Quality of life, debt, and burnout among doctors-in-training (residency)

The term "resident" can mean different things, so I chose to use the phrase "doctors-in-training." Didn't want to confuse people who are thinking about long-term care residents.

This JAMA article titled, "Quality of Life, Burnout, Educational Debt, and Medical Knowledge Among Internal Medicine Residents," concludes:

In this national study of internal medicine residents, suboptimal QOL and symptoms of burnout were common. Symptoms of burnout were associated with higher debt and were less frequent among international medical graduates. Low QOL, emotional exhaustion, and educational debt were associated with lower IM-ITE scores (Internal Medicine In-Training Examination (IM-ITE) scores).

Here's what the researchers found:

• Quality of life was rated “as bad as it can be” or “somewhat bad” by 2402 of 16 187 responding residents (14.8%). 
• Overall burnout and high levels of emotional exhaustion and depersonalization were reported by 8343 of 16 192 (51.5%), 7394 of 16 154 (45.8%), and 4541 of 15 737 (28.9%) responding residents, respectively.
• In multivariable models, burnout was less common among international medical graduates than among US medical graduates (45.1% vs 58.7%; odds ratio, 0.70 [99% CI, 0.63-0.77]; P < .001). Greater educational debt was associated with the presence of at least 1 symptom of burnout (61.5% vs 43.7%; odds ratio, 1.72 [99% CI, 1.49-1.99]; P < .001 for debt >$200 000 relative to no debt).
• Residents reporting QOL “as bad as it can be” and emotional exhaustion symptoms daily had mean IM-ITE scores 2.7 points (99% CI, 1.2-4.3; P < .001) and 4.2 points (99% CI, 2.5-5.9; P < .001) lower than those with QOL “as good as it can be” and no emotional exhaustion symptoms, respectively.
• Residents reporting debt greater than $200 000 had mean IM-ITE scores 5.0 points (99% CI, 4.4-5.6; P < .001) lower than those with no debt. These differences were similar in magnitude to the 4.1-point (99% CI, 3.9-4.3) and 2.6-point (99% CI, 2.4-2.8) mean differences associated with progressing from first to second and second to third years of training, respectively.

So, what does this suggest? For one thing, residency is grueling and many people burn out or feel that life is terrible. Does this change once physicians complete their residency and enter the busy working world of high-volume patients and stressful working conditions? For some, their outlook improves because their salary has significantly gone up. For others, they battle with greater stress and anxiety because they now have more responsibilities to shoulder as an attending. They no longer have that backup or safety net they used to have during residency training. 

It sounds to me like residency programs need to take a hard look at collecting feedback from their residents and implementing some new steps to boost workplace morale and to provide more emotional support. Otherwise, we'll find more residents and physicians dropping out of clinical medicine. They'll be leaving to search for alternative careers that are less stressful and that provide an improved work/life balance. Some will be drawn to jobs that pay more. Others will be drawn to career opportunities that may appear lucrative but that end up becoming enslaving in different ways. 

Mindfulness to minimize physician burnout

Author: Jenny Mesrie

Research has shown that practicing mindfulness may actually improve physician well-being and attitudes associated with patient-centered care. In an article published in JAMA, Krasner et al studied the effects of an intensive educational program in mindfulness, communication, and self-awareness.

Primary care physicians are working hard these days. Up to 60% of primary care physicians report symptoms of burnout. Many physicians report personal consequences such as substance abuse, stress-related health problems, and marital discord.

Physician burnout = poorer quality care for patients

How can we begin to solve this problem? While primary care physicians are caring for the general public, who is looking out for them?

Docs cut work hours

According to the Associated Press: "Docs cut hours as primary care shortage looms"
Average hours drop from 55 to 51 — equivalent of losing 36,000 physicians

This is based on a recent article on JAMA "Trends in the Work Hours of Physicians in the United States"

Results: After adjusting for inflation, mean physician fees decreased nationwide by 25% between 1995 and 2006, coincident with the decrease in physician hours. In 2001, mean physician hours were less than 49 hours per week in metropolitan areas with the lowest physician fees, whereas physician hours remained more than 52 hours per week elsewhere

Conclusion: A steady decrease in hours worked per week during the last decade was observed for all physicians, which was temporally and geographically associated with lower physician fees.

