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September 22, 2009JAMA news releases are made available to the public after 3 pm US Central time on the first 4 Tuesdays of each month. The Archives of 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 CONTENTS
JAMA NEWS RELEASES — Theme Issue on Medical Education
(Embargoed for Release: 3 p.m. CT Tuesday, September 22, 2009)
JAMA REPORT (VIDEO SCRIPT)
INFORMATION CONTAINED IN THESE NEWS RELEASES IS PROTECTED BY COPYRIGHT. JOURNAL ATTRIBUTION IS REQUIRED. JOURNALISTS CAN NOW ACCESS EMBARGOED JAMA/ARCHIVES STUDIES ON-LINE. Go to www.jamamedia.org for more information and to apply for access. TV Note: This week's JAMA Report video is on a program to help reduce physician burnout. The report will be fed Tuesday, September 22, from 9:00 - 9:15 a.m. ET and 2:00 - 2:15 p.m. ET, on Galaxy 28 (C-Band), Transponder 15, downlink frequency: 4000 vertical, audio 6.2/6.8. For more information, call 312/464-JAMA. The JAMA Report video is also now available on Pathfire every Tuesday, in VNF Provider A. Please look for the JAMA Report tab. Please Note: Because JAMA does not publish on the 5th Wednesday of a month, there will be no JAMA or news releases for September 30. Please Note: The FOR THE MEDIA website now has a search feature to enable media to find previous JAMA/Archives news releases on specific medical topics. This search feature link is located on the home page at www.jamamedia.org EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), Tuesday, September 22, 2009
Where Physician Completed Obstetrical Residency May Provide Quality of Care Indicator
CHICAGO—A ranking of obstetrics and gynecology training programs based on the maternal complication rates of their graduates' patients found these rankings consistent across individual types of complications, suggesting that these rates may reflect measures of overall quality, according to a study in the September 23/30 issue of JAMA, a theme issue on medical education. "Many physicians and nonphysicians likely assume that some residency programs tend to produce better physicians than others—either because those residency programs train physicians better or because those residency programs can recruit more capable trainees. Although plausible, these intuitions have not been empirically tested," according to background information in the article. The authors add that this information could be useful in several ways, including indicating what makes certain programs better; and helpful to patients selecting a physician. "Some patients might already be preferentially seeking physicians who have graduated from programs they believe to be elite, but without the evidence to support their intuition." David A. Asch, M.D., M.B.A., of the Philadelphia Veterans Affairs Medical Center and University of Pennsylvania, Philadelphia, and colleagues examined whether obstetrics and gynecology (OB) residency programs could be evaluated according to the risk-adjusted rates of maternal complications of the patients of the graduates of these programs. The study included data on Florida and New York obstetrical hospital discharges between 1992 and 2007, representing 4,906,169 deliveries performed by 4,124 obstetricians from 107 U.S. residency programs. Maternal complications were analyzed separately by delivery mode, including vaginal and cesarean births reflecting laceration, hemorrhage, and all other complications after vaginal delivery; hemorrhage, infection, and all other complications after cesarean delivery; and composites for vaginal and cesarean deliveries and for all deliveries regardless of mode. The researchers found that adjusted rates of complications from physicians trained in the top-quintile (fifth) programs were substantially lower than from those physicians trained in the bottom-quintile programs. "All else equal, a woman choosing an obstetrician who trained at a program in the top tier would face a 10.3 percent risk of a major complication compared with 13.6 percent if she chose an obstetrician trained at a program from the bottom tier," the authors write. "In general, the bottom-quintile programs had complication rates approximately one-third higher than those of the top-quintile programs." The rankings of residency programs based on each of the measures were similar. "More generally, residency programs that produced physicians with low adjusted rates of one complication also produced physicians with low adjusted rates of other complications." Adjustment for medical licensure examination scores did not substantially change the program ranking. "To our knowledge, these findings provide the first empirical support for widely-held intuitions about the clinical implications of variation in medical education. The often large and uniformly positive correlations across the 9 separate measures lend support to the view that rates of individual complications track together at the level of the residency program and suggest that these rates may reflect good measures of overall quality," the researchers write.
