“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 nearly a century, the third year of medical school has been a pivotal point in training, a crucial step in the development of professional skills and attitudes toward patients. Recently, however, the tradition of monthlong “rotations” – a speed-dating introduction to the major disciplines of medicine and the issues patients face – has come under fire.

During their third year, medical students are under constant pressure to perform for an ever-changing group of senior physicians, who in turn must evaluate the students based on brief interactions. Sailing through as many as six disciplines in just under a year, students have opportunities for only transient relationships, garnering mere snapshots of their patients’ illnesses and lives.

Not surprisingly, studies have shown that these experiences result in “ethical erosion.” Students’ sense of empathy and bedside manner deteriorate, and many begin to refer to their patients not as people but as diseases, that dehumanizing shorthand of the wards.

Now a growing number of educators are working to reinvent the crucial third year of medical school. A recent article in the journal Academic Medicine explains how one program has successfully eliminated traditional block rotations, promoting instead yearlong relationships between students and their patients and capitalizing on the patient-centered values and humanistic impulses that led the students to medicine in the first place.

Since 2004, the Harvard Medical School-Cambridge Integrated Clerkship has assigned every third-year medical student to a “panel” of up to 100 patients to care for over the course of the year. Students see their patients in the clinics of the Cambridge Health Alliance health system where the program is based, but also follow and assist with any outside consultations, admissions to the hospital, operations and even home visits. During the year, students are also required to shadow several assigned preceptors, senior physicians from the major specialties, in their clinics every week.

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Mimicking an illness is far more than play-acting.

"It's absolutely key to medical student training," said Dr. Paul Paulman, professor of family medicine and assistant dean for clinical skills and quality at the University of Nebraska College of Medicine. The clinical training department oversees the use of "standardized patients" to help teach medical students.

"The students can make errors, and they're not going to cause harm," Paulman said. "You can be observed and get feedback, and you can stretch out the encounters.

Doctors must have good communication skills, he said. "People who are fearful and ill are not at their best. If there's not a relationship developed, the physician isn't going to give good care and the patient is not going to receive good care."

Standardized patients work one-on-one with medical students and also come to classrooms, where students practice dealing with difficult situations such as talking about reproductive issues, delivering bad news and dealing with adolescents or angry patients.

Sometimes students will use a manikin to practice a procedure, such as chest compressions, while simulated family members become upset and do things that might distract a doctor or nurse — a realistic situation that students must learn how to manage.

"We pull our training from real life," Paulman said, and the students love it.

"Would you rather do a paper case or would you rather talk to a human?" he said. "This is what we're going to do for the rest of our lives, so let's practice the real thing. We want to be able to parallel the real world as closely as we can."

To add more reality to the training and bolster its cast of about 70 standardized patients, the college is seeking more minorities, including Hispanics, and young people who are available during daytime class hours.

Source.

New York State’s prestigious teaching hospitals could lose more than $1 billion a year as part of plans under negotiation in Washington to reduce the federal deficit that the hospitals say will lead to drastic service reductions.

The cuts would reduce the Medicare subsidy for training doctors and for providing intensive medical services like trauma centers and burn units and sophisticated equipment that the teaching hospitals offer. The plan would apply to teaching hospitals nationwide but would have its most profound impact in cities like New York and Boston, where medical schools and their affiliated hospitals have a significant presence.

Dating to the 1960s, the subsidy has helped make New York State the world capital of medical education, training about 16,000 doctors a year, or 14.5 percent of the nation’s total, more than any other state.

The benefits have been criticized for years by both conservatives and liberals who see them as a sweetheart deal for teaching hospitals in a few states. But now, with the pressure on the federal budget, they are being seriously considered in talks among the Obama administration and leaders of both parties in Congress.

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Innovating and Updating the Medical School Curriculum
Presented by the Josiah Macy, Jr. Foundation and the New York Academy of Sciences

Overview
The New York Academy of Sciences recently launched the Translational Medicine Initiative, which through ongoing programming at the Academy provides a unique, recurring forum that unites physicians with basic researchers, industry and academic scientists, public health experts, and regulatory personnel to spark an interdisciplinary and scholarly discussion of recent breakthroughs and remaining challenges in translating basic science into clinical applications. The inaugural event of this initiative titled "Innovating and Updating the Medical School Curriculum," sought to assess innovative models for training physicians so that a new generation will be prepared to face the challenges of practicing medicine in the 21st century.

Despite vast advances in biomedical research and
technology, the medical school curriculum has
remained mostly static for the past half century.
However, several medical schools have begun to
implement innovative curricula based on new
methods of physician training and new technologies
for learning. The goals of this conference were to
highlight these new models for physician training
motivated by advances in science and technology,
and to consider how to effect widespread revision
of the standard medical school learning methods.

On June 23, 2010, at the New York Academy of Sciences, 191 participants, including medical school deans, faculty, and students; physicians; governing board members; accrediting institution members; Continuing Medical Education administrators; and health profession educators convened to discuss these innovative curricula and the use of new technologies in medical school education.

Read the entire overview.

Listen to a panel discussion: How to Use Technology as an Educational Tool