To read the full text JAMA article, click here.

A depressing study about depression meds on JAMA

There's a JAMA (Journal of the American Medical Association) review article that was published on January 6 titled, "Antidepressant Drug Effects and Depression Severity." The authors performed a patient-level meta-analysis and looked at quite a few different clinical studies to explore the effects of antidepressant medications in patients who have clinical depression. Here's what they found:

Conclusions: The magnitude of benefit of antidepressant medication compared with placebo increases with severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. For patients with very severe depression, the benefit of medications over placebo is substantial.

So what does this really mean? Does it mean that those patients who have mild or moderate depression are mainly experiencing a clinical benefit derived from the placebo effect? Could this review article be flawed? Maybe the authors missed a critical factor among patients who have mild or moderate depression.

In any case, this is certainly a depressing study for pharmaceutical companies who are sell antidepressant medications. I'm sure this article will stir some considerable controversy among those who are considered "high volume" prescribers of antidepressant medications like SSRIs and SNRIs. We're talking about drugs like: bupropion, citalopram, duloxetine, escitalopram, fluoxetine, fluvoxamine, mirtazapine, nefazodone, paroxetine, sertraline, trazodone, and venlafaxine.

To read the abstract on JAMA, click here.

Telemedicine and ICU outcomes

Telemedicine, defined as the "use of electronic information and communication technologies to provide health care when the caregiver and patient are geographically distanced," is an increasing trend in inpatient medicine.

A recent article published in the Journal of the American Medical Association (JAMA) shows that the use of telemedicine for remote patient monitoring was not associated with an overall improvement in mortality or length of stay in the intensive care unit (ICU) setting. Since some hospitals face a shortage of intensive care unit physicians (intensivists), they rely on telemedicine to allow intensivists to monitor patients from remote locations. Can you imagine being in a room filled with monitors, TV screens, microphones, and computers? How in the world are you supposed to follow what's going on with everyone? It's difficult enough to maintain proper ventilator settings, adjust pressors to optimize perfusion without causing tissue necrosis, and remember which IV drips are running on each patient. Could you do all of this from a remote location?

So the objective of the study was: To assess the association of remote monitoring of ICU patients (ICU telemedicine [tele-ICU]) with mortality, complications, and length of stay (LOS).

Here's a summary of the study design:

Observational study conducted in 6 ICUs of 5 hospitals in a large US health care system to assess the use of tele-ICU. The study included 2034 patients in the preintervention period (January 2003 to August 2005) and 2108 patients in the postintervention period (July 2004 to July 2006).

Now, what are we supposed to conclude based on this study? Considering that some of the early studies are from 2003, that seems like a long time ago when we look at how quickly communications technology has advanced. If we were to repeat the same study with modern computes and telecommunications, perhaps the outcome would be different. What are we to conclude from this observational study? Will we see randomized control trials designed to evaluate the efficacy of telemedicine in the ICU? I don't think so. If you were a critically ill patient, would you rather have a remote doctor or an in-hospital doctor taking care of you?

To read the abstract on JAMA, click here.

Facebook misconduct by medical students

Some medical students are using social media very poorly. They are posting inappropriate comments, pictures, and videos using Facebook, YouTube, Twitter, and other social media outlets. We are seeing articles in journals like the Journal of the American Medical Association (JAMA) about this and MSNBC is picking up on these stories as well.

The JAMA article is titled, "Online Posting of Unprofessional Content by Medical Students"
The MSNBC story is titled, "Facebook misconduct: Med students cross line"

What more will we see in the near future? The bottom line is that medical students need to be very cautious when they use social media. Something that may seem harmless may come back to haunt you down the road. I'm a big fan of social media, but I try to use them cautiously to balance my personal life (on sites like Facebook) with my professional life and my blogs.

