Introduction

This blog is about medical education in the US and around the world. My interest is in education research and the process of medical education.



The lawyers have asked that I add a disclaimer that makes it clear that these are my personal opinions and do not represent any position of any University that I am affiliated with including the American University of the Caribbean, the University of Kansas, the KU School of Medicine, Florida International University, or the FIU School of Medicine. Nor does any of this represent any position of the Northeast Georgia Medical Center or Northeast Georgia Health System.



Monday, April 15, 2019

What is wrong with the Match?


On March 15th, 2019 another group of poor medical students went through the archaic and brutal gauntlet that is known simply as the Match.  The Match is more formally known as the National Resident Match Program. It has existed in virtually the same manner for decades, matching medical students to hospitals with residency programs.  There are some really great things about the Match, and some other things that are problematic.  I thought it would be worthwhile to discuss some of these today. 

The Match began in 1952. (1) Prior to the Match, senior medical students around the country would work all year to secure an internship. They were looking for a hospital that had a good reputation and clinical mentors that would teach them.  Often these connections were made from their mentors in medical school.  But honestly, the hospitals had all the power in this situation. They were paying little to nothing to the interns. There were no regulations on duty hours or work conditions. And the hospitals had very little responsibility to the interns. Sometimes a medical student would show up to a hospital expecting an intern position only to find out that their position had been given to someone else.  It was in this environment that the Match was created. 

At its simplest, the Match allows medical students to rank the residency programs where they have interviewed and residency programs to rank the medical students that they have interviewed. Afterwards a computer algorithm "matches" the students and the programs.  Every student in the nation finds out their match on Match Day in the middle of March. 

Over the years, the Match has had issues. Medical students have complained on multiple occasions that the algorithm favors the hospitals. In fact, a detailed analysis of incomplete Match data reported that the algorithm favored hospitals and that the NRMP had misrepresented that knowledge to medical students for years. (2) In 2002, a group of medical students filed a class-action lawsuit against the NRMP and several large teaching hospitals. The suit claimed that the Match unfairly kept residency wages low because of the lack of competition for residency positions. This suit was dismissed in 2004, after the US Congress passed a law that gave the NRMP anti-trust protection. (3) In 2015 an MIT Professor published an analysis of 2003 to 2011 Match data in the American Economic Review. He concluded that the Match lowered resident salaries by an average of $23,000 per year. (4)

But overall, I believe that the NRMP has worked hard to make the Match fair and accessible to everyone-students and residency programs, but there will always be questions when the stakes are this high.  The Match determines where a medical student / resident will spend the next three to eight years of their life. The medical student is moving to a new city, finding a place to live, and uprooting their spouse and/or family.  They may be joining a training program after spending one day interviewing and meeting program faculty and the other residents. And to top this all off, their peer residents are completely unknown to them until after the Match. They do not even know who their residency classmates will be, their partners if you will, until Match Day. Imagine that. You take a job, not even knowing who you will be working with, for up to 80 hours a week.  That takes some faith!

And there is some data that shows that the quality of the hospital that a resident trains in will affect the quality of care that they deliver to their patients for decades. (5) In a study of Obstetrics & Gynecology residency graduates, those who trained in hospitals in the bottom quintile for risk adjusted complications such as laceration, hemorrhage, and infection had 33% higher complication rates once they were practicing physicians when compared to physicians who trained in higher quality of care hospitals. It is not just in obstetrics. A 2016 study of General Surgery residency graduates found that patients operated on by surgeons who were trained in high quality residency programs (top tertile for adverse outcomes) were less likely to experience an adverse event than were patients operated on by surgeons trained in residency programs that were ranked in the bottom tertile. Adverse events included death, complications, and increased length of stay. (6)

So, I guess my bottom line is that Match Day remains an important milestone for physicians.  The Match is not perfect but this year it brought my institution  a crop of new resident physicians.
Our first residents as a new Sponsoring Institution.  I hope we were their first choice!

References

(1)   Roth AE. The Origins, History, and Design of the Resident Match. JAMA  2003; 289 (7): 909-912.
(2)   Williams KJ. A reexamination of the NRMP matching algorithm. National Resident Matching Program. Acad Med 1995; 70 (6): 470-6.
(3)   Robinson S. Antitrust Lawsuit Over Medical Residency System Is Dismissed. New York Times. Published 8/14/2004
(4)   Agarwal N. An Empirical Model of the Medical Match. American Economic Review 2015; 105 (7): 1939-1978.
(5)   Asch DA, Nicholson S, Srinivas S, et al. Evaluating Obstetrical Residency Programs Using Patient Outcomes. JAMA  2009; 302 (12): 1277-1283.
(6)   Bansal N, Simmons KD, Epstein AJ, et al. Using Patient Outcomes to Evaluate General Surgery Residency Program Performance. JAMA Surg 2016; 151 (2): 111-119.

