PrimeCuts: This Week in the Journals

March 1, 2010

sedonaIshmeal Bradley MD

Faculty peer reviewed

As America enters Year Two of the current economic recession, unemployment and underemployment still remain incontrovertibly high. Not surprisingly, doctors, like other Americans, are working fewer hours these days, too. The New York Times published the result of a study from JAMA this week about the decline in the number of hours that physicians put in per week (1, 2). In their population survey study, they queried over 27,000 doctors from 1977 to 2007 about how much they worked in the preceding week. What they found was rather surprising.Between 1977 and 1997, the average number of weekly hours remained relatively constant at about 55 hours per week. This included both resident and non-resident physicians. However, for the next ten years, that weekly average began to drop. Between 1996 and 2008, the number of hours declined from 55 to 51, or 7.2%. This reduction was rather dramatic. For non-resident physicians, the decline in hours was 5.7%, while that for residents was 9.8% (partly due to work hour regulations implemented in 2003).

Although the advent of work hour regulations did cause resident work hours to decrease, it was not the driving force behind the cut in work hours. The study authors cite several other potential, but non-significant factors, like the increase in female physicians and younger doctors going into more “lifestyle” fields with smaller time commitments. But none of these other factors could fully explain the downward trend.

Perhaps the most significant reason was the decrease in real wages for physicians during this time period. Adjusted for inflation, the average doctor saw a 25% decrease in fees in 2006 compared to 1995. This drop in income has made doctors less likely to work longer hours if their time is not going to be compensated. Further supporting this claim are data showing that those metropolitan areas that saw the largest decline in physician salaries were also the areas that had the largest decline in physician work hours, and vice versa.

What this study highlights is the impending crisis in healthcare. Out of 630,000 physicians in the U.S., this decline in hours worked per week is equal to the net loss of 36,000 physicians. The current healthcare reform debates taking place in Washington may ultimately provide coverage for more patients, stressing an already over-burdened and understaffed system, and unfortunately, making the shortage of primary care physicians even more acute.

Since we are working fewer hours than before, what are we really doing with our time in the hospital? A study from the Archives of Internal Medicine examined the amount of time that internal medicine residents spend on documentation and clerical duties. (3) The authors surveyed nearly 86% of all U.S. internal medicine residents in 2006 about the amount of time they spend on clinical documentation and clerical duties (including notes, forms, orders, dictations) versus face-to-face patient contact time. Two-thirds of respondents said that they spend >4 hours per day doing documentation compared with 39% who said that they spend >4 hours in face-to-face patient contact. The amount of time used for non-direct patient contact continues to grow and can affect the educational impact of residency training. With rules regarding how many hours a resident can work, providing more clerical services to help with the marginal duties can allow residents more time to hone their clinical skills, which really is the purpose of training.

While on the subject of hospital-based medicine, there was plenty of discussion in the journals this week about the optimum management of critical care and surgical patients. As internal medicine housestaff rotate through the ICUs and ER, they become intimately familiar with early goal-directed therapy for sepsis management, the main principle of which is to reestablish adequate tissue perfusion as quickly as possible. Early trials have, so far, focused mainly on central venous oxygen saturation as a marker of tissue perfusion. However, continuous measurement of ScvO2 has proven difficult to incorporate into the sepsis guidelines because of the specialized equipment and technical expertise needed to place and monitor the intravenous catheter. Measuring serial serum lactate levels, though, is much easier to do. In a randomized controlled trial published in JAMA, the authors report on a non-inferiority study to see if following serum lactate levels was as effective as following ScvO2 in the management of severe sepsis and septic shock. (4)

They randomized 300 patients presenting to the emergency department into a ScvO2 group and a lactate group. All patients received the same early goal-directed care, including aggressive fluid resuscitation, ionotropic support if needed, and blood transfusion if needed. The primary endpoint was in-house mortality, with several secondary endpoints (ICU length of stay, hospital length of stay, ventilator-free days, and new onset multiorgan failure). Using intention-to-treat analysis, absolute in-hospital mortality for the two groups was 23% for the ScvO2 group versus 17% for the lactate, a difference of 6%, below the predefined -10% non-inferiority threshold. Their results add to a growing body of literature suggesting that other markers of tissue perfusion (which can be more easily obtained) other than central venous saturation can be used to monitor our septic patients.

Another possible change in critical care management may be coming. Although those of us at NYU are familiar with team ICU rounds with an intensivist, nursing, and sometimes a clinical pharmacist, that is by far not the national norm. The Archives published a retrospective study looking at the effect of multidisciplinary care teams on ICU mortality. (5) The researchers looked at medical ICU admissions and discharges at two-thirds of the non-federal acute care hospitals in Pennsylvania. Their primary outcome was 30 day mortality. Not surprisingly, they found that intensivist staffing and multidisciplinary care teams were more common in teaching hospitals and those with critical care fellowships. Multidisciplinary care teams were associated with a 16% reduction in odds of death (OR-0.84). Intensivist staffing was also associated with a 16% reduction. Together, having both an intensivist and a multidisciplinary care team resulted in a 22% reduction in the odds of death. Given the shortage of critical care physicians, their study shows that having a multidisciplinary care team can also be used to optimize medical care in the ICU and to improve patient survival.

Finally, another new trend in hospital care is worth mentioning. More and more surgical patients are being managed by internists. (6) Another study in the Archives this week examined the growth in medical hospitalist management of surgical patients between 1996 and 2006. The retrospective cohort study examined patients that were admitted for the fifteen most common surgical procedures (including cholecystectomy, CABG, hip replacement, among others). They noticed an increase of 20.5% to 31.3% of surgical patients having an internist co-managing their care over this time period. Much of this was due to the increase in hospitalist care, with an increase from 1.7% in 1996 to 12.5% in 2006. Older patients, women, and patients with more medical comorbidities were all more likely to have an internist on board. This study highlights the expanding role of the hospitalist today, namely perioperative management. This has implications for the future of residency training. Currently, the ACGME does not mandate competency in perioperative medicine. The growth in co-management of these patients may ultimately cause a shift towards more formalized education of perioperative medicine during residency. And what could this mean? More medical consult shifts at Bellevue? That’s just quite possible.

Dr. Bradley is a 3rd year resident in internal medicine at NYU Medical Center.

Sources:

1. Associated Press. Docs Cut Work Hours as Primary Care Shortage Looms. New York Times. 2010 February 24.
2. Staiger, Douglas O., David I. Auerbach, and Peter I. Buerhaus. Trends in the Work Hours of Physicians in the United States. JAMA 2010;30(8)3:747-753.
3. Oxentenko, Amy S. et al. Time Spent on Clinical Documentation. Arch Intern Med 2010;170(4):377-380.
4. Jones, Alan E. et al. Lactate Clearance vs Central Venous Oxygen Saturation. JAMA 2010;303(8):739-746.
5. Kim, Michelle M. et al. The Effect of Multidisciplinary Care Teams on Intensive Care Unit Mortality. Arch Intern Med 2010;170(4):369-376.
6. Sharma, Gulshan et al. Comanagement of Hospitalized Surgical Patients by Medicine Physicians in the United States. Arch Intern Med 2010;170(4)”363-368.

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