Tuesday, 17 September 2013

Duty hours of residents don’t seem to make a systematic difference!!

It’s hard not reach this conclusion after reading the 2011 review concerning Patient Safety, Resident Education and Resident Well-Being Following Implementation of the 2003 ACGME Duty Hour Rules [J Gen Intern Med 26(8):907–19]. The authors warn us about comparing apples with oranges but the lack of any overall pattern regarding the impact on patients and residents is striking. For example, medical and surgical complications were interesting, with some improving and others worsening. The authors try to explain such differences as a product of less exhausted residents or worse continuity of care etc...As noted by the authors, the greatest limitation of the review is that conclusions rest upon studies demonstrating association, not causality. The authors collate a considerable amount of information, but the review (as acknowledged by the authors) doesn’t succeed in communicating the context. 

GPs decision making

A BMJ Open paper [BMJ Open 2013;3:e002982. doi:10.1136/bmjopen-2013-002982] evaluated compliance on treatment recommendations from clinical practice guidelines in their decisions on the management of heart failure patients. This was a vignette study with 451 Dutch GPs (but statistical power was weakened by low number of doctors that followed the recommendations). Maybe the most interesting results were; the fact that none of the 451 GPs took the four optimal decisions presented and that none of the relevant doctor characteristics was related to doctor compliance with clinical practice guidelines recommendations on all four treatment decisions. Obviously something else is at work here, but what?

Thursday, 12 September 2013

What is the purpose of medical education?

There is an engaging article in the recent issue of medical education [MEDICAL EDUCATION 2013; 47: 942–949]. It’s actually an email dialogue between  Dr David Hirsh and Professor Paul Worley. They attempt to address three important questions; Who are medical schools for? What is medical education for? What is the telos (the ultimate aim) of medical education? There is a lot of rich material in the exchange and I can’t do it proper justice here, but I will select out the elements that I liked best:
1.    The goals and purpose of medical education should be community engaged. Thus, communities should be co-creators of the curriculum and its delivery.
2.    There is a need to move beyond student-centeredness in medical education.
3.    The article highlights Cuba and the Barrio Adentro programme in Venezuela as exemplars of community engagement, and suggests that such models could fuel discovery and innovation.
4.    The final line of the paper is quotable; “The systemic result is that the goal of transforming medical education to repair society may actually transform us!”
These are just four parts that I liked; the paper is definitely worth a read. It’s rare that we see a paper exploring the values needed in medical education

Contradictions between resident education and patient safety?

A recent JAMA paper [JAMA INTERN MED/VOL 173 (NO. 8), APR 22, 2013] reports on a randomised experiment that compares between the 2003 and 2011 duty hour restrictions for US residents. The 2011 rules mandate rest periods between duty periods, increased supervision for junior trainees, and a 16-hour limit on continuous duty hours for postgraduate year 1 (PGY-1) trainees (interns). In a nutshell, the new regulations equal more work compression. Compared with a 2003- compliant model, two 2011 duty hour regulation– compliant models were associated with increased sleep duration during the on-call period, but with deteriorations in educational opportunities, continuity of patient care, and perceived quality of care.
Viewing the paper from an organisational psychology perspective, there is a very bizarre narrative going on. There is an overwhelming sense in the paper that we can’t really shorten the hours of residents, and it almost reads like a ‘I told you so!!’ (my interpretation not the authors). Indeed, the authors cite many studies in their conclusion section that found similar results. Additionally, the new system increased handoff related mistakes.  Speaking as a non-physician, the important issue that was screaming out was; WHY ARE HOSPITALS/HEALTHCARE ORGANISED IN THIS WAY? This is a complicated question, but rather than getting everybody focused on more sleep for residents (which is desirable), I want to know the vision and values of everybody at these hospitals. I can imagine that the healthcare professionals are increasingly prompted towards self-preservation rather than a meaningful balance between patient safety and healthcare well being. Finally, there is a really interesting contradiction between less educational opportunities and time. So rather than having meaningful discussions about the way that residents spend their time (in educational terms), we are forced to accept that the system is that way it is. Physicians reading my opinions may be thinking the same way (i.e., we can’t really change the system), but surely the paper suggests that there is no other alternative but to reimagine the system. Let’s get serious about analysing the systems

Wednesday, 21 August 2013

Do physicians need empathy?

The answer depends on the papers you read. A 2011 paper [Acad Med. 2011;86:359–364.] found that higher empathy was related to better clinical outcomes for diabetic patients. Good news, yes? Well, it seems so until you read the paper and discover that the research was based in a sample of 29 family physicians (but 891 patients). The paper had good methodology but how far can we get with 29 people? In contrast to this, a 2012 paper [Medical Teacher- 2012; 34: e116–e122] looking at the importance of empathy on changing specialty among medical students (858/1321 students from 5 medical schools) found that is wasn't important and changed little over the course of one year. Finally,  a 2013 paper [Medical Teacher-2013; 35: e946–e951] examined empathy among 72 medical students longitudinally (during 5th and 6th year). The study threw two interesting findings; (1) students were reported less empathy over time, which the authors report as being due to additional clinical responsibility, more patient contact and more management decisions, and (2)  students who self-rated as having more empathy received lower competence evaluations  from their peers. In my opinion (not the authors), it sounds like the organisation is very effectively teaching them that empathy is not so important.

Three very different studies, with the first one relating to family physicians and the second two concerning medical students. Difficult to know what to conclude, but food for thought none the less. If we actually reinforce medical students not to be have empathy, maybe we should ask why?

Monday, 19 August 2013

Surgeons and illicit drug use

A recent paper in BMC Medicine [Franke et al. BMC Medicine 2013, 11:102] indicates that German surgeons use illicit and prescription drugs for both cognitive enhancement and mood enhancement. The researchers used two different methods, but overall the prevalence is estimated between 15-20%. The research didn’t have a satisfactory response rate (36.4%), but the fact that nearly 1 out 5 surgeons are using drugs in this way is a cause of concern. The survey looked a list of factors that influence such use, and pressure to perform at work, pressure in perform in private life and gross income were positively related to drug use. Interestingly the following factors were not associated with drug use; gender, age, family status, living with children, type of employer, employment status, hours of work, satisfaction with professional success, and evaluation of career opportunities. The authors of the research don’t mention it, but one is left wondering; (1) how did the surgeons ‘learn’ that such behaviour is appropriate/acceptable, and (2) what lessons such behaviour teaches future generations of surgeons. However, it’s too simple to lay the blame on the surgeons, and we must appreciate the way that patient expectations and public expectations about zero errors contributes to a performance culture which has its roots in medical education. 

Saturday, 27 July 2013

Are physicians responsible for reducing costs?

According to a recent paper in JAMA [JAMA. 2013;310(4):380-388. doi:10.1001/jama.2013.8278], the answer seems to be no. The authors surveyed (randomly) physicians from the AMA masterfile. They had a decent response rate (56%) and sample size (n = 2556). Only 36% reported that practicing physicians have a responsibility to reduce costs. The authors argue that the picture is complex and that this raw statistic hides the devil in detail. For example, 78% reported that (78%) and that “doctors need to take a more prominent role in limiting use of unnecessary tests”. Looking at the data from an organizational perspective, I wonder whether the data reveal something important about the way that doctors feel that they do not belong to their organisations. Thus, the data might be a symptom of a more serious malady. The feeling that one does not fully belong to an organisation is unlikely to be fixed by changing payment plans.