Top 5 medical journals to generate advertising revenue in 2009

Here's the list of the top 5 medical journals that generate advertising revenue:

1. New England Journal of Medicine (NEJM)
2. Journal of the American Medical Association (JAMA)
3. American Family Physician - this is the journal of AAFP
   
4. Journal of Clinical Oncology (JCO) - this is the journal of ASCO
   
5. Family Practice News

Are you surprised by the list? The world of oncology is strong with pipeline drugs, biologic agents, and profits from sales. The pharma/biotech advertising trend appears to be moving away from traditional print and more to online formats.

Do you think we'll ever see medical journals that are free of advertising? How would publishers survive?

Group Backs Telemedicine for Stroke Care

This is a guest post by Ethan Segal, MD. If you're interested in submitting a guest post, please contact me.

An article “Groups Back Telemedicine for Stroke Care” appearing in the July 1, 2009 issue of JAMA reports how the American Heart Association and the American Stroke Association in early May 2009 released a statement which demands that all facilities which lack an onsite stroke neurologist should have teleconferencing systems in place to consult expert stroke neurologists at another facility. These neurologists could then remotely evaluate an acute stroke patient possibility needing tPA treatment. The group defines teleconferencing as “the use of dedicated, high quality, interactive, bidirectional audiovisual systems coupled with teleradiology for remote review of brain images.”

The main author of the statement by the AHA is Lee H. Schwamm, MD, a pre-eminent stroke neurologist at Massachusetts General Hospital. Dr. Schwamm cites preliminary work published in Neurology, which supports the notion that using telemedicine with remote neurology consultation dramatically improves acute stroke outcomes. Dr. Schwamm also raises the issue of a scarcity of stroke neurologists available in the US to see acute stroke patients (Currently, there are only four neurologists per 100,000 people in the US and many are not experts in stroke. Compare that with 700,000 acute strokes occurring annually in the US causing 163,000 deaths).

Highly critical of the statement is Dr. Robert Solomon, MD, an ER physician, and board member on the ACEP. “The committee noted a lack of comparative assessment of telemedicine to alternatives that could also improve stroke care…” notes Dr. Solomon on the supporting studies cited by Dr. Schwamm. He continues, “There seems to be an inherent assumption that if the hospital does not have a neurologist available to come to the emergency department to see the patient at the time of initial presentation, that that situation fits the definition of ‘these people don’t know what they’re doing’ and clearly they must have telemedicine with a neurologist. That’s not the reality; there are lots of hospitals where patients are getting excellent care where the neurologist is nonexistent or cannot see the patient at the time of presentation.”

Regardless, there are many obstacles to providing telemedicine at the bedside. There remain strict guidelines by Medicare on reimbursement for telemedicine consultation, only in specifically designated rural areas. Many insurers are extremely reluctant to pay for such consultation. Furthermore, there remain problems of licensing by state medical boards that restricts the out-of-state use of the technology, and liability concerns. On April 23, a bill was introduced in the House called the Medicare Telehealth Enhancement Act, which would provide $30 million to help health facilities pay for telemedicine equipment and expand Medicare reimbursement to urban and suburban areas (HR 2068 [http://thomas.loc.gov]).

Personally, I feel there would be a more direct way to deal with the shortage of stroke specialistsincrease the number of training programs. I am currently applying to neurology residency positions in the match and it seems like the average neurology class has maybe three positions. Some have one position for the entire class. Compare that with typical residency class sizes of other advanced specialties, like anesthesiology, having two or three times as many spots. 30 million dollars a year could provide a lot of neurology residency spots and stroke fellowships. Being a current applicant, maybe this is just my bias, but it seems neurology has to do more to expand training programs in the US, especially considering the rapidly aging population. The current scarcity of neurologists could very well be due to the highly inaccurate view of neurologists as “medical nihilists,” therefore useless to the medical community. Im glad that the AHA and ASA realize the urgent need in this country for neurologists and their expertise.

Telemedicine could do wonders outside the US, in desperate areas of Africa and Asia. I was lectured, by a nephrologist, on how he used teleconferencing to teach doctors at the bedside in Africa. I regularly attended grand rounds in neurology at my own medical school, which is conducted through teleconferencing between all three Boston area hospitals that make up the program. Clearly, there are educational applications for this technology. As the population continues to age and the physician shortage becomes more apparent, telemedicine and its clinical applications in the US will no doubt continue to be a hotly debated topic.

