JAMA news releases are made available to the public after 3 pm US Central time on the first 4 Tuesdays of each month. The Archives Journals news releases are made available to the public after 3 pm Central time on Mondays. We also provide a list of previous news releases.
THIS WEEK'S CONTENT
JAMA NEWS RELEASES
(Embargoed for Release: 3:00 p.m. CT, Tuesday, September 4, 2007)
JAMA NEWS RELEASES — THEME ISSUE ON MEDICAL EDUCATION
TWO STUDIES EXAMINE MORTALITY AMONG HOSPITALIZED PATIENTS FOLLOWING WORK HOURS REFORM FOR PHYSICIANS-IN-TRAINING
PHYSICIANS WITH LOW COMMUNICATION SCORES ON EXAMS MORE LIKELY TO RECEIVE COMPLAINTS FROM PATIENTS TO REGULATORY AUTHORITIES
STUDY SUGGESTS MANY MEDICAL RESIDENTS LACK BIOSTATISTICS KNOWLEDGE NEEDED TO INTERPRET CLINICAL RESEARCH
JAMA REPORT (VIDEO SCRIPT)
VIDEO: Windows Media | Quicktime
STUDY SHOWS NO INCREASE IN PATIENT DEATH RATES AFTER CUTBACK IN RESIDENT WORK HOURS
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Embargoed for Release: 3:00 p.m. CT, Tuesday, September 4, 2007
Media Advisory: To contact Kevin G. Volpp, M.D., Ph.D., call Christine Weeks at 215-823-4159. To contact editorial co-author David O. Meltzer, M.D., Ph.D., call John Easton at 773-702-6241.
TWO STUDIES EXAMINE MORTALITY AMONG HOSPITALIZED PATIENTS FOLLOWING WORK HOURS REFORM FOR PHYSICIANS-IN-TRAINING
CHICAGO—In a national study of more than 8 million hospitalized Medicare patients, there was no increase in mortality in the first two years following duty hour reform that limited work hours for resident physicians, according to an article in the September 5 issue of JAMA, a theme issue on medical education.
“Widespread concern about the number of deaths in U.S. hospitals from medical errors prompted the Accreditation Council for Graduate Medical Education (ACGME) to implement duty hour regulations effective July 1, 2003, for all ACGME-accredited residency programs. Work limitations for residents included no more than 80 hours per week, with 1 day in 7 free of all duties, averaged over 4 weeks; no more than 24 continuous hours with an additional 6 hours for education and transfer of care; in-house call no more frequently than every third night; and at least 10 hours of rest between duty periods,” the authors write. They add that although there is evidence linking fatigue and impaired cognitive performance, the association of duty hour reform with the rate of death among patients in teaching hospitals nationally has not been well established.
Kevin G. Volpp, M.D., Ph.D., and colleagues at the Philadelphia Veterans Affairs Medical Center, University of Pennsylvania School of Medicine, and Center for Outcomes Research of the Children's Hospital of Philadelphia, studied the association between changes in the ACGME duty hour rules and death rates among 8,529,595 Medicare patients in 3,321 hospitals of different teaching intensity, analyzing data from July 2000 to June 30, 2005. The patients had diagnoses of heart attack, congestive heart failure, gastrointestinal bleeding, or stroke or a diagnosis related group classification of general, orthopedic, or vascular surgery.
The researchers found that in medical and surgical patients, no significant relative increases or decreases in the odds of death for more vs. less teaching-intensive hospitals were observed in either post-reform year 1 or 2, compared with the pre-reform years. Compared with nonteaching hospitals, the most teaching-intensive hospitals had an absolute change in death rate from pre-reform year 1 to post-reform year 2 of 0.42 percentage points (4.4 percent relative increase) for patients in the combined medical conditions group and 0.05 percentage points (2.3 percent relative increase) for patients in the combined surgical categories group, neither of which were statistically significant.
“These results do not address whether the current design of duty hour rules is optimal, as other work has found significantly lower rates of errors with 16-hour vs. 24-hour to 36-hour shifts. Given the lack of evidence of improvements in outcomes in this study, research should focus on examining different approaches to duty hour design as well as measuring resident work intensity and clinically relevant patient outcomes in addition to mortality,” the authors conclude.
(JAMA. 2007;298(9):975-983. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
RESIDENT DUTY HOUR REFORM ASSOCIATED WITH DECREASED RISK OF DEATH FOR PATIENTS AT VETERANS AFFAIRS HOSPITALS WITH CERTAIN CONDITIONS
In another study, Dr. Volpp and colleagues examined whether the change in duty hour regulations was associated with relative changes in the rate of death in hospitals of different teaching intensity within the U.S. Veterans Affairs (VA) system. The study included all patients (318,636) admitted to acute-care VA hospitals (n = 131), with data from July 2000 to June 30, 2005. All patients had diagnoses of heart attack, congestive heart failure, gastrointestinal bleeding, or stroke or a diagnosis related group classification of general, orthopedic, or vascular surgery.
