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4月27日 医療一般

From Medscape Medical News
Fewer Medical Students Choosing General Internal Medicine Careers
Emma Hitt, PhD

April 25, 2011 ― Compared with graduating medical students in 1990, students in 2007 were more satisfied with internal medicine (IM) training but were more likely to select a subspecialty rather than chose general practice in IM, a new study has found.

Mark D. Schwartz, MD, from the New York University School of Medicine, New York City, and colleagues reported their findings in the April 25 issue of the Archives of Internal Medicine.

"The United States faces a troubling shortage in its primary care medical workforce," Dr. Schwartz and colleagues note, and add that "the United States is not prepared to meet the health care needs of the growing number of older adults."

According to the researchers, earlier studies indicated that the number of medical students matching into IM residency positions decreased 32% from 1985 to 2008. Furthermore, the number of US students selecting residency training in primary care IM decreased by 54% between1999 (575 US medical students) and 2008 (264 US medical students.) In addition, those choosing to practice general IM after residency training declined from 54% in 1999 to 20% in 2008.

In the current study, the researchers sought to compare responses from a secondary analysis of 2 similar surveys of senior medical students: one conducted in 1990 (1244 students at 16 schools; response rate, 75%), and the other conducted in 2007 (1177 students at 11 schools; response rate, 82%).

A similar proportion of students planning careers in IM, including both general and subspecialty careers, was reported in 1990 (24%) and 2007 (23%); however, plans to practice general IM dropped from 9% to 2% (P < .001). The researchers also found that the appeal of primary care as an influence toward IM declined from 57% to 33% (P < .001) from 1990 to 2007.

They also found that more women surveyed in 2007 than in 1990 (52% vs 37%; P < .001), and that there was greater educational debt (mean, $101,000 vs $63,000; P <.001).

Both cohorts thought that workload and stress were greater in IM than in other fields; however, more students in 2007 reported a high level of satisfaction with the IM clerkship (78% vs 38%; P < .001). In addition, students in 2007 felt that opportunities for meaningful work in IM were greater than did students in 1990 (58% vs 42%; P < .001).

"Persistent unfavorable perceptions of income disparity, workload, and stress appeared to counter the gains from perceptions of meaningful work," Dr. Schwartz and colleagues note.

They also pointed out that the income gap between generalist and subspecialist physicians is now nearly 3-fold what it was, resulting in an income disparity of $3.5 million throughout a 40-year career.

Limitations of the study include its self-report survey design, which can introduce social desirability bias; the possibility that the samples did not accurately represent the demographics of graduating classes from 1990 and from 2007; the inability to assess the influence of becoming a hospitalist on career choices for students, as that specialty was unavailable in 1990; and a lack of appreciation of the differences between general and subspecialty IM by some medical students.

"To rebuild the generalist physician workforce, improving students' experience of IM in medical school is no longer sufficient," the authors conclude. "Bolder payment and practice reform will be required to reduce the remuneration gap between primary care and subspecialty physicians and to address the adverse work conditions in general IM that students identify in clerkships."

The 1990 study was funded by the American College of Physicians and the American Board of Internal Medicine. The 2007 study was supported by the Shadyside Hospital Foundation of Pittsburgh, Pennsylvania, and the American Board of Internal Medicine Foundation. The authors have disclosed no relevant financial relationships.

Arch Intern Med. 2011;171:744-749.

WSJ BLOGS / Health Blog : WSJ's blog on health and the business of health.
Med Students Like Internal Medicine OK. Primary Care? Not So Much.

By Katherine Hobson
APRIL 25, 2011, 5:47 PM ET

Despite some efforts to make primary care more appealing to med students and residents, there’s still a shortage of those doctors looming ― particularly with more people gaining coverage under the health-care overhaul law.

A study just published in the Archives of Internal Medicine compares med students’ attitudes about internal medicine careers in 1990 and 2007. And it finds that while about the same percentage of med students ― 23% in the earlier survey of 1,244 students, and 24% in the later survey of 1,177 students ― plan internal med careers, the proportion planning to go into primary care fell to 2% from 9%.