This guest post was written by Ethan Segal, MD. Ethan Segal earned a BA from Amherst College and a MD from Tufts University School of Medicine. He is currently working freelance as a medical writer and applying to residency programs for July 2010. He can be reached at Ethan.Segal(at)mac.com

Misguided health article on CNN about CRP

CNN has a story that has a misguided title (in my opinion). The story is titled, "Study suggests C-reactive protein doesn't cause heart disease." If we focus on causality, we may be missing the boat.

C-reactive protein (CRP) may not cause heart disease, but it may be a marker of underlying inflammation. Chronic inflammation may lead to coronary heart disease (CHD). If that's all true, then the title of the story can be misguiding. We often think in terms of cause and effect. If you have blood stasis (not moving), then you can form a blood clot. Cause and effect. So, if cardiovascular inflammation causes CHD, can you have inflammation without an elevation in CRP? Can you also develop CHD without any inflammation if you also have really high cholesterol levels? I think we're learning that the pathophysiology of CHD is not as simple as we learned about in medical school.

Well, if CRP doesn't cause heart disease, so what? What if CRP is an indicator of heart disease? That's the real question. It may not have a causal relationship, but that statement may be misguiding.

The JUPITER study published in the New England Journal of Medicine (NEJM) showed that a cholesterol-lowering drug Crestor (rosuvastatin) significantly reduced the incidence of major cardiovascular events in healthy-appearing patients who had low and normal cholesterol levels. This was such a groundbreaking study that it stirred significant controversy about CRP and the high-sensitivity CRP (hs-CRP).

CNN quotes the lead author of the JUPITER study in this story as "Another leading CRP researcher who isn't so sure about the findings published in the Journal of the American Medical Association (JAMA)." Dr. Paul M. Ridker, the director of the Center for Cardiovascular Disease Prevention at Brigham and Women's Hospital, in Boston, Massachusetts, said: "A null Mendelian randomization may not mean very much... While it does not support causality, I don't think most genetic statisticians believe it excludes a causal pathway either."

Are you familiar with Mendelian Randomization and Genetic Association Studies? Good, me too. The JAMA studied used this as one of its steps: " A mendelian randomization study for the most associated single-nucleotide polymorphism (SNP) in the CRP locus in our data together with published data on CRP variants with CHD let us assess the potential causal association of CRP with CHD." Did you catch all that? Good, me too.

Dr. Ridker argues that clinicians should still measure hs-CRP for the following reasons:

• A, it predicts vascular risk even when cholesterol is low and other risk factors are absent, and,
  
• B, because we have clinical trial data demonstrating that if you have an increased level of [hs-CRP], you will live longer and have fewer heart attacks and strokes if you take a statin.

Dr. Ridker goes on to say: "I have always felt that CRP is a good clinical biomarker of inflammation (and high vascular risk) but that it is inflammation that is likely to be causal for atherosclerosis, not CRP itself." To read the CNN story, click here.

MIT: The Future of Science Journalism

As a blogger, I consider myself to be an informal medical journalist. Some people like CNN's Dr. Sanjay Gupta have created tremendous careers in science and medical journalism.

This video is from an MIT presentation on science journalism. MIT President Dr. Susan Hockfield states that science journalism “is now, and in the decades ahead, absolutely indispensable.” As we confront global warming and health pandemics, science reporting must be sustained, Hockfield says, “in its rightful place, at the top of the profession and in the thick of the national conversation.”


Speakers:
Jill Abramson
Managing Editor, The New York Times

Philip Hilts
Director, Knight Science Journalism Fellowships, MIT

Cristine Russell
Senior Fellow, Harvard Belfer Center for Science and International Affairs

Andrew Revkin
Reporter and blogger, The New York Times

Ivan Oransky
Managing Editor, Online, Scientific American (previously served as deputy editor of , editor in chief of the medical student section of the Journal of American Medical Association or JAMA.

