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.”

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.

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.

Around the country, print, broadcast and online media outlets are covering the groundbreaking work of Robert Wood Johnson Foundation (RWJF) leaders, scholars, fellows and grantees. Some recent examples:

The Philadelphia Inquirer reports on the Foundation’s 40th anniversary celebration last week, as well as some of its most notable accomplishments during its first four decades. Learn more about RWJF’s anniversary, and about the “Force Multipliers” it is saluting this year.  The Foundation also announced ten winners of its first-ever RWJF Young Leader awards last week.

RWJF Physician Faculty Scholar Ruchi Gupta, MD, MPH, gave comments to Reuters about a study that finds babies are less likely to get eczema if their mothers take probiotics during pregnancy. Gupta, who was not involved in the research, calls the findings “fascinating.” Read a post Gupta wrote for the RWJF Human Capital Blog about her professional and personal experience with children’s food allergies.

Kristy Nichols, MS, an RWJF Community Health Leader, spoke to the Associated Press about cuts to Louisiana State University’s (LSU) hospital health care system, and proposed changes to the state’s graduate medical education training program.

Every year, fourth-year medical students anxiously await “Match Day,” when they learn where they will complete their residencies. But long before they receive their sealed envelopes, an algorithm is at work matching them with schools based on their own rankings and those of the institutions to which they are applying. This week, two men responsible for that algorithm were recognized with the Nobel Prize in Economic Sciences.

In the 1950s and 60s, Lloyd Shapley, PhD, helped create the main concept of “pairwise matching,” or how individuals can be paired up if they have different views regarding who would be the best match. His model was the basis for the National Resident Matching Program (NRMP).

Alvin Roth, who worked independently of Shapley but had closely studied the algorithm as well as other countries’ medical markets, helped redesign the NRMP in 1995 to take into account married couples searching for residencies in the same region or at the same hospital, and to eliminate the system’s bias for hospitals over students.

The new system is still used today, and helps match more than 20,000 positions a year. The scholars’ work is also used to match students to high schools and to match up kidney donors.

Read a press release about the prize.
Read more about Roth and Shapley’s work.
Read a New York Times story about Roth and Shapley.

Catherine Dower, JD, is the associate director for research at the Center for the Health Professions at the University of California, San Francisco. Dower recently wrote a policy brief for Health Affairs about the state of graduate medical education funding. Read the brief on the Robert Wood Johnson Foundation website.

Human Capital Blog: What is graduate medical education (GME) and why is it important?

Catherine Dower: GME refers to the practical training doctors undergo after medical school, when they work for a few years as ‘residents’ – usually in hospitals – under more experienced physicians before they can practice on their own. As all doctors must go through GME before being licensed, it’s a big piece of their professional preparation.  Also, the number of doctors who go through GME correlates directly with the number of doctors who can be newly licensed each year, affecting supply. The number of residencies has always been larger than the total number of U.S. medical school graduates, with the gap being filled by internationally-trained medical graduates, who often stay in the U.S. to practice. Importantly, residents play a big role in a hospital’s labor force and GME is expensive.

Susan Kosman, RN, BSN, MS, is Chief Nursing Officer for AETNA.

The ever-changing health care landscape presents challenges and opportunities to new nursing graduates, as well as those changing specialties or worksites, regardless of their clinical background. Implementing appropriate training will benefit nurses, the organizations that employ them, and most importantly, the patients and caregivers who depend on their skills and services.

An opportunity exists to transform nurses’ professional development and to improve health care quality and affordability through nurse residency programs. These programs need to go beyond basic orientation and provide a clinical preceptorship focused not just on delivering competent care, but also in how to develop and grow in the nursing profession. A survey of new nurses found many challenges - a lack of confidence; difficulty with work relationships; frustrations relating to the work environment; lack of time and guidance for developing organizational and priority-setting abilities; and overall high levels of stress. These factors likely contribute to the high turnover rate among new nurses, estimated at between 35 and 60 percent within the first year (“The Value of Nurse Education and Residency Programs," 2011).

The opportunity exists to improve nurses’ work experiences, to increase retention of new nurses, and to show financial return for organizations investing in nurses as resources. Residency evaluations show increases in leadership and communication skills and decreases in stress and turnover.