many doctors trained under the old system think that today’s residents don’t get enough training under the new system. You hear a lot of senior physicians looking at younger doctors coming out of training and saying, ‘They’re not as prepared as we were.’”

The findings of the study should assuage these fears, Jena said.

The researchers found no significant differences in 30-day mortality, 30-day readmissions, or inpatient spending between physicians who completed their residency before and after the residency hour reforms.

“We found no evidence that the care provided by physicians who trained under the 80-hour-a-week model is suboptimal,” Jena said.

Given the changes in hospital care over the past decade, the researchers knew that they couldn’t just compare the difference between outcomes of recently trained doctors before and after the cap, since overall outcomes have improved thanks to better diagnoses and treatments, better coordination of care and new digital tools designed to prevent harmful drug interactions and other human errors.

Comparing new physicians trained before reform with those trained after would confound the effect of changes in training with the effect of overall changes in hospital care. To avoid conflating the two, the researchers compared new physicians before and after the reforms with senior physicians who had trained before the reform.

The study analyzed 485,685 hospitalizations of Medicare patients before and after the reform.

The training hour reforms were not associated with statistically significant differences in patient outcomes after the physicians left training.

For example, 30-day mortality rates among patients cared for by first-year attending internists during 2000-2006 and 2007-2012 were 10.6 percent (12,567/118,014) and 9.6 percent (13,521/140,529), respectively. In comparison, the 30-day mortality among patients cared for by tenth-year attending physicians was 11.2 percent (11,018/98,811) and 10.6 percent (13,602/128,331) for the same years.

Further statistical analysis to eliminate the unwanted effects of other variables showed that these differences translated into a less than 0.1 percentage point gap between the groups. The difference in hospital readmission rates was similarly minuscule: 20.4 percent for patients cared for by first-year physicians in both 2000-2006 and 2007-2012, compared with 20.1 percent and 20.5 percent, respectively, among patients treated by senior physicians.

Taken together, these findings suggest that U.S. residency work hour reforms have not made a difference in the quality of physician training, Jena said.

As a way of magnifying any possible gaps in care stemming from a difference in training hours, the researchers looked specifically at outcomes for high-risk patients, in whom even small differences in quality of care would become apparent.

“We looked at patients who were particularly ill. In these cases, one little mistake could mean the difference between life and death,” Jena said. “Even for these sickest patients we found that the reduced training hours had no effect on patient mortality.”

Monica Farid of Harvard University, Daniel Blumenthal of HMS and Massachusetts General Hospital and Jayanta Bhattacharya of Stanford University also contributed to this study.

This research was supported by a grant from the Office of the Director, NIH (1DP5OD017897). The authors reported no competing interests or financial ties that might be related to the subject of this research.

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The Accidental General with Gen. Shane Lee, M.D.

The Accidental General with Gen. Shane Lee, M.D.

MARION – The city of Marion is an old town rich in Alabama history that pre-dates the Civil War. It’s home to many antebellum homes, Judson College and Marion Military Institute, the nation’s oldest military junior college. Few people may know that a young Coretta Scott, born and raised in Marion, wed her husband, Rev. Dr. Martin Luther King Jr., on the front lawn of her mother’s home just north of Marion in 1953. It’s this small town’s amazing history that called out to Dr. Shane Lee when he was looking to set up a practice.

Dr. Lee had finished medical school at The University of Alabama in Tuscaloosa and did his residency in Selma where he met Dr. Donald Overstreet. The two hit it off, and as with many of his residents, Dr. Overstreet quickly became a mentor and close friend of Dr. Lee’s. Sadly, Dr. Overstreet passed away in June.

“Dr. Overstreet cold-called me from Selma,” Dr. Lee explained. “He was sort of half Marcus Welby and half Donald Trump – he was a wheeler-dealer, and he got stuff done. At the time, his was the only family practice residency program financially stable in the state. He taught us the managerial aspects of running a medical practice as a business. And, it is a business that can work you very quickly into bankruptcy. I was attracted to Selma because of my love of history, and at the time Selma was going through a little bit of a renaissance. I hadn’t been there before, so it was something different for me.”

His love of history may have brought him to the Selma area, but the quality of the residency program kept him there…and the fact that Dr. Overstreet allowed the residents the opportunity to hunt in their own club didn’t hurt.

“It really was an excellent residency program. They grabbed you by the collar, threw you into the trenches, and said, ‘Go!’ All the doctors you worked with, from family medicine to internal medicine, to surgeons and orthopaedists, were all so desperately overloaded that they were thrilled to have the help. It was a very procedure-oriented program, which is critical. I think that’s something we need to do better now. We aren’t as procedure-oriented now as we used to be. So, if you get out into the rural areas, you need to be more of a one-stop shop as much as possible to maintain the best standard of care.”

Dr. Lee does what he can to provide the best possible standard of care to the residents of Marion and the surrounding area, even if that means making house calls. In Dr. Lee’s case, sometimes a house call is just another day on the job. The thing is, Dr. Lee has a second job. He’s also a two-star general in the U.S. Army.