In post-reform year 2, the odds of death decreased significantly in more teaching-intensive hospitals for medical patients, but not surgical patients. Compared with hospitals in the 25th percentile of teaching intensity, there was an absolute improvement in mortality from pre-reform year 1 to post-reform year 2 of 0.70 percentage points (11.1 percent relative decrease) and 0.88 percentage points (13.9 percent relative decrease) in hospitals in the 75th and 90th percentile of teaching intensity, respectively, for the combined medical conditions.
“Further assessment of how the reforms affected other clinical and educational outcomes in both VA and non-VA settings would be important before modification of the current duty hour standards,” the researchers write.
As for possible reasons for the differences in findings between these two studies by Volpp and colleagues, “they include the markedly greater mean resident-to-bed ratios at VA teaching hospitals compared with non-VA teaching hospitals, potentially greater autonomy for residents at VA hospitals, differences in staffing models and clinical volume, differing balances between the effects of decreased fatigue and worsened continuity, and potentially different degrees of unmeasured confounders,” the authors write.
(JAMA. 2007;298(9):984-992. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
EDITORIAL: EVALUATING RESIDENT DUTY HOUR REFORMS — MORE WORK TO DO
In an accompanying editorial, David O. Meltzer, M.D., Ph.D., and Vineet M. Arora, M.D., M.A., of the University of Chicago, comment on the studies in this week’s JAMA on duty hour reforms.
“These results, together with another recent large study that found some evidence of mortality reductions in medical patients in teaching hospitals following duty hour reforms using data from a large fraction of U.S. hospitals, may be reassuring to those who feared that duty hour reforms would adversely affect patient outcomes. These studies may also provide some encouraging news for others who had hoped that duty hour reforms would improve outcomes.”
(JAMA. 2007;298(9):1055-1057. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Please see the article for additional information, including financial disclosures, funding and support, etc.
For More Information: Contact the JAMA/Archives Media Relations Department at 312/464-JAMA (5262) or email: mediarelations{at}jama-archives.org.
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Embargoed for Release: 3:00 p.m. CT, Tuesday, September 4, 2007
Media Advisory: To contact Robyn Tamblyn, Ph.D., call Mark Shainblum at 514-398-2189. To contact editorial co-author Gregory Makoul, Ph.D., call Marla Paul at 312-503-8928.
PHYSICIANS WITH LOW COMMUNICATION SCORES ON EXAMS MORE LIKELY TO RECEIVE COMPLAINTS FROM PATIENTS TO REGULATORY AUTHORITIES
CHICAGO—Canadian physicians who score poorly on the patient-physician communication portion of the national licensing examination receive more complaints to regulatory authorities on issues such as communication or quality-of-care problems, according to an article in the September 5 issue of JAMA, a theme issue on medical education.
Previous research has indicated that poor skills in patient communication are associated with lower levels of patient satisfaction, higher rates of complaints, an increased risk of malpractice claims and poorer health outcomes, according to background information in the article. Medical schools have responded by incorporating training in patient communication and clinical skills in the curriculum.
Robyn Tamblyn, Ph.D., of McGill University, Montreal, and colleagues investigated the ability of clinical skills examinations (CSE) to predict future complaints in medical practice. The study included all 3,424 physicians taking the Medical Council of Canada CSE between 1993 and 1996 who were licensed to practice in Ontario and/or Quebec. Participants were followed up until 2005, including the first two to 12 years of practice. The researchers analyzed data regarding patient complaints to medical regulatory authorities against physicians in the study.
The researchers found that 1,116 complaints were filed for 3,424 physicians, and 696 complaints were retained after investigation. Of the physicians in the study, 21.5 percent had at least one complaint filed, and 17.1 percent had complaint(s) retained in their file after investigation. The majority (81.9 percent) of retained complaints were for attitude/communication and quality-of-care problems. Communication problems in management and inappropriate treatment/follow-up were the most common causes of quality-of-care complaints. A 2-standard deviation decrease in communication score was associated with a 38 percent increase in the complaint rate.
“Our results provide some feedback for medical educators and licensing authorities. Our study supports the predictive validity of providing a standardized assessment of communication skills prior to entry into practice,” the authors write. “Current examinations could be modified to test these attributes more efficiently and at earlier points in the training process. Future research should examine whether remediation of communication problems can reduce complaints, and whether other indicators of the quality of practice could be assessed by a clinical skills examination.”