Evan Hadingham
Senior Science Editor, NOVA

The Addictive Potential of ADHD Stimultants According to JAMA

Provigil® (Modafinil) is a stimultant drug that is used to treat attention-deficit/hyperactivity disorder (ADHD). It is also a drug that is often misused by students to help them increase their study performance, and there have been many ethical debates on this issue. At what point does "off-label" cross ethical boundaries?

Recently on JAMA, an article came out titled, "Effects of Modafinil on Dopamine and Dopamine Transporters in the Male Human Brain: Clinical Implications." Can you guess what it was about? Students who are really driven are often looking for ways to increase their grades (unless they easily get straight A's and they're already at the top of their class). The misuse of stimulants has been such a hot topic recently. The authors of this JAMA article concluse that, "Because drugs that increase dopamine in the nucleus accumbens have the potential for abuse, and considering the increasing use of modafinil, these results highlight the need for heightened awareness for potential abuse of and dependence on modafinil in vulnerable populations."

What exactly does this mean? Provigil is a Class IV controlled substance and is in that class with benzos and anabolic steroids.

Medicare and Care Coordination - a disappointing study in JAMA

There's an interesting article in JAMA this month. It's titled, "Effects of Care Coordination on Hospitalization, Quality of Care, and Health Care Expenditures Among Medicare Beneficiaries"

Here's the bottom line: Care coordination programs don't seem to reduce healthcare costs among Medicare beneficiaries. This is very disappointing since you would hope that patient education would improve clinical outcomes. In this instance, nurses were contacting patients roughly twice each month. Since the patients mainly had heart failure, heart disease, and diabetes, these were patients with significant medical problems.

In my opinion, patient education that only occurs twice per month is not enough. We now have ways to automate and tailor messages. These can be sent via phone, SMS, e-mail, and a variety of other ways. When this study was designed, these resources may not have been refined like they are now. I'm sure a better study could be conducted that utilizes some of these automated technologies. After all, now we have older patients with implanted defibrillators living at home where wireless data is being captured and sent to clinicians in hospitals and offices. These types of systems can all be integrated with a robust care coordination program that can alert patients when they need to make some changes in their lifestyle before they end up being hospitalized.

Experimental Advanced Prosthetic Arm Systems

I've always loved biomedical engineering. When I went to MIT, I thought I was going to pursue a career in biomedical engineering. Now, the concept of biomedical engineering has evolved in bioengineering (tissue, molecular, and genetic biology) and of course you still have people working in biomechanical engineering (that would have been my choice many years ago).

There's a really neat story in JAMA about patients using experimental advanced prosthetic arms. Does this remind you of a movie with Arnold Schwarzenegger? I love the Terminator series. I think it's great to see advances in engineering that are improving healthcare.

Ghost writing - a dying practice

The practice of "ghost writing" seems to be dying quickly. Merck is being heavily scrutinized because of everything that happened with Vioxx, and this week, JAMA has published some case studies about this very practice.

What does all this mean for those medical communication companies that develop articles for publication in peer-reviewed journals? Well, for starters, all author information will need to be fully disclosed in every publication. We've started to see this in several journals. Clinicians are listing and acknowledging the names of writers who may be employed by medical communications companies. However, some proponents are arguing that medical communications companies should not even be involved in writing any of the content for these manuscripts. Does this mean that professional medical writers may need to start looking for other opportunities?

The buzzword these days is "transparency." Companies and clinicians must fully disclose all relevant information and be completely transparent. This is happening in the world of CME. Professional education that is CME certified should be fair-balanced, free of bias, and evidence-based. All faculty members who develop or present CME programs are required to fully disclose all affiliations that may potentially influence of bias their message.

Transparency is being taken a step further these days. In a bold move, Lilly began a new CME grant transparency process and started posting data about their CME dollars. People can see how Lilly is spending CME dollars. Take a look at their grant office registry report:

https://www.lillygrantoffice.com/grant_registry.jsp

The buzzword "transparency" will continue to permeate industry. The FDA, the OIG, and all other stakeholders will demand full transparency whenever research is published. Perhaps those ghost writing companies will need to refocus and find other opportunities...