Noting that “online technologies present both opportunities and challenges to professionalism,” the American College of Physicians and the Federation of State Medical Boards recently issued a position paper offering guidance to physicians looking to “strike the proper balance” between harnessing opportunities and navigating challenges inherent to technology.

The paper takes five positions:

1. Standards for professional interactions should be consistent across all forms of communication between physician and patient, and care should be taken to preserve the relationship, and maintain confidentiality, privacy and respect. “Friending” or Googling patients can result in providers observing “risk-taking or health-adverse behaviors,” and can compromise trust between the two parties. The paper urges physicians to avoid using online forums to “vent” or air frustrations.

2. Physicians should make an effort to keep professional and social spheres separate and behave professionally and cautiously in both. They should be aware that information posted online can quickly be widely disseminated or taken out of context.

3. Electronic communications should only be used by physicians in an established patient–physician relationship and with patient consent. Documentation of these communications should be included in patient’s medical records, and physicians should be aware of legal and state medical board requirements for these communications in their state.

In 2011, the Accreditation Council for Graduate Medical Education (ACGME) limited shifts for first-year medical residents, or interns, to 16 hours, in an effort to improve their well-being. But two studies published online this week in the Journal of the American Medical Association (JAMA) find that these regulations may not be improving resident well-being—and that they may be decreasing both the quality of care they provide and their educational opportunities.

Although interns worked fewer hours after implementation of the shift length restriction in 2011, researchers found no change in their sleep duration or symptoms of depression. That study, led by Srijan Sen, MD, PhD, of the University of Michigan in Ann Arbor, also found an increase in self-reported medical errors among interns (from 20% in 2009 to 23% in 2011). The researchers hypothesize that the increase in errors may be due, in part, to interns having to perform more handoffs—where medical errors are known to occur—and to a lack of additional clinical staff that may mean “residents [are] expected to complete the same amount of work as previous cohorts but in less time.”

Another study, led by Sanjay V. Desai, MD, of Johns Hopkins University, also found “unintended consequences” of duty hour regulations. Although that study found more consistent sleep patterns for interns, it also found that nurses, as well as the interns themselves, believed the quality of patient care suffered. Desai’s research team found a concerning balance between the interns’ workload and their time spent on educational activities. “Concerns have been raised about the competency achievable with less hospital experience during any fixed duration of training,” they write. “Opportunities were reduced with restricted shifts, many of which occur solely during evening hours, precluding participation in traditional core educational components of medicine residency programs, such as noontime conference and morning rounds.”

An annual Physician Retention Survey from Cejka Search and the American Medical Group Association (AMGA) finds that medical groups had an average physician turnover rate of 6.8 percent in 2012, up from 6.5 percent in 2011 and the highest rate since 2005. The increased turnover correlates with the nation’s economic recovery; improvements in the housing market and recovery in stock prices may have made physicians more likely to move or retire, experts say.

The survey, which drew responses from 80 medical organizations that collectively employ more than 19,000 physicians, also finds that medical groups expect an increase in turnover in the coming year due to accelerating retirement and competition to hire and retain top physicians. Seventy-six percent of respondents plan to hire more primary care physicians in the next 12 months.

“The survey findings provide evidence that recruitment and retention continue to be major challenges for health systems,” Donald W. Fisher, PhD, CAE, president and chief executive officer of AMGA, said in a news release about the survey. “To rise to these challenges, medical groups are demonstrating remarkable leadership by investing in new staffing and delivery models, building and nurturing their teams in a strategic way, and making accountable care work for their patients and their communities.”

For the second year, the survey also asked about turnover among advanced practice clinicians, including physician assistants and nurse practitioners. That turnover rate in 2012 was 11.5 percent, essentially unchanged from the previous year.

Read more about the survey.

More U.S. medical students “matched” to primary care residency positions this year than in 2012, according to data from the National Resident Matching Program (NRMP). Almost 400 more students chose primary care fields— internal medicine, family medicine, and pediatrics—than last year.  NRMP is a private, non-profit organization established in 1952 to provide a mechanism for matching the preferences of applicants for U.S. residency positions with the preferences of residency program directors.

Of the 17, 487 graduating seniors who participated in Match Day 2013, 3,135 matched to internal medicine—a 6.6 percent increase from last year. The number of seniors who matched to pediatrics (1,837) represents a 105 percent increase over last year.

This year’s Main Residency Match was the largest in NRMP history, with more than 40,000 student and independent registrants. NRMP attributes the increase to three new medical schools graduating their first classes, and expanded enrollment in existing medical schools.

Conducted annually by the NRMP, The Match uses a computerized mathematical algorithm to align the preferences of applicants with the preferences of residency program directors in order to fill the training positions available at U.S. teaching hospitals.

Read a NRMP news release about this year's Match Day results.

A report from the Association of American Medical Colleges (AAMC) documents an overall trend toward increased diversity among students applying to medical school.

AAMC’s Diversity in Medical Education: Facts and Figures 2012 finds that nearly half of the applicants to U.S. medical schools in 2011 were non-White. Whites were the largest group of applicants, followed by Asians. “Compared with 2010, in 2011 the percentage of Hispanic or Latino applicants increased by 5.7 percent and the number of Black or African American applicants grew by 5 percent,” the report says.

But only 2.5 percent of medical school applicants in 2011 were Black men. Twice as many Black women as men applied to medical school that year, creating the biggest gender gap in medical school applicants among all racial or ethnic groups.

“We have a major, major problem in this country,” Marc Nivet, EdD, AAMC’s chief diversity officer, told American Medical News. “There is just simply an enormous amount of indisputable evidence that we’re not intervening as effectively as we’d like as a society to increase the talent pool of African-Americans who are capable of taking advantage of the science curricula available up and down the pipeline.”

Antoinette L. Laskey, MD, MPH, FAAP, is an associate professor of pediatrics and division chief and medical director at the Center for Safe and Healthy Families at the Primary Children’s Medical Center at the University of Utah in Salt Lake City. She is an alumna of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program (2001-2003).

During medical school at the University of Missouri-Columbia, I had my first exposure to child abuse pediatrics.  As a third-year student on my pediatrics clerkship, I had the opportunity to participate in the care of a child whom I suspected had been beaten.  From that point forward I knew this was where I wanted to spend my career. 

I started looking into fellowship opportunities even before I had started my residency.  Early in my intern year in 1998, I reached out to Des Runyan, MD, DrPH, a pioneer in child abuse pediatrics and an alumnus of the RWJF Clinical Scholars program (1979-1981) who was then at University of North Carolina at Chapel Hill and who is now national program director of the RWJF Clinical Scholars program.  We arranged a visit so that I could learn more about the field through his expert eyes.

Before child abuse pediatrics was recognized as an official subspecialty of pediatrics, there were two different paths to enter practice: a one-year “apprenticeship” or a two-year clinical and research fellowship.  In my short visit to Chapel Hill, it became apparent to me that an RWJF Clinical Scholars position was the way I needed to go to not only practice in the field of child abuse pediatrics but to also gain the knowledge base necessary to move the field forward. 

Four in 10 physicians say their typical patient load “exceeds safe levels” at least once a month, causing the quality of care they provide to suffer, according to a study by researchers at Johns Hopkins University, published online in the Journal of the American Medical Association (JAMA). More than one-third of physicians (36%) reported their workloads exceeded safe levels at least weekly.

In the survey of more than 500 self-identified hospitalists in an online physician community, respondents said their workloads had caused patient care to suffer. Respondents reported that inadequate time with a patient had caused them to order potentially unnecessary tests or procedures, and that their workloads had “likely contributed” to a host of poor patient outcomes, including morbidity and mortality.

Among the other problems physicians attributed to excessive workloads: inability to fully discuss treatment options; delayed admissions and discharge; increased readmissions; worsened patient satisfaction; and worsened overall quality of care.

Read the study abstract.
Read more about the results in Medpage Today [free subscription required].

A report completed this month by the Congressional Research Service (CRS), which conducts analysis for members and committees of Congress, examines how the Affordable Care Act (ACA) will affect the nation’s supply of physicians. In particular, the report focuses on the workforce’s size, composition and geographic distribution.

Size
The health care system cannot work effectively or efficiently without a physician workforce of appropriate size. Too few physicians means delayed care, and too many physicians can mean unnecessary or duplicate care. But measuring the size of the physician workforce—and the future physician population—is challenging, and estimates vary. The CRS report notes that “predicting the timing, content, and effect of policy change is difficult, which adds to the uncertainty of the projections.”

The ACA authorizes funding for additional medical residency training programs through the Health Resources and Services Administration (HRSA) and the ACA’s own Prevention and Public Health Fund. It requires that Medicare-funded residency training slots be redistributed from hospitals that are not using them or that have closed, to hospitals seeking to train additional residents. It also includes provisions designed to increase physician productivity and the volume of physician services available. The law encourages care coordination—in medical homes and accountable care organizations, for example—and expands the non-physician workforce that can augment or substitute for physician services.

Two newly published studies examining different aspects of physician workforce trends suggest that the long-expected shortfall in primary care physicians could be averted or lessened.

A study in Pediatrics finds pediatric residents are more likely to consider primary care or hospital practice––rather than a subspecialty that requires additional training––if they have more educational debt. The researchers found that residents with at least $51,000 in debt were about 50 percent more likely to be planning a primary care or hospitalist career than residents who owed less or no money, Reuters reports. They also found that educational debt rose 34 percent from 2006 to 2010 for pediatric residents.

While an unintended consequence of student loan debt may be that it helps relieve the primary care shortage, another recent study in Health Affairs casts some doubt on the severity of that shortage. Most existing estimates of the primary care physician shortage are based on a simple ratio of one physician for every 2,500 patients, the study says, which does not take into account changing patient demographics and alternative care-delivery methods. The researchers found that the use of health care teams and non-physicians, as well as improved information technology and data-sharing have “the potential to offset completely the increase in demand for physician services while improving access to care, thereby averting a primary care physician shortage.”

Read the study in Pediatrics.
Read the study in Health Affairs.

Long working hours that cause fatigue, sleepiness, burnout and depression are a threat to the personal safety of medical residents, according to a Mayo Clinic study published this month. Working conditions associated with these characteristics are linked to motor vehicle crashes and near crashes, and may contribute to exposure to blood and body fluids on the job.

In the survey of 340 internal medicine residents in training at the Mayo Clinic, 168 respondents (56%) reported a motor vehicle incident during their training. Of those incidents, 34 were motor vehicle crashes, and 130 were near misses. Sixty residents reported falling asleep while driving, and 53 reported falling asleep while stopped in traffic. Residents attribute these incidents to diminished quality of life, exhaustion and depression, and fatigue and sleepiness, the study finds.

Residents also reported exposure to blood and body fluid during their training, some of which was attributed to fatigue. The researchers call the rates “reassuringly low,” but caution that “it is not possible to definitively rule out associations of distress with [blood and body fluid] exposure.”

“These findings indicate that resident distress is related not only to patient safety and quality of care but to residents’ personal safety as well,” the study says. “In addition to ongoing efforts to limit physician fatigue and sleepiness, interventions to promote well-being and reduce distress among physicians are needed to improve both patient and resident safety.”

Read the study.