Burnout, Dissatisfaction Seem Rampant Among Medical Residents

By Kathleen Doheny

HealthDay Reporter

Latest Mental Health News

MedicineNet.com

TUESDAY, Sept. 6 (HealthDay News) -- The medical resident of today -- possibly your doctor in the future -- is exhausted, emotionally spent and likely stressed out about debt, a new study indicates.

"About 50% of our trainees are burned out," said study leader Dr. Colin P. West, an associate professor of medicine and biostatistics at the Mayo Clinic in Rochester, Minn.

Higher levels of stress translated into lower scores on tests that gauge medical knowledge and more emotional detachment, among other fallout.

The study is published in the Sept. 7 issue of the Journal of the American Medical Association, a themed issue devoted to doctors' training.

West and his team evaluated results of surveys and exams given to nearly 17,000 internal medicine residents, who were said to represent about 75% of all U.S. internal medicine residents in the 2008-9 academic year. The participants included 7,743 graduates of U.S. medical schools. They were asked about quality of life, work-life balance, burnout and their educational debt.

Among the findings:

• Nearly 15% said their overall quality of life was "somewhat bad" or "as bad as it can be."
• One-third said they were somewhat or very dissatisfied with work-life balance.
• Forty-six percent said they were feeling emotionally exhausted at least once a week.
• Nearly 29% said they felt detached or unable to feel emotion at least once a week.
• More than half said they had at least one symptom of burnout.

 The more educational debt the residents had incurred, the greater their emotional distress, the researchers found. Those with more than $200,000 of debt had a 59% higher chance of reporting emotional exhaustion, 72% greater likelihood of suffering burnout, and an 80% higher chance of feeling depersonalization.

Perhaps more alarming is the finding that greater stress was associated with lower test scores, and those students who were academically hurt by stress never caught up with their peers.

West said he can't explain why those more laden with debt are more stressed out. One possibility is that they may be more prone to stress to begin with.

Medical residents' stress has made news for years, and efforts are under way to improve their working conditions. However, West said, "to our knowledge, this is the first national study of residents' distress issues. And it's also the first national study to connect those issues to other important outcomes like medical knowledge."

As for solutions, he said "we have not yet identified the best ways to reduce burnout and promote well-being for residents, or for physicians in general."

He hopes that this new data, now gathered nationally, will help lead to solutions.

The findings come as no surprise to Dr. Peter Cronholm, an assistant professor of family medicine and community health and also a senior fellow at the Center for Public Health Initiatives of the University of Pennsylvania.

Cronholm, who published a study on resident burnout in 2008, said the residents of today may put more emphasis on work-life balance than previous generations.

One disturbing finding, he said, is that a stressed-out resident has less empathy over time. Already, close to one-third said they felt detached emotionally at least weekly.

However, he said, it's difficult to balance obligations to patients and get sufficient sleep and personal time. "Those two things sort of continue to compete with each other," he said.

Solutions aren't available yet, as "the problem is not yet totally understood. This is part of the conversation about health care reform," he said.

Obama Administration Removes Doctor Disciplinary Files From the Web

By Duff Wilson
The New York Times: Prescriptions - The Business of Health Care
Published September 15, 2011

Three journalism organizations on Thursday protested to the Obama administration a decision to pull a database of physician discipline and malpractice actions off the Web.

The National Practitioner Data Bank, created in 1986, is used by state medical boards, insurers and hospitals. The Public Use File of the data bank, with physician names and addresses deleted, has provided valuable information for many years to researchers and reporters investigating lax oversight of doctors, trends in disciplinary actions and malpractice awards.

On Sept. 1, responding to a complaint from Dr. Robert T. Tenny, a Kansas neurosurgeon, the Health Resources and Services Administration, an agency of the Department of Health and Human Services, removed the public use file from its Web site, said an agency spokesman, Martin A. Kramer. The agency also wrote a reporter a letter to warn he could be liable for $11,000 or more in civil fines for violating a confidentiality provision of the federal law. Both actions outraged journalism groups.

“Reporters across the country have used the public use file to write stories that have exposed serious lapses in the oversight of doctors that have put patients at risk,” Charles Ornstein, president of the Association of Health Care Journalists and a ProPublica reporter, said in an interview. “Their stories have led to new legislation, additional levels of transparency in various states, and kept medical boards focused on issues of patient safety.”

Two other national journalism organizations, Investigative Reporters and Editors and the Society of Professional Journalists, joined the health reporters’ group in the letter to Mary K. Wakefield, administrator of the federal office.

“If anything, the agency erred on the side of physician privacy,” they wrote.

The entire story can be read here.

Medical Schools Teaching Little About Gay Health

By CARLA K. JOHNSON, AP Medical Writer

Future doctors aren't learning much about the unique health needs of gays and lesbians, a survey of medical school deans suggests.

On average, the schools devoted five hours in the entire curriculum to teaching content related to lesbian, gay, bisexual and transgender patients, according to the survey results appearing in Wednesday's Journal of the American Medical Association. A third of the schools had none during the years students work with patients.

More than a quarter of the medical school deans said their school's coverage of 16 related topics was "poor" or "very poor." The topics included sex change surgery, mental health issues and HIV-AIDS.

While nearly all medical schools taught students to ask patients if they "have sex with men, women or both" while obtaining a sexual history, the overall curriculum lacked deeper instruction to help "students carry that conversation as far as it needs to go," said lead author Dr. Juno Obedin-Maliver of the University of California, San Francisco.

Without such education, doctors are left guessing and can make faulty assumptions, Obedin-Maliver said. For instance, lesbians need Pap tests, which screens for the sexually spread virus that causes most cervical cancer, as often as heterosexual women do. But some doctors assume they don't need them.

"I'm an ob-gyn and I have had lesbian patients come to me and say I haven't had a Pap test in 20 years because my doctors said I didn't need one," Obedin-Maliver said.

Earlier this year, the Institute of Medicine reported that there's little research to guide doctors in the treatment of lesbians and gays. But some things are known: There are increased risks of depression, suicide attempts, homelessness and being victims of violence for lesbians, gay men and bisexuals. Lesbians and bisexual women may get less preventive care to stay healthy, and have higher rates of obesity and breast cancer.

The Association of American Medical Colleges recommends that medical schools ensure students master "the knowledge, skills and attitudes necessary to provide excellent comprehensive care" for gay, lesbian, bisexual and transgender patients.

The new findings are based on a Web-based survey that drew responses from 85 percent of U.S. and Canadian medical schools.

That's a remarkably high response rate, which shows the deans believe it's an important issue, said Dr. Raymond Curry, vice dean for education at Northwestern University Feinberg School of Medicine in Chicago.

In an accompanying editorial, Curry wrote that the researchers missed the opportunity to find out how many medical schools have gay and lesbian faculty and how many have student groups for gays and lesbians.

"Trying to assess the adequacy of a curriculum in addressing these issues is perhaps not best approached in counting hours of instruction," Curry said.

Original article in JAMA found here.

When Physicians Treat Members of Their Own Families

By J.L. Puma, C. B. Stocking, D. LaVoie, and
C.A. Carling

New England Journal of Medicine, October 31, 1991

STORIES have been told about physicians who treat their own family members, but to the best of our knowledge, this practice has not been studied. Family members may benefit; they may avoid the inconvenience and expense of an office visit and gain an especially caring, available expert who is able to interpret medical language and help them maneuver through medical systems. Physicians may also benefit; accustomed to caring for patients and surrounded by books, tools, and pharmaceuticals, they may consider attending to ill family members a natural and rewarding opportunity.

Ethical questions have been raised, however, about physicians who treat members of their own families. McSherry found incomplete physical examinations, medical records, and immunizations to be undesirable consequences of physicians' treating their own children.1 The 1901 code of ethics of the American Medical Association (AMA) noted that a family member's illness "tends to obscure [the physician's] judgement and produce timidity and irresolution in his practice."2 In 1977, a revised admonition was dropped by the AMA with other "outmoded matters of medical etiquette."3In 1989, fearing financial abuse by unscrupulous providers, Medicare barred payment to physicians who care for "immediate family members."4

In this study, in an attempt to understand current practice, we asked these questions: Which family members request advice, diagnosis, or treatment? How do physicians respond to such requests? Which, if any, requests make physicians feel uncomfortable? And under what circumstances do physicians refuse requests from family members for medical assistance?

(Jump to the discussion)

DISCUSSION

To understand current norms, we gathered empirical data on which family members ask physicians for advice, diagnosis, or treatment and how physicians respond to these requests. We also attempted to understand the dilemmas inherent in this practice. In general, physicians reported providing services to relatives in proportion to how often and by whom they were asked.

Family Members' Requests

The services family members request and the services their physician relatives offer are probably different. Family members may request care that requires a complete history and physical examination, new knowledge, or facilities that are unavailable, thus sometimes embarrassing and frustrating their physician relatives. Conversely, many young children are simply given medical care by their parents. Although most respondents reported requests from their children, we did not distinguish among children's own requests, another parent's requests for them, and the physician parent's own wish to provide care.

Physicians' Responses

Caring for family members has advantages for patients with minor illnesses, especially when the physician is in primary care, although advantages for patients near the end of life have also been described.5 Recurrent problems such as conjunctivitis and pediatric pharyngitis are usually minor, have predictable courses, and may seem too trivial to trouble an unrelated doctor about. For all patients, our medical—financial complex is best negotiated by a strong patient advocate, conveniently located and readily accessible, who is both altruistic and self-interested.

The most important diagnoses physicians gave to family members ranged from trivial to grave. The breadth of these diagnoses and the relatively narrow range of operations performed suggest that personal, psychological, and familial factors contributed to the assessment of "most important." It is uncertain whether respondents made these diagnoses informally, as knowledgeable spouses (for example, a wife asks her physician husband about a breast lump she has found, which he then palpates), or formally, as attending physicians (a physician daughter takes her father's blood pressure regularly, reviewing his age, diet, weight, medications, electrocardiogram, and family history).

Sources of Discomfort

The central reason for physicians' refusal of and discomfort with requests appears to be missing medical information. About a third of the respondents mentioned colleagues who appeared to be inappropriately involved in the care of family members, describing the care provided as inadequate or contraindicated or reporting the obstruction of other providers' care. Respondents inferred that this poor quality of care resulted from their colleagues' closeness to the patient, but this inference may be scientifically unjustified. Comparative process and outcome evaluations of care provided to patients who are family members and to those who are not would permit a more complete assessment of the quality of care.

Our data suggest that along with limiting their active participation, physicians attempt to limit their emotional involvement in family members' care. Setting limits may reflect physicians' recognition of the emotional complexity of having dual roles,6 physicians' difficulty in providing reassurance when a serious illness is suspected,2 or the problems anticipated when there is a family relationship instead of a potentially therapeutic doctor–patient relationship.

The entire article can be read here.

Thanks to Gary Schoener for this information.  Our Ethics Committee is currently working on a vignette that relates to this article.

Antipsychotics overprescribed in nursing homes

By M. Price

The Monitor on Psychology

September 2011, Volume 42, No. 8

Print Version: Page 11

Physicians are widely prescribing antipsychotics to people in nursing homes for off-label conditions such as dementia, and Medicare is largely picking up the bill, even though Medicare guidelines don't allow for off-label prescription reimbursements, according to an audit released in May by the U.S. Department of Health and Human Services Office of the Inspector General.

The findings underscore the fact that antipsychotics are often used when behavioral treatments would be more effective, psychologists say.

The office reviewed Medicare claims of people age 65 and older living in nursing homes in 2007—the most recent data at the time the study began—and found that 51 percent of all claims contained errors, resulting $116 million worth of antipsychotics such as Abilify, Risperdal and Zyprexa being charged to Medicare by people whose conditions didn't match the drugs' intended uses. Among the audit's findings are:

• 14 percent of the 2.1 million elderly people living in nursing homes use Medicare to pay for at least one antipsychotic prescription.
• 83 percent of all Medicare claims for antipsychotics are, based on medical reviews, prescribed for off-label conditions, specifically dementia.
• 22 percent of the claims for antipsychotics do not comply with the Centers for Medicare and Medicaid Services' guidelines outlining how drugs should be administered, including those guidelines stating that nursing home residents should not receive excessive doses and doses over excessive periods of time.

The report suggests that Medicare overseers reassess their nursing home certification processes and develop methods besides medical review to confirm that medications are prescribed for appropriate conditions.

Why such high rates of overprescription for antipsychotics? HHS Inspector General Daniel Levinson argued in the report that pharmaceutical companies' marketing tactics are often to blame for antipsychotics' overprescribing. Victor Molinari, PhD, a geropsychologist at the University of South Florida in Tampa, says that another important issue is the dearth of psychologists trained to provide behavioral interventions to people in nursing homes. While he agrees that people in nursing homes are taking too much antipsychotic medication, he believes nursing home physicians are often responding to a lack of options.

Many nursing home administrators are quite savvy in their mental health knowledge and would prefer to offer their residents the option of behavioral treatments, Molinari says, but when residents need immediate calming, physicians will turn to antipsychotic medication because it's quick and available. Additionally, he says, many nursing home staff aren't educated enough about nonmedical options, so they go straight for the antipsychotics.

"It follows the saying, 'If your only tool is a hammer, everything is a nail,'" