Thursday, August 07, 2014

What residents teach us about residency programs

Medscape has issued its 2014 Residents Salary and Debt Report.  Here are some interesting charts, along with their associated description and my commentary:

Although 25% of residents have no debt, over a third (36%) still owe more than $200,000 after five years in residency. The Association of American Medical Colleges (AAMC) reports that the median four-year cost to attend medical school for the class of 2013 is $278,455 at private schools and $207,868 at public ones. Given these high tuitions, resident indebtedness has risen much more rapidly than inflation or resident compensation. According to the AAMC, medical school debt has increased by 6.3% since 1992 compared with the Consumer Price Index increase of 2.5%.

Perhaps, as we consider the high cost of health care in America, we should factor in the need for doctors to recover their education costs, something not necessary in many countries of the world, where there is little or no tuition charged to medical students.

When asked about relationships with nurses and physician assistants, there was very little difference in the opinions of male and female residents, with 62% of women and 66% of men saying that their relationships were very good to excellent. The most common complaint among write-in comments from residents with poorer relationships was the lack of respect paid to them by nurses. A small study of pairs of residents and nurses found a lack of shared perception and expectations.

Here's where many residents live in a dreamworld.  Their perception of the positive relationship with nurses is, in my experience, off-base.  There is extremely little communication at all--measured in minutes per day, and then often in machine gun format: "Do this."  When I've talked to nurses, they often say that the residents don't respect their abilities and greater knowledge of the patient's status.  Many residents display a lack of trust in nurses, and this does not go unnoticed by the nurses.

A number of studies have found a decline in idealism among medical students beginning as early as the second year of school. The Medscape survey suggests that idealism declines further during residency. In comparing responses by residents in post-med school years 1-4 with years 5-8, a shift occurred, with fewer residents finding patient gratitude rewarding in the later years (61%) compared with in their early years (67%), and more residents in later years looking to make "good money" (43% versus 36%). Authors of a 2014 study commented that as "students make choices in their medical careers, such as specialty choice or consideration of primary care, the influences of job security, student debt and social status increasingly outweigh idealistic motivations."

So we start with highly motivated and idealistic young people and beat it out of them!

Female residents tend to cite more idealistic rewards of their job than male residents do, with 72% of women selecting patient relationships compared with 62% of men. And only 28% viewed money as rewarding compared with 43% of men.

Remind me to request a female resident next time I am in the hospital!

When residents were asked to give their opinions on the quality of their training, 43% thought their own was superior and 29% felt that it was equal to others'. This was an informal opinion, based on perceptions only.

This is similar to the Lake Wobegon effect. Once you've matched, you really want to believe that you've made the right choice. 

We know, from hundreds of residents who attend the Telluride summer patient safety camps, that most trainees get virtually no training in quality and safety, in obtaining truly informed consents, in disclosure and apology for medical error, and in reporting adverse events and near misses.  In that regard, virtually all training programs are substandard and don't meet the requirements the ACGME says are expected.


Barry Carol said...

I’m not sure if the increase in average debt coming out of medical school is attributable to more of the student body coming from less wealthy families than previously or the underlying cost of educating a doctor is rising faster than general inflation. If it’s the latter, I don’t understand why that is as medical schools are presumably not subject to the same pressure as undergraduate universities to beef up administrative staff and increase expensive amenities like dorms, dining facilities, fitness centers, student unions, etc. to enhance what’s called the student life experience as opposed to academic excellence.

Anonymous said...

Their perception of the positive relationship with nurses is, in my experience, off-base. There is extremely little communication at all--measured in minutes per day, and then often in machine gun format: "Do this."

I don't agree. I am a nurse who works in a military hospital and I believe our relationships with our surgeons are very collegial. We are a team. We enjoy working with them and appreciate the work they do; that respect and camaraderie is returned.

Paul Levy said...

I'm happy for you. Maybe it is different in the military.

Anonymous said...

At Beth Israel Deaconess Medical Center Urology the Resident was standing outside the examining room door. The patient greeted the Resident in the hallway, the Resident closed the examining room door isolating patient and Resident MD from one another. There's got to be a better response for good doctor-patient communication. Later when the Resident entered and after the consultation with the Resident an Attending MD turned up for a few moments not really establishing good doctor-patient communication in the examining room. An insensitive intimidating arrangement, a bad clinic setup. Followup hampered because the Urology Department didn't have the name of the Resident and contact information. For all the claims about the medical center, the claims didn't pan out in practice... "We Never Forget That Before You're A Patient, You're A Person"