"These results may have important implications for patients," they add. "If these findings are confirmed and refined, women might select obstetricians in part by where they were trained. The general consistency in programs' rankings despite different measures of quality supports the validity of the measures and also suggests that top programs may be likely to produce physicians who are better in unmeasured ways as well."
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 JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org. EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), Tuesday, September 22, 2009
Many Medical Schools Report Incidents of Students Posting Unprofessional Content Online
CHICAGO—A majority of medical schools surveyed report they have experienced incidents of students posting unprofessional content online, including incidents involving violation of patient confidentiality, with few schools having policies to address these types of postings, according to a study in the September 23/30 issue of JAMA, a theme issue on medical education. Internet applications built around user-generated content, termed Web 2.0, include social networking sites (e.g., Facebook, Twitter), media-sharing sites (e.g., Flickr, YouTube), blogs, wikis, and podcasts. A risk of these sites in the posting of unprofessional content online that can reflect poorly on individuals, affiliated institutions, and the medical profession, according to background information in the article. "Medical schools are tasked with establishing the foundation of professional behavior in a generation of students who use Web 2.0 and expect digital connectedness. There are few data to document unprofessional behavior in medical student-posted online content. Also, the adequacy of current institutional professionalism policies, given these new challenges, is unknown," the authors write. Katherine C. Chretien, M.D., of the Washington D.C. VA Medical Center, and colleagues examined reported incidents of medical students posting unprofessional content online at U.S. medical schools. An anonymous survey was sent to deans of student affairs, their representatives, or counterparts from each institution in the Association of American Medical Colleges. Data were collected in March and April 2009, with 60 percent of U.S. medical schools responding (78/130). The researchers found that of the schools that responded, 60 percent (47/78) reported ever having incidents involving students posting unprofessional content. "In the past year, 13 percent (6/47) of these had no incidents, 78 percent (36/47) had fewer than 5 incidents, 7 percent (3/47) had 5 to 15 incidents, and 2 percent (1/47) had some incidents but did not know how many. Incidents involving violation of patient confidentiality in the past year were reported by 13 percent (6/46). Student use of profanity, frankly discriminatory language, depiction of intoxication, and sexually suggestive material were more commonly reported. Issues of conflict of interest were rare," the authors write. "Of 45 schools that reported an incident and responded to the question about disciplinary actions, 30 gave informal warning (67 percent) and 3 reported student dismissal (7 percent). Policies that cover student-posted online content were reported by 38 percent (28/73) of deans. Of schools without such policies, 11 percent (5/46) were actively developing new policies to cover online content. Deans reporting incidents were significantly more likely to report having such a policy (51 percent vs. 18 percent), believing these issues could be effectively addressed (91 percent vs. 63 percent;), and having higher levels of concern." According to the researchers, there are a number of actions that medical schools could take that might address some of the concerns raised by these findings. "The formal professionalism curriculum should include a digital media component, which could include instruction on managing the 'digital footprint,' such as electing privacy settings on social networking sites and performing periodic Web searches of oneself. This is important given that residency program directors, future employers, and patients may access this information."
"Discussions among students, residents, and faculty should occur to help define medical professionalism in the era of Web 2.0."
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 JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org. EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), Tuesday, September 22, 2009
Among Resident Physicians, Higher Levels of Fatigue, Distress Associated With Self-Perceived Medical Errors
CHICAGO—Internal medicine residents who reported higher levels of fatigue and distress were more likely to report a medical error, according to a study in the September 23/30 issue of JAMA, a theme issue on medical education. "Medical errors and patient safety continue to be an important concern for patients and physicians, especially since the Institute of Medicine reported in 1999 that between 48,000 and 98,000 Americans die each year due to preventable adverse events," according to background information in the article. "Fatigue and distress have been separately shown to be associated with medical errors. The contribution of each factor when assessed simultaneously is unknown." Colin P. West, M.D., Ph.D., of Mayo Clinic, Rochester, Minn., and colleagues assessed the independent contributions of fatigue and distress to self-reported medical errors when considered simultaneously. The study included data provided by 380 internal medicine residents who began training from 2003 to 2008 and completed surveys quarterly through February 2009. The surveys included self-assessment of medical errors, overall quality of life (QOL) and fatigue; and measures of burnout, depression, and sleepiness. The average response rate to individual surveys was 67.5 percent. Of the 356 participants (93.7 percent) providing error data, 39 percent reported making at least 1 major medical error during the study period. In analyses, there was an association of subsequent self-reported error with measures of sleepiness and fatigue score. Each 1-point increase in fatigue or sleepiness score was associated with a 14 percent and 10 percent increase, respectively, in the odds of reporting a medical error. Subsequent error was also associated with burnout, a positive depression screen and overall QOL. "Fatigue and distress variables remained statistically significant when modeled together with little change in the point estimates of effect. Sleepiness and distress, when modeled together, showed little change in point estimates of effect, but sleepiness no longer had statistical significance associated with errors when adjusted for burnout or depression," the researchers write.