Sunday, March 10, 2019

A Wellness Framework, Part 2


A Wellness Framework (Part 2)

In 2009, Levy (3) described that resident physicians had many sources of stress (as any physician can attest to), but that many resident stressors are considered to be part of the job. For the most part, at least historically, we have just accepted them. The Resident Service Committee of the Association of Program Directors in Internal Medicine (APDIM) divided these into three categories including: professional (patient responsibility, supervision of junior learners, difficult clinical situations), situational (long hours, sleep deprivation, clerical responsibilities), and personal (financial, family, isolation). (4) In 1981, Dr Small described what he termed as “house-officer stress syndrome”.  Almost all residents experience four of the seven attributes of this syndrome, episodic cognitive impairment, anger, cynicism, and family discord. The other three are more problematic and may suggest further resident impairment.  These include depression, suicidal ideation, and substance abuse. (5)

Harassment can be a cause of resident stress. Historically, there was a high tolerance for harassment in medical training. In fact, one of my favorite stories is of a senior surgical resident whose favorite saying was “stupid, medical students.”  We didn’t even think twice about it.  A talk I attended at AMEE 2018, looked at the prevalence of bullying and harassment in Radiology residents. They found that more than 50% percent of the trainees had experienced harassment but only a small percent were willing to report the harassment. 

Burnout is another risk factor for resident physicians.  A study of Internal Medicine residents found that by the end of the first year of residency, more than 50 percent of residents met the criteria for burnout (emotional exhaustion and depersonalization). (6) A cross specialty study by Martini and colleagues, found that burnout varied by specialty during residency. (7) The overall burnout rate was 50% and ranged from 27% to 75% among different specialties. The variation among specialties was not statistically significant.

Depression and suicidal ideation are another area. It is not clear if the suicide rate for resident physicians is higher than the general population, but studies suggest that it is higher for physicians overall. The ACGME is concerned. (8) Part of the impetus for the ACGME focus on Well-being is tied to the deaths of residents and physicians due to suicide. There is also this concern that the lack of Well-being in residency carries on into a physician’s career. I experienced this in my own professional career when my boss, the CEO of our hospital system, killed himself unexpectedly in 2016. A systematic review of 14 international studies of suicide in physicians, in articles published from 1963 to 1991, found higher rates of suicide in physicians compared with the general population The higher risk was from 1.1 to 3.4 in male physicians and from 2.5 to 5.7 in female physicians. (9)  A cohort study from 1979 to 1995 in  England and Wales found elevated suicide rates in female physicians. (10)

Fortunately, there are some things that help but more research is needed to determine best practices and interventions. Universal opt-out programs seem to help. Basically, all residents need to be set up to meet with your wellness counselling center at the beginning of residency. This seems to make them more comfortable in reaching out to the counselors when they need assistance. (11)  Making residents comfortable with the concept of seeking out mental health services is an integral part of ensuring wellness. Small groups, such as the Balint groups that are common in Family Medicine programs, seem to be helpful, and not just as “bitch” sessions. But more broadly as a way to discuss difficulties that residents at different levels are experiencing.

So, what did we do in our institution? We started with the Core Values of our institution. These values were coalesced during a year-long process that included representation from all of our employees, from housekeepers to vice presidents, from nurses and physicians, from volunteers to our board members.  It was an inclusive process.  We believe that our core values define the ethos of our institution. Therefore, it makes sense that these values should inform the wellness program for our residency training programs. Our Core Values are: Respectful Compassion, Responsible Stewardship, Deep Interdependence, Passion for Excellence. 

We have tried to hardwire these into the operations of our GME office. We hired a Director of Resident Wellness. We created a GME / Resident Wellness committee. We engaged with our organizational EAP program. We looked for Institutional and Physician Champions. And at the leadership level, I have tried to keep this front of mind. So far, while there have been barriers, we are trying to keep pushing forward. Not everyone thinks that this is important, but there has been some recognition by physicians. The Medical Staff Executive Committee even hosted a speaker to discuss burnout. But in a world that is ruled by RVU generation, there is still resistance to the concept of physicians working less hard or focusing on wellness or anything outside of medicine. There is still the belief that residents already have it easy and they should not complain. The argument often goes, “I worked hard in residency and look how great I am”, so the residents should work just as hard in their training programs. 

Clearly, there is still a lot of work to do…   

  References

1. Maslach C, Jackson SW, Leiter MP. Maslach Burnout Inventory. 3rd ed. Mountainview, CA: Consulting Psychologists Press; 1996.
2. Eckleberry-Hunt J, et al Changing the Conversation From Burnout to Wellness: Physician Wellbeing in Residency Training Programs. J GME  2009; 26(1): 225-230.
3. Levey RE. Sources of Stress for Residents. Acad Med.  2001;76(2): 142-150.
4. Stress and impairment during residency training: strategies for reduction, identification, and management. Ann Intern Med  1988;109:154–61
5. Small GW. House officer stress syndrome. Psychosomatics. 1981;22:860–9.
6. Rosen IM, Gimotty PA, Shea JA, et al. Evolution of sleep quantity, sleep
deprivation, mood disturbances, empathy and burnout among interns. Acad Med. 2006;81(1):82–85.
7. Martini S, Arfken CL, Churchill A, et al. Burnout comparison among residents in different medical specialties. 2004; 28(3):240–242.
8. Nasca T.  President’s Address. 2018 ACGME Annual Educational Conference. Orlando, Florida. 
9. Lindeman S, et al. A systematic review on gender-specific suicide mortality in medical doctors. Br J Psychiatry. 1996;168:274-279.
10. Hawton K, et al. Suicide in doctors: a study of risk according to gender, seniority and specialty in medical practitioners in England and Wales, 1979-1995. J Epidemiol Community Health. 2001;55:296-300.
11. Batra M, et al. Improving Resident Use of Mental Health Resources: It's Time for an Opt-Out Strategy to Address Physician Burnout and Depression 2018; 10 (1): 67–69.