In the era of the 80-hour workweek, having surgical residents involved in trauma care might have an adverse effect on patient outcomes, researchers reported.

In a retrospective study, admission to teaching trauma centers was associated with an increased rate of major complications compared with centers that do not teach resident physicians, according to Marko Bukur, MD, and colleagues at Cedars-Sinai Medical Center in Los Angeles. Teaching center admission was also associated with an increased rate of failure to rescue patients after an in-hospital complication, Bukur and colleagues reported in the September issue of Archives of Surgery.

The researchers cautioned that the study can't tease out cause and effect, but said the findings might "add weight to the criticism that resident involvement in post-injury care is potentially hazardous in the 80-hour workweek era."

One possible explanation of the findings, they argued, is that the change in hours means resident surgeons must hand off patients more frequently than before, with the attendant risk of missed communication leading to harm to patients.

Although the analysis is "interesting and thought-provoking," it should be treated with "due caution," commented Matthew Martin, MD, of Madigan Army Medical Center in Tacoma, Wash.

A study that finds shortcomings in hospital practice should be listened to carefully, Martin wrote in an invited critique, but not necessarily believed without careful consideration. In this case, he noted, the number of factors that might confound the result "would likely run into the hundreds." Combined with the "limitations and peculiarities of the data set," there is ample reason to be skeptical of the findings, he argued.

Martin said his experience leads him to be biased in favor of teaching hospitals and "the results of this study have not significantly altered my bias." Nonetheless, the study raises important issues that need constant vigilance, he concluded.

Several studies have suggested that surgical and trauma outcomes have not been affected by the change in hours implemented by the Accreditation Council for Graduate Medical Education in 2003, Bukur and colleagues noted.

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Primary care physicians who felt "called" to practice medicine were more likely to be satisfied helping patients with difficult-to-treat conditions such as as nicotine and alcohol addiction as well as obesity, researchers found.

A survey of primary care physicians found that those who were happy with their medical careers were more likely to report "some or a lot" of satisfaction treating nicotine dependence (62%), obesity (57%), and alcoholism (50%), according to Kenneth Rasinski, PhD, of the University of Chicago, and colleagues.

However, primary care professionals who were unhappy in their careers were less likely to be satisfied treating these disorders, especially if they said they held their patients responsible, the authors reported in a research letter in the August 27 issue of the Archives of Internal Medicine.

All three conditions have been shown to respond to treatment by primary care physicians, but research also has suggested that established treatment protocols are rarely used in the primary care setting. "It may be that physicians shy away from addressing these multifaceted, often obdurate conditions because they find that treating them is unsatisfying," the authors stated. They mailed a survey to 1,504 U.S. primary care doctors (general internal medicine, family medicine, or general practice with no secondary specialty) who were 65 years or younger. The survey was conducted from 2009 to 2010 and the overall response rate was 63%.

They found a significant association with personal feelings of practicing medicine as a calling, and personal satisfaction with treating patients with nicotine dependence, (adjusted odds ratio 1.9, 95% CI 1.2 to 2.9), obesity (aOR 1.9, 95% CI 1.2 to 3.0), and alcoholism (aOR 1.6, 95% CI 1.1 to 2.6). Those who said they were dissatisfied with a medical career were significantly less likely to report satisfaction treating nicotine dependence (aOR 0.7) and alcoholism (aOR 0.6).

Similarly, physicians were less inclined to report satisfaction treating patients for alcoholism if they felt patients were "a lot" responsible for their alcoholism -- versus not at all -- at an aOR of 0.3 (95% CI 0.1 to 0.8).

The authors noted that the study was limited by self-report, bias due to nonresponders. Also, a cross-sectional study cannot determine causation, they said. They added that follow-up studies could analyze satisfaction and responsibility measures against implementation of treatment for the three conditions.