And the appeal of primary care as a reason to go into internal medicine fell to 33% from 57%.

Med students are “drawn more to what they see from specialties,” Mark Schwartz, a study author and associate professor of medicine at NYU Langone Medical Center, tells the Health Blog.

Med schools have made efforts to improve the quality of the internal-med educational experience, Schwartz says. But there may not be much more room for them to boost the appeal of the career ― not when there’s an estimated $3.5 million lifetime income gap between generalist and sub-specialist doctors, and the average respondent in the 2007 survey reported $101,000 in educational debt.

To significantly shore up the appeal of primary care with more money and improved work-life balance, “bolder payment and practice reform” are necessary, the authors write:

Such policies include expanding scholarships and loan repayment opportunities for those choosing primary care training and practice, addressing physician work-life concerns by carefully designing patient-centered medical home models to reward visits that are not face-to-face and promote a satisfying and sustaining clinician experience and helping primary care physicians slow the productivity treadmill by shifting away from the fee-for-service system driven by volume incentives to one driven by value incentives.

The authors note that many of those measures are part of pilot programs included in the health-care overhaul law.

As the WSJ has reported, however, where the rubber meets the road on incentives ― at least for Medicare, which also drives Medicaid and private reimbursement ― is the Relative Value Scale Update Committee, known as RUC, which is made up of physicians who decide how to divvy up the Medicare pie between types of procedures and visits.

Any tipping of the financial balance from specialties to primary-care doctors would likely have to take root there, and primary-care docs have argued that the makeup of the committee makes that unlikely.

Changes in Medical Students' Views of Internal Medicine Careers From 1990 to 2007
Mark D. Schwartz, MD; Steven Durning, MD; Mark Linzer, MD; Karen E. Hauer, MD
Arch Intern Med. 2011;171(8):744-749. doi:10.1001/archinternmed.2011.139
April 25, 2011

Background The United States faces a shortage of primary care physicians and declining number of medical students choosing primary care careers.

Methods We conducted a secondary analysis of 2 similar national surveys of senior medical students from 1990 and 2007 that addressed student characteristics, specialties chosen, clerkship experiences, perceptions of internal medicine (IM) compared with other specialties, and influential aspects of IM. We compared responses from 1990 and 2007 by analyzing a merged data set of identical items from the 2 surveys (65% of the items).

Results The total sample of 2421 students comprised 1244 at 16 schools in 1990 (response rate, 75%) and 1177 at 11 schools in 2007 (82%). In 2007, there were more women (52% vs 37%, P < .001) and more educational debt (mean, $101 000 vs $63 000, P < .001). Similar proportions of students planned IM careers (23% vs 24%), although plans to practice general IM dropped from 9% to 2% (P < .001). The appeal of primary care as an influence toward IM declined from 57% to 33% (P < .001). More 2007 students reported high satisfaction with the IM clerkship (78% vs 38%, P < .001). Both cohorts thought that workload and stress are greater in IM than in other fields. Students in 2007 felt that opportunities for meaningful work in IM were greater than did students in 1990 (58% vs 42%, P < .001).

Conclusions More students in 2007 than in 1990 viewed IM as a potentially meaningful career. However, the 2007 students had higher debt, more negative perceptions of workload and stress in IM, and less career interest in general IM. To rebuild the generalist physician workforce, improving students' experience of IM in medical school is no longer sufficient. Bolder reform will be required to improve the educational pipeline, practice, and payment of generalist IM physicians.

地域医療の現状学ぶ 大分大医学科6年生
[2011年04月27日 10:06] 大分合同新聞




2011年4月27日 10:24 [治療]|[医療全般]


 アイルランド、ユニバーシティ・カレッジ・コーク校医学部ヒューマンファクター(人間工学)教授のTony Gallagher氏らは、外科医に非常に高度な認知力と知覚力を要求する低侵襲の腹腔鏡手術に着目し、2つの研究を実施した。1つ目の研究では、腹腔鏡スキル初心者である科学専攻大学生16人を対象に、模擬手術の前夜に禁酒、あるいは酔った状態になるまで飲酒させた。2つ目の研究では、専門医8人に飲みたいだけ飲むことを許可した。


 研究の結果、学生の飲酒群と禁酒群の指定時刻でのスコアに有意差はなかったが、飲酒者のほうがミスは多かった。専門医でも飲酒に関係する同様の問題がみられたが、差は午後1 時にピークに達し、午後4時までには横ばい状態になった。ミスは1日中みられたが、午後1時時点で統計学的に有意であった。また、過剰飲酒の翌朝はベースラインよりも手技の速度が速かったが、研究者らによればこれは「抑制の喪失」によるものという。禁酒した対照群の学生ではディナー前後のミスの発生率に差がみられなかった。

 Gallagher氏は「外科医やその他の医療従事者は手術前夜に過剰飲酒してはならないことは明白である。過剰の定義は、外科医団体が定義する必要のある問題である」と述べている。研究結果は、医学誌「Archives of Surgery(外科学)」4月号に掲載された。(HealthDay News 4月18日)

Copyright (c) 2011 HealthDay. All rights reserved.

Arch Surg. 2011 Apr;146(4):419-26.
Persistent next-day effects of excessive alcohol consumption on laparoscopic surgical performance.
Gallagher AG, Boyle E, Toner P, Neary PC, Andersen DK, Satava RM, Seymour NE.
MRCS, National Surgical Training Centre, Royal College of Surgeons in Ireland, RCSI House, 121 St Stephen's Green, Dublin 2, Ireland. emboyle@rcsi.ie.

OBJECTIVE: To examine the effect of previous-day excessive alcohol consumption on laparoscopic surgical performance.

DESIGN: Study 1 was a randomized controlled trial. Study 2 was a cohort study.

SETTING: Surgical skills laboratory.

PARTICIPANTS: Sixteen science students (laparoscopic novices) participated in study 1. Eight laparoscopic experts participated in study 2.

INTERVENTIONS: All participants were trained on the Minimally Invasive Surgical Trainer Virtual Reality (MIST-VR). The participants in study 1 were randomized to either abstain from alcohol or consume alcohol until intoxicated. All study 2 subjects freely consumed alcohol until intoxicated. Subjects were assessed the following day at 9 am, 1 pm, and 4 pm on MIST-VR tasks.

MAIN OUTCOME MEASURES: Assessment measures included time, economy of diathermy use, and error scores.

RESULTS: In study 1, both groups performed similarly at baseline, but the alcohol group showed deterioration on all performance measures after alcohol consumption. Overall, although the time score differences between the 2 groups were not statistically significant (P = .29), there was a significant difference between the 2 groups' diathermy (P < .03) and error (P < .003) scores. There was also a significant effect for time of testing (P < .003), diathermy (P < .001), and errors (P < .001). In study 2, experts demonstrated a similar postalcohol performance decrement for time (P < .02), diathermy (P < .001), and error scores (P < .001).

CONCLUSION: Excessive consumption of alcohol appeared to degrade surgical performance the following day even at 4 pm, suggesting the need to define recommendations regarding alcohol consumption the night before assuming clinical surgical responsibilities.

PMID: 21502449 [PubMed - in process]

2011.4.27 14:31 産經新聞




2011/04/27 09:30 四国新聞





参院委で山下氏 指針見直し要求




 山下氏は、全壊した8病院のうち6病院が公立病院だと指摘。「沿岸過疎地で救急を担い、過疎地の医療を支えてきた地域の基幹病院だ」と強調するとともに、多くの病院が地震直後から、(1)入院患者の避難(2)緊急の治療・救命(3)患者・住民に対する救護・医療(4)安全な場所への患者の移送 (5)医療支援チームの取りまとめ―などの役割を果たしてきたと紹介しました。




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