"In summary, this study suggests that fatigue, sleepiness, burnout, depression, and reduced QOL are independently associated with an increased risk of future self-perceived major medical errors. In addition to the national efforts to reduce fatigue and sleepiness, well-designed interventions to prevent, identify, and treat distress among physicians are needed. Additional research is necessary to determine the most effective strategies for accomplishing these goals. Changes to the process of physician training should address both resident fatigue and distress in an effort to improve resident and patient safety," the authors conclude.
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 JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org. EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), Tuesday, September 22, 2009
Program for Physicians Emphasizing Self-Awareness Associated With Improvements in Burnout, Mood and Patient Empathy
CHICAGO—Primary care physicians who participated in an educational program that included an emphasis on mindful communication reported improvement in personal well-being, emotional exhaustion, empathy and attitudes associated with patient-centered care, according to a study in the September 23/30 issue of JAMA, a theme issue on medical education. "Primary care physicians report alarming levels of professional and personal distress. Up to 60 percent of practicing physicians report symptoms of burnout, defined as emotional exhaustion, depersonalization (treating patients as objects), and low sense of accomplishment. Physician burnout has been linked to poorer quality of care, including patient dissatisfaction, increased medical errors, and lawsuits and decreased ability to express empathy," according to background information in the article. The authors add that another consequence of physician burnout is a decline in the percentage of graduates entering careers in primary care in the last 20 years, with reasons related to burnout and poor quality of life. "Even though the problem of burnout in physicians has been recognized for years, there have been few programs targeting burnout before it leads to personal or professional impairment and very little data exist about their effectiveness." Michael S. Krasner, M.D., of the University of Rochester Medical Center, Rochester, N.Y., and colleagues designed a continuing medical education (CME) course to improve physician well-being. "One proposed approach to addressing loss of meaning and lack of control in practice life is developing greater mindfulness-the quality of being fully present and attentive in the moment during everyday activities," the researchers write. The course is based on 3 techniques: mindfulness meditation, narrative medicine, and appreciative inquiry. "Mindfulness meditation is a secular contemplative practice focusing on cultivating an individual's attention and awareness skills. Both narrative medicine and appreciative inquiry involve focusing attention and awareness through telling of, listening to, and reflecting on personal stories." Seventy primary care physicians participated in the course, which included an 8-week intensive phase (2.5 hours/week, 7-hour retreat), followed by a 10-month maintenance phase (2.5 hours/month). The course included mindfulness meditation, self-awareness exercises, narratives about meaningful clinical experiences, appreciative interviews, didactic material and discussion. Physicians were surveyed before, during and after the course regarding levels and measurements of mindfulness, burnout, empathy, psychosocial orientation, personality and mood. "Our study demonstrated that primary care physicians participating in a CME program that focused on self-awareness experienced improved personal well-being, including burnout (emotional exhaustion, depersonalization, and personal accomplishment) and improved mood (total and depression, vigor, tension, anger, and fatigue). They also experienced positive changes in empathy and psychosocial beliefs, both indicators of a patient-centered orientation to medical care that has been associated with patient-centered behaviors such as attending to the patient's experience of illness and its psychosocial context and promoting patient participation in care," the authors write.
"The skills cultivated in the mindful communication program appeared to lower participants' reactivity to stressful events and help them adopt greater resilience in the face of adversity," they add. "Further study will be necessary to investigate the effects on practice efficiency, patients' experience of care, and clinical outcomes."
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. Editorial: Enhancing Meaning in Work
Tait Shanafelt, M.D., of the Mayo Clinic, Rochester, Minn., writes in an accompanying editorial that physicians will likely face many new challenges over the next decade as the nation reforms its health care system.
"Although many physicians may be tempted to respond to this challenge by retreating from work (e.g., more time off, reduced scope of practice, retirement), the study by Krasner and colleagues demonstrates that training physicians the art of mindful practice has the potential to promote physician health through work. Physicians continue to control the most sacred and meaningful aspect of medical practice—the encounter with the patient and the reward that comes from restoring health and relieving suffering. Reminding physicians of this fact and helping them recognize and enhance the meaning they derive from the practice of medicine may help protect against burnout and promote patient-centered care for the benefit of both physicians and their patients."
Editor's Note: Please see the article for additional information, including financial disclosures, funding and support, etc. For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org. EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), Tuesday, September 22, 2009
Surgery Residents Indicate Satisfaction With Training, But Concerns With Confidence, Career Motivation
CHICAGO—A survey of nearly 4,500 general surgery residents finds that the majority are satisfied with their training and relationships with faculty and peers, but also indicated concerns regarding motivations for pursuing surgical careers and the need to complete specialty training, according to a study in the September 23/30 issue of JAMA, a theme issue on medical education. General surgery residency training is facing formidable pressures, including less attraction to surgery as a profession, increasing interest in surgical subspecialization, and estimated attrition rates of 17 percent to 26 percent among categorical general surgery residents, rates that are higher than other medical residencies, according to background information in the article. "At the same time, a substantial shortage of general surgeons is predicted. Strategies responding to these complex and competing challenges can be informed by understanding general surgery residents' attitudes and experiences regarding training, and their association with attrition," the authors write. Heather Yeo, M.D., M.H.S.R., of the Yale University School of Medicine, New Haven, Conn., and colleagues conducted a survey in January 2008 of U.S. general surgery residents to characterize their attitudes, experiences, and expectations regarding residency training and to identify predictors of attrition from residency training. Of 5,345 categorical general surgery residents, 4,402 (82.4 percent) responded, representing 248 of 249 surgical residency programs. The researchers found that the majority of respondents (3,686, 85.2 percent) expressed high levels of satisfaction with training. "The majority of respondents (71.6 percent) reported that their program has support structures for residents who are struggling and that they can turn to the faculty when having difficulties in the program (71.9 percent). Residents generally reported very positive collaborative relationships with peers, with [84.2 percent] indicating that they can count on other residents to help them out when they are having a problem," the authors write. A series of items examined various sources of stress and concern among residents. "Notable proportions of residents reported feeling uneasy or troubled by aspects of training and skill development," the researchers write. Of the respondents, 30.7 percent reported that the stress of work is causing strain on their family life. Also, 27.5 percent expressed apprehension about their clinical skills, worrying that they will not feel confident enough to perform procedures by themselves before they finish training, while 63.7 percent reported worry about hurting patients. Additionally, 63.8 percent of respondents indicated that they will need to complete additional specialty training in order to be competitive in the job market. Regarding selected items analyzed by sex, men were more likely to report being satisfied with residency training than women, and women were more likely to have considered leaving residency during the prior year; men were more likely to feel their training program would provide them with someone to turn to when they are struggling and to feel they can turn to members of the faculty when having difficulties in the program. "Reports of having considered leaving training in the prior year differed significantly across years, highest in postgraduate year 2 (19.2 percent) and lowest in postgraduate year 5 (7.2 percent)," the researchers add.
"This baseline descriptive study ...may help inform efforts to respond to the complex pressures facing the surgical profession, including the ability to attract and retain increasingly diverse general surgery residents and the projected shortage of general surgeons in the coming decades," the authors conclude.
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 JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org.
JAMA REPORTS
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MINDFUL COMMUNICATION MAY HELP PHYSICIANS BATTLE BURNOUT
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