(JAMA. 2007;298(9):993-1001. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
EDITORIAL: THE VALUE OF ASSESSING AND ADDRESSING COMMUNICATION SKILLS
In an accompanying editorial, Gregory Makoul, Ph.D., and Raymond H. Curry, M.D., of the Northwestern University Feinberg School of Medicine, Chicago, write on what can be done regarding communication skills.
“In terms of communication, initiatives could include more systematically assessing interpersonal skills during the admissions process, better connecting clerkship and residency experiences to earlier training in communication skills, and ensuring that clinical skills assessments include a communication component. The momentum is building. More medical schools are adopting a competency-based approach that features interpersonal and communication skills, paralleling the framework that is in place for residency programs and for maintenance of certification.”
“At the same time, clinical skills laboratories and simulated-patient expertise are now expanding within U.S. medical schools and rapidly spreading to graduate and continuing medical education. The finding that clinical skills examination scores predict future patient complaints is an important step toward establishing the value of efforts to improve both medical education and patient care.”
(JAMA. 2007;298(9):1057-1059. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Please see the article for additional information, including financial disclosures, funding and support, etc.
For More Information: Contact the JAMA/Archives Media Relations Department at 312/464-JAMA (5262) or email: mediarelations{at}jama-archives.org.
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Embargoed for Release: 3:00 p.m. CT, Tuesday, September 4, 2007
Media Advisory: To contact Donna M. Windish, M.D., M.P.H., call Karen Peart at 203-432-1326.
STUDY SUGGESTS MANY MEDICAL RESIDENTS LACK BIOSTATISTICS KNOWLEDGE NEEDED TO INTERPRET CLINICAL RESEARCH
CHICAGO—Internal medicine residents had low scores in a test of biostatistics knowledge, and about three-fourths of the residents surveyed indicated they have low confidence in understanding the statistics they encounter in medical literature, according to an article in the September 5 issue of JAMA, a theme issue on medical education.
“Physicians must keep current with clinical information to practice evidence-based medicine,” the authors write. “… to answer many of their clinical questions, physicians need to access reports of original research. This requires the reader to critically appraise the design, conduct, and analysis of each study and subsequently interpret the results.” Little is known about residents’ ability to understand statistical methods or how to appropriately interpret research outcomes.
Donna M. Windish, M.D., M.P.H., of the Yale University School of Medicine, New Haven, Conn., and colleagues conducted a multiprogram assessment of residents’ biostatistics knowledge and interpretation of research results. The study consisted of a cross-sectional survey of 277 internal medicine residents in 11 residency programs. The survey included a biostatistics/study design multiple-choice knowledge test.
The overall average percentage correct on statistical knowledge and interpretation of results was 41.4 percent vs. 71.5 percent for fellows and general medicine faculty with research training. Higher scores in residents were associated with additional advanced degrees (50 percent vs. 40.1 percent); prior biostatistics training (45.2 percent vs. 37.9 percent); enrollment in a university-based training program (43 percent vs. 36.3 percent); and male sex (44 percent vs. 38.8 percent).
On individual knowledge questions, 81.6 percent correctly interpreted a relative risk. Residents were less likely to know how to interpret an adjusted odds ratio from a multivariate regression analysis (37.4 percent) or the results of a Kaplan-Meier analysis (10.5 percent). Seventy-five percent indicated they did not understand all of the statistics they encountered in journal articles, but 95 percent felt it was important to understand these concepts to be an intelligent reader of the literature.
“The poor knowledge in biostatistics and interpretation of study results among residents in our study likely reflects insufficient training. Nearly one-third of trainees indicated that they never received biostatistics teaching at any point in their career,” they write. “Our results suggest the need for more effective training in biostatistics in residency education.”
“If physicians cannot detect appropriate statistical analyses and accurately understand their results, the risk of incorrect interpretation may lead to erroneous applications of clinical research. Educators should re-evaluate how this information is taught and reinforced in order to adequately prepare trainees for lifelong learning, and further research should examine the effectiveness of specific educational interventions.”
(JAMA. 2007;298(9):1010-1022. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
For More Information: Contact the JAMA/Archives Media Relations Department at 312/464-JAMA (5262) or email: mediarelations{at}jama-archives.org.