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Research over the last 10 years has shown that burnout – the particular constellation of emotional exhaustion, detachment and a low sense of accomplishment – is widespread among medical students and doctors-in-training. Nearly half of these aspiring doctors end up becoming burned out over the course of their schooling, quickly losing their sense of empathy for others and succumbing to unprofessional behavior like lying and cheating.

Now, in what is the first study of burnout among fully trained doctors from a wide range of specialties, it appears that the young are not the only ones who are vulnerable. Doctors who have been practicing anywhere from a year to several decades are just as susceptible to becoming burned out as students and trainees. And the implications of their burnout — unlike that of their younger counterparts, who are often under supervision — may be more devastating and immediate.

Analyzing questionnaires sent to more than 7,000 doctors, researchers found that almost half complained of being emotionally exhausted, feeling detached from their patients and work or suffering from a low sense of accomplishment. The researchers then compared the doctors’ responses with those of nearly 3,500 people working in other fields and found that even after adjusting for variables like gender, age, number of hours worked and amount of education, the doctors were still more likely to suffer from burnout.

“We’re not talking about a few individuals who are disorganized or not functioning well under pressure; we’re talking about one out of every two doctors who have already survived rigorous training,” said Dr. Tait D. Shanafelt, the lead author of the study and a professor of medicine at the Mayo Clinic in Rochester, Minn. “These numbers speak to bigger problems in the larger health care environment.”

The doctors’ burnout appeared to have little to do with hours worked or even the ability to balance personal life with work. Instead, the only factor predictive of a higher risk was practicing a specialty that offered front-line access to care. More than half of the doctors in family medicine, emergency medicine and general internal medicine experienced some form of burnout.

The study casts a grim light on what it is like to practice medicine in the current health care system. A significant proportion of doctors feel trapped, thwarted by the limited time they are allowed to spend with patients, stymied by the ever-changing rules set by insurers and other payers on what they can prescribe or offer as treatment and frustrated by the fact that any gains in efficiency offered by electronic medical records are so soon offset by numerous, newly devised administrative tasks that must also be completed on the computer.

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In a survey, 30% of respondents reported that either they or a family member or friend have experienced a medical error such as receiving the wrong medication, dosage or treatment.

In addition, more than one in five respondents reported having been misdiagnosed by their physician and 45% reported having received an incorrect bill from their healthcare provider.

Regardless of whether they reported having experienced a medical error, 73% of respondents said they are concerned about medical errors and 45% reported being "very concerned" about such errors. Women (76%) expressed concern on a greater scale than men (68%), as did respondents ages 35 to 54 (76%) versus those who are younger (66%).

Despite high levels of concern about medical errors, Americans have confidence in technology to help reduce mistakes, according to the survey. The majority, 68%, believe that as the healthcare field continues to adopt new technologies, medical errors likely will decrease.

The survey was conducted on behalf of Wolters Kluwer Health by Ipsos among 1,000 U.S. consumers ages 18 and older. Survey questions focused on uncovering consumer experiences with medical errors, consumer perceptions on why errors occur and patient habits to help prevent errors at the point of care.

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RIVERSIDE, Calif. — In the Inland Empire, an economically depressed region in Southern California, President Obama’s health care law is expected to extend insurance coverage to more than 300,000 people by 2014. But coverage will not necessarily translate into care: Local health experts doubt there will be enough doctors to meet the area’s needs. There are not enough now.

Other places around the country, including the Mississippi Delta, Detroit and suburban Phoenix, face similar problems. The Association of American Medical Colleges estimates that in 2015 the country will have 62,900 fewer doctors than needed. And that number will more than double by 2025, as the expansion of insurance coverage and the aging of baby boomers drive up demand for care. Even without the health care law, the shortfall of doctors in 2025 would still exceed 100,000.

Health experts, including many who support the law, say there is little that the government or the medical profession will be able to do to close the gap by 2014, when the law begins extending coverage to about 30 million Americans. It typically takes a decade to train a doctor.

“We have a shortage of every kind of doctor, except for plastic surgeons and dermatologists,” said Dr. G. Richard Olds, the dean of the new medical school at the University of California, Riverside, founded in part to address the region’s doctor shortage. “We’ll have a 5,000-physician shortage in 10 years, no matter what anybody does.”

Experts describe a doctor shortage as an “invisible problem.” Patients still get care, but the process is often slow and difficult. In Riverside, it has left residents driving long distances to doctors, languishing on waiting lists, overusing emergency rooms and even forgoing care.

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Surgery residents committed eight times as many errors during simulated procedures when realistic distractions and interruptions were introduced than when they completed procedures without interruption, investigators reported.

The residents made major surgical errors during eight of 18 simulated procedures with distractions versus only one of 18 operations that occurred without intrusions.

Additionally, more than half of the residents forgot a key memory task related to the surgery when they were interrupted as compared with 22% during uninterrupted surgery, as reported online in Archives of Surgery.

"This study provided statistically significant evidence to support the hypothesis that realistic operating-room (OR) distractions and interruptions increase the likelihood of errors in a simulated laboratory setting with novice surgeons," Robin L. Feuerbacher, PhD, of Oregon State University-Cascades in Bend, Ore., and co-authors wrote in conclusion.

"This finding is important because it implies that OR distractions and interruptions may lead to adverse patient outcomes," they added.

Despite the high error rate, the authors said the results should not be interpreted as representative of operating-room (OR) experience in general.

"It must be noted that the distractions and interruptions were timed to occur at critical points and occurred more frequently than observed in an OR," they wrote. "Consequently, these results should not be used to infer that almost half of all surgical procedures with distractions and interruptions are expected to have major surgical errors."

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“Don’t get sick in July.”

This is a common refrain in teaching hospitals. It’s driven by the academic calendar: July is when the new interns — fresh out of medical school — start work. It’s also when the senior trainees, the residents and fellows, graduate to supervisory, self-managed patient care roles. In other words, it’s when everyone is most inexperienced. The worry is that this inexperience leads to mistakes.

But what is less clear is how a doctor’s experience influences the quality of their care. On its face, it makes sense that the longer a doctor practices, the more expertise she gains — which means better care for you. But, in reality, it’s not that simple.

Say, for instance, your doctor tells you: “In my experience, this antibiotic works great for sinus infections.” Fair enough. It may also be completely true from your doctor’s perspective: when she has prescribed antibiotics in the past for sinus infections, patients got better. But statements like this make us cringe, for two reasons.

First, as it turns out, antibiotics don’t actually work for most sinus infections. In a large study published in the Journal of the American Medical Association earlier this year, people with sinusitis were randomly assigned to take antibiotics or a placebo. People treated with antibiotics did no better than those who got the sugar pill. The reason that bacteria-killing antibiotics don’t help when you have sinusitis is because the infection is almost always caused by a virus.

The second — and perhaps more cringe-worthy — part is the summoning of the phrase “in my experience” as the major reason to prescribe the drug. In the case of sinus infections and antibiotics, doctors’ experiences (and those of patients) support the wrong decision. Here’s why: the natural course of most sinus infections is to resolve on their own over time. People tend to go to the doctor — and get their antibiotics — when they are at their sickest. So they and their doctors falsely attribute their improvement to the antibiotic pills. Here, experience gets in the way of the right medical decision, which is to avoid antibiotics in the first place.

So let’s get back to the July effect and the inexperienced, error-prone interns. On one hand, some studies suggest that the July effect is a myth: a recent study examining 10 years of data on patients undergoing neurosurgery showed that July was no more dangerous than other months. On the other hand, reports have found that July patients do indeed fare worse: in a study of patients undergoing surgery for spine-related cancer, July patients were more than twice as likely to have a surgical complication and 81% more likely to die, compared with August or June patients.

A recent systematic review of all the research done on the topic concluded that many of the studies showing no July effect had small sample sizes and were not rigorously done, but the bigger and better investigations leaned toward finding that July is truly a more dangerous month in teaching hospitals.

