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Career Plans Among Internal Medicine Residents

Career Plans Among Internal Medicine Residents

General internists are expected to play a pivotal role in providing healthcare as the population ages, the burden of chronic disease grows, and healthcare reform tries to improve coverage for millions of currently uninsured patients. Studies suggest that only 20% to 25% of internal medicine (IM) residency grad­uates pursue general medical careers. Complicating the problem is that fewer medical students appear to be interested in general medicine and primary care. Career Plans Among Internal Medicine Residents It’s unclear to what degree primary care training program graduates favor general IM careers, and few studies have explored how career plans may differ across sociodemographic factors. In JAMA, Denise M. Dupras, MD, PhD, and I had a study published that looked at the career plans of IM residents by training program, sex, and medical school location. We also looked at how career plans evolved during training. According to our results, graduates of primary care IM training programs, women, and medical school graduates were more likely than their counterparts to report generalist career plans. These residents were also more likely to remain interested in generalist careers over the course of their training. However, general medicine career plans were less common than subspecialty career plans in each of these groups. The small number of IM residents reporting plans for generalist careers means that only a limited number of generalists can be expected to enter practice each year. Serious Implications on General Internal Medicine Overall, only one in five IM graduates planned a career in general internal medicine. Even in primary care IM residency programs that are dedicated to generalist and primary care training, most graduates still...

Should Resident Work Hours Be Capped?

Blogging at his site “Adventures in Emergency Medicine,” Dr. Sam Ko says resident work hours should be limited to 40 per week. Via Twitter, I warned him that I would rebut his assertion. Without any data or references except a tangential one, he bases his opinion on four premises: 1. “Residents will be happier and nicer to patients because they will be less stressed.” There is no proof that this is so. In fact, a recent paper in JAMA Surgery says about one-third of interns who work a maximum of 16 hours per day “demonstrated weekly symptoms of emotional exhaustion (28%) or depersonalization (28%), or reported that their personal-professional balance was either “very poor” or “not great” (32%). And “at the end of their intern year, 44% [of interns] said they did not believe that the work hours limits led to reduced fatigue.” This is not a very resounding confirmation of the theory that reducing work hours leads to happier or more rested residents. 2. “But we did it so you have to do it too.” Under this heading, Dr. Ko says, “We are busier than they were 20 to 30 years ago. Before, they probably got more sleep and had less patients in the hospital.” With the exceptions of more paperwork and the burden of the electronic medical record, I’m not so sure residents are busier today, but if they are, what’s making them busier is REDUCED WORK HOURS. This recent paper from JAMA Internal Medicine concluded the following: “Compared with a 2003-compliant model, two 2011 duty hour regulation-compliant models were associated with increased sleep duration during the on-call period...
Remediation & Attrition in General Surgery Residents

Remediation & Attrition in General Surgery Residents

The Accreditation Council for Graduate Medical Education (ACGME) unveiled a new model to measure resident performance in 1999 that endorsed six general competencies. These include patient care, medical knowledge, practice-based learning, interpersonal and communication skills, professionalism, and system-based practice. The purpose behind the ACGME’s shift in measuring resident performance was to create an effective way to educate and evaluate physicians, explains Christian de Virgilio, MD. “The ultimate goal was to breed physicians who are well trained, educated, ethical, and compassionate.” Few studies have examined how successful surgical residency programs have been at achieving the ACGME-endorsed competencies. “The advent of the 80-hour workweek restriction and a 16-hour shift limit for interns has affected educational quality,” says Dr. de Virgilio. “Residents are now forced to compress required tasks into a shorter timeframe with reduced work hours. In turn, this can increase the likelihood that future surgical residents will be inadequately trained.” Examining Remediation Among Surgery Residents There are several measures of the adequacy of education for surgery residents. One of these measures is whether or not residents require any form of remediation during their residency. In the September 2012 Archives of Surgery, Dr. de Virgilio and colleagues had a study published that aimed to determine the frequency of resident remediation with regard to the six ACGME competencies. The study team also sought to identify factors predictive of the need for remediation and the rate of attrition by surgical residents. Dr. de Virgilio says “this information may provide insights into ways that we can more effectively modify the surgical curriculum in this new era of limited hours.” After conducting an 11-year retrospective...

Improving Surgeon Skills With Simulator Training to Automaticity

Studies have shown that using surgical simulators to improve skills in the operating room (OR) can be effective for surgeons in training. To maximize the effectiveness of simulation training, a proficiency-based training paradigm in which trainees are required to achieve expert-derived performance goals has been suggested. This type of training is tailored to individual needs and ensures the acquisition of uniform skills. However, while proficiency-based curricula have been effective in improving operative performance, studies show that simulator-trained learners do not always reach expert performance in the OR. “Simulators cannot always reliably predict when skill acquisition is complete because the currently used metrics of performance may have limited sensitivity,” explains Dimitrios Stefanidis, MD, PhD, FACS. “This can be problematic should problems emerge in the demanding environment of the OR.” According to Dr. Stefanidis, most simulation curricula traditionally use time and errors as metrics of performance. “The problem with these metrics is they don’t provide a complete picture of trainee performance. They give no information about the attention demands required by the task, the effort the trainee had to invest to achieve a level of performance, and the quality of the learning that occurred. While two different surgeons may get equal results on time and accuracy measurements, they may have substantial differences in workload, attention demands, and physiologic parameters that reflect differences in learning, true skill level, and experience.” Defining Automaticity in Surgery One of the key characteristics that distinguishes experts from novices is their ability to engage in certain activities without requiring significant attention. “Psychologists have called this ‘automaticity,’ ” says Dr. Stefanidis. “Many habitual or highly practiced motor acts...

Law School Applications Down; Are Med Schools Next?

The number of people applying to law schools is in steep decline. So says a recent post on a website called “The National Jurist.” The post cited some remarkable data from the American Bar Association. In 2012, law school applicant numbers were down 14% from 2011 and 23% from 2010. For the fall of 2012, there were 44,481 first-year law students enrolled, down about 4,000 from 2010. Many schools have decreased enrollments, with more than 90 trimming class sizes by more than 10%. On January 2, the Wall Street Journal reported: “The Bureau of Labor Statistics estimates that the economy will provide 21,880 new jobs for lawyers annually between 2010 and 2020; law schools since 2010, however, have produced more than 44,000 graduates each year.” For the non-math majors, that’s a ratio of more than two graduates for every job. There are way too many lawyers around anyway. Could something like this happen in medicine? It might not be exactly the same, but an interesting dilemma is looming. A 2011 paper in the New England Journal of Medicine expressed concern that in a couple of years, the number of US medical school graduates will exceed the number of first-year residency training positions available. In response to projected physician shortages, many medical schools have expanded their class sizes, and several new medical schools have opened or are soon to open. But the problem is that many years ago, the federal government established a cap on the number of residency training positions in this country. And there are persistent rumors that spending on graduate medical education (GME) will be among the many future...
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