When you walk into his office in The Marion Clinic, the walls are covered with photos and memorabilia of his travels. From the jungle of Nicaragua to the desert of the Middle East, Dr. Lee has traversed the globe on medical mission trips and deployments, each trip leaving a lasting impression on him. Just inside the door is a well-worn, green denim pouch just a bit larger than a baseball cap. The hash marks drawn in black marker are nearly all faded now, but the memories of what they stand for are still fresh for Dr. Lee. The pouch was part of his uniform during Operation Desert Storm. It contained his gas mask. The hash marks were those he made every time the camp warning siren blasted of a possible attack by scud missile or gas.

“I’m a blue-collar kid from Hueytown. I would never have thought I would have done the things that I have. If it hadn’t been for the military, I wouldn’t have been able to. If you don’t draw a line, the practice can be all consuming, so it gives me a legitimate reason to blow town. People don’t argue with me if I have to leave and I’m on orders,” he laughed. “I’m an accidental general. It wasn’t my goal. I just hung in there. There are certain career checkpoints you have to make, and it was a labor of love for me, really. There are some very qualified guys, much more qualified than me, that didn’t make flag rank just because when it came up, there weren’t any vacancies. Anyone who’s made general, if they don’t tell you that it’s a little bit of luck and time, they’re lying, because it really is.”

The deployments are a little different now. Dr. Lee and his unit are on a medical mission trip to Kauai, Hawaii. After the end of a training cycle, if the unit doesn’t deploy into an active area, they go somewhere else.

“We’ve started doing these IRTs, or innovative readiness trainings, where we will take a medical unit and send them to an underserved area. We just got back from one we did in Virginia in coal mining country. We take a medical section, vet section, optometry, pharmacy, mental health…we sort of mix it up depending on the needs and what we have,” Dr. Lee explained.

The IRTs are clinics set up in conjunction with a local host, which is part of the purpose of the mission. Connecting with the local medical community, public health services, law enforcement, church groups and other military groups helps to teach skill sets on both sides of the table. The IRTs don’t always have to be in a rural area, either. Dr. Lee’s unit has done trainings in Camden and Selma as well.

“These trainings aren’t successful unless we can get civilian involvement. What you really want to do is get people plugged into the system. What we do, the real-time good, is pull teeth, cut glasses, spay dogs, do rabies shots. The big draws are dental, optometry and veterinarian services. Those get the most attention. It really is a phenomenal change in an area and a good feeling to know the change you can leave behind,” Dr. Lee said.

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Match Day 2017 Successful for Alabama’s Medical Students

Match Day 2017 Successful for Alabama’s Medical Students

MOBILE — The excitement was thick in the ballroom of the Arthur R. Outlaw Mobile Convention Center on in March for Match Day. What is perhaps the most important day for each graduating medical school student can also be the most stressful. This day serves as a focus of celebration for medical schools and students nationwide – the day medical students learn the locations of the residency programs in which they will continue the next phase of their medical training.

Match Day is the result of medical students nationwide interviewing with different residency programs and ranking their top-choice programs in order of preference with the training programs doing the same. The National Residency Matching Program uses a mathematical algorithm to designate each applicant to a residency program.

Each student receives their sealed match letter at promptly 10:45 a.m. (CT). At 11 a.m., the students rip open their letters to learn the location of their residency program. It is truly a day of well-earned pageantry.

“Match Day is the most important day in a medical student’s career,” said Dr. Susan LeDoux, associate dean of medical education and student affairs at the University of South Alabama. “They work so hard to get into the specialty they like, and once they are in that specialty they continue to work hard throughout their training.”

According to USA, of the 70 College of Medicine seniors, 22 students went to Alabama medical institutions, including 12 who will do their residencies at USA hospitals. Forty-eight others, or 69 percent, drew out-of-state residencies in a total of 22 other states.

The University of Alabama-Birmingham also had impressive results. UAB’s match rate was 98 percent, or 173 students, from its School of Medicine seniors. Its students matched in 75 institutions in 29 states.

The inaugural class of the Alabama College of Osteopathic Medicine in Dothan experienced its first Match Day this year with outstanding results as well. ACOM students achieved positions in 15 disciplines, 97 unique institutions/programs, and 29 states.

According to NRMP, the 2017 Match Day was the largest on record with 35,969 U.S. and international students and graduates vying for 31,757 positions – the most ever offered during a match.

“The number of U.S. allopathic seniors who submitted program choices is an all-time high. The number of students/graduates of osteopathic medical schools who submitted program choices, as well as their match rate, are all-time highs,” said Mona M. Signer, NRMP president and CEO. “It’s also a good sign for primary care.”

National Match by the Numbers

  • Internal Medicine, Family Medicine and Pediatrics added a combined 2,900 positions, a 25.8 percent increase
  • Emergency Medicine offered 2,047 first-year positions, 152 more than in 2016, and filled all but six
  • Psychiatry offered 1,495 first-year positions, 111 more than in 2016, and filled all but four
  • Specialties with more than 30 positions that achieved the highest percentages of positions filled by U.S. allopathic seniors, were Integrated Plastic Surgery, Orthopedic Surgery and Otolaryngology
  • Applicants who did not match participated in the NRMP Match Week Supplemental Offer and Acceptance Program®. This year, 1,177 of the 1,279 unfilled positions were offered during SOAP.

*Special thanks to University of South Alabama College of Medicine, University of Alabama Birmingham School of Medicine and the Alabama College of Osteopathic Medicine in Dothan for participating in this article. Photo courtesy of Bill Starling, photographer with USA.

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