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Prodded by efficiency pressures from managed care and the reality that most internists couldn’t feasibly do inpatient and outpatient medicine at the same time, the “hospitalist” subspecialty was created — doctors who would work full time on the inpatient side, caring for hospitalized patients on the minute-to-minute basis that they require, ideally staying fully in touch with the patient’s primary care doctor.

For better or worse, the last 15 years have solidified this model. There are now some 30,000 hospitalists, not to mention a professional hospitalist society, specialized journals and academic meetings.

There are many critics of the new model, rightly pointing out that it fragments care even more. But having practiced on both sides of the divide, I think that it is impossible to return to the old-style doc who does everything. Each job is all-consuming, and the patients require full energy and focus. There really isn’t any way to do both well.

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For over a generation now, efforts to make health care more patient-friendly have focused on getting patients and doctors to work together to make decisions about care and treatment. Numerous research papers, conferences and advocacy organizations have been devoted to this topic of “shared decision-making,” and even politicians have clambered aboard the train, devoting several provisions in the Affordable Care Act to “preference-sensitive care.”

But one thing has been missing in nearly all of these earnest efforts to encourage doctors to share the decision-making process. That is, ironically, the patient’s perspective.

Now a study published in the most recent issue of Health Affairs has begun to uncover some of that perspective, and the news is not good. In our enthusiasm for all things patient-centered, we seem to have, as the saying goes, taken the thought of including patient preferences for the deed.

The researchers conducted several focus groups with 48 patients from five primary care physicians in the San Francisco Bay area. First, they showed the patient participants a short video on several equally effective but very different treatment approaches for a heart ailment. Then, they asked them questions about what they did with their own doctors when faced with a choice among several treatment options that might be equally effective but could differ in lifestyle effects, cost or range of complications. Finally, the researchers asked the participants if they were comfortable asking doctors about different treatments, discussing their values and preferences or disagreeing with their doctors’ recommendations.

The participants responded that they felt limited, almost trapped into certain ways of speaking with their doctors. They said they wanted to collaborate in decisions about their care but felt they couldn’t because doctors often acted authoritarian, rather than authoritative. A large number worried about upsetting or angering their doctors and believed that they were best served by acting as “supplicants” toward the doctor “who knows best.” Many also believed that they could depend only on themselves for getting more information about treatments or diseases. Some even said they feared retribution by doctors who could ultimately affect their care and how they did.

The findings fly in the face of previous optimistic assumptions about shared decision-making that were based mostly on studies that examined physicians’ intent, but not patient perceptions. “Many physicians say they are already doing shared decision-making,” said Dominick L. Frosch, lead author of the new study and an associate investigator in the Department of Health Services Research at the Palo Alto Medical Foundation Research Institute in California. “But patients still aren’t perceiving the relationship as a partnership.”

Interestingly, most participants in this study were over 50, lived in affluent areas and had either attended or completed graduate school. “It’s hard to think that people from more disadvantaged backgrounds would find it any easier to question doctors,” Dr. Frosch said.

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For patients, navigating the medical system is a struggle — even when they are relatively well. It’s worse when they’re sick, such as patients with complex medical problems requiring urgent attention, like work-ups for cancer. Simply trying to coordinate appointments between specialists can be incredibly frustrating and time-consuming. And because specialists often work in individual silos, they don’t communicate with one another, leaving hapless patients and their families to shuffle themselves and their reams of information from one specialist to the next.

A recent survey commissioned by ZocDoc, which is trying to apply an OpenTable-style online scheduling model to health care, found that young adults are especially frustrated with the current health-care infrastructure. More than half of 2,000 18-to-34-year-olds surveyed said they delayed getting medical care because the process is a “pain.” More than 60% of these tech-savvy Gen Yers — who are accustomed to scheduling their lives with the touch of a screen — said they felt they were at the mercy of their doctor’s receptionist just to make an appointment.

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