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JAMA REPORTS
VIDEO: Windows Media | Quicktime
STUDY SHOWS NO INCREASE IN PATIENT DEATH RATES AFTER CUTBACK IN RESIDENT WORK HOURS
INTRO:
Sleep-deprived physicians may be more prone to make mistakes. So in 2003, the organization in charge of physicians-in-training, or residents, reduced the number of hours they could work to eighty hours a week. New research says reducing those work hours has not increased patient deaths, and may have even improved patient care. Mavis Prall explains in this week’s JAMA Report.
VIDEO:
NAT SOT UP FULL FOR :03
Female resident examining female patient in hospital bed
AUDIO:
“I’m just gonna take a listen to your heart.”
VIDEO:
B-ROLL
More residents administering care to hospitalized patients
AUDIO:
DURING THEIR TRAINING, RESIDENTS PROVIDE CARE TO MILLIONS OF PATIENTS IN THE U.S. THEY USED TO WORK UP TO ONE-HUNDRED-TWENTY HOURS A WEEK. IN 2003, NEW REGULATIONS CUT THOSE HOURS TO EIGHTY.
VIDEO:
SOT/FULL
@ :14
Super: Kevin Volpp, M.D., Ph.D.
Philadelphia Veterans Affairs Medical Center
Runs :12
AUDIO:
“As a patient, you should be glad that the residents who are caring for you are probably better rested because on average they’re working fewer hours than they used to work before work hours were regulated.”
VIDEO:
B-ROLL
Sequence of Dr. Volpp at computer
GFX/JAMA COVER
More residents administering care to hospitalized patients
AUDIO:
DR. KEVIN VOLPP, OF PHILADELPHIA VETERANS AFFAIRS MEDICAL CENTER AND UNIVERSITY OF PENNSYLVANIA, IS AN AUTHOR OF TWO STUDIES IN THE ANNUAL MEDICAL EDUCATION THEME ISSUE OF JAMA, JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION. HE AND COLLEAGUES REVIEWED DATA ON MORE THAN EIGHT MILLION MEDICARE PATIENTS AND MORE THAN THREE-HUNDRED THOUSAND VETERANS AFFAIRS PATIENTS, TO SEE IF DEATH RATES CHANGED AFTER THE 2003 REDUCTION IN RESIDENT WORK HOURS. DR. JEFFREY SILBER ALSO AUTHORED THE STUDIES.
VIDEO:
SOT/FULL
@ :51
Super: Jeffrey Silber M.D., Ph.D.
Children’s Hospital of Philadelphia
Runs :07
AUDIO:
“What we found was that there was no catastrophe, there was not an increased number of deaths.”
VIDEO:
B-ROLL
More residents administering care to hospitalized patients
Patient
Resident(s)
AUDIO:
SOME PEOPLE HAD THOUGHT REDUCING RESIDENT HOURS WOULD RESULT IN INCREASED DEATHS, BECAUSE PATIENTS’ CARE WOULD BE HANDED OFF BETWEEN MORE RESIDENTS.
VIDEO:
SOT/FULL
Kevin Volpp, M.D., Ph.D.
Philadelphia Veterans Affairs Medical Center
Runs :15
AUDIO:
“There’s advantages to the system in that the average resident is going to be better rested because they’re working fewer hours. On the other hand, there may be some risks in terms of more transitions of care required because each resident is in the hospital for fewer hours.”
VIDEO:
B-ROLL
More residents administering care to hospitalized patients
AUDIO:
THAT MAY BE WHY THE WORK HOUR REDUCTION DIDN’T YIELD MORE IMPROVEMENTS IN DEATH RATES, THOUGH SOME TYPES OF V-A PATIENTS DID SEE THOSE RATES DECREASE.
VIDEO:
SOT/FULL
Kevin Volpp, M.D., Ph.D.
Philadelphia Veterans Affairs Medical Center
Runs :09
AUDIO:
“We need to continue working to try to develop better models of work hour regulation that may lead to further improvements in outcomes.”
VIDEO:
B-ROLL
Dr. Pugh standing at patient bedside
cutaway patient
AUDIO:
THIS RESIDENT SAYS IT REALLY COMES DOWN TO ONE THING.
VIDEO:
SOT/FULL
@ 1:40
Super: Meredith Pugh, M.D.
Chief Medical Resident, Univ. of PA
Runs :10
AUDIO:
“Really the goal should be to try to decrease the amount of fatigue and to provide safe options so we can continue to take good care of our patients.”
VIDEO:
B-ROLL
Residents providing care
AUDIO:
THIS IS MAVIS PRALL WITH THE JAMA REPORT.
TAG:
The authors say the improvement in some of the VA system death rates may have been due to better information for residents to use in patient care. The entire VA system has electronic health records, which improve transitions of patient care between doctors and can provide less opportunity for error. For more information, visit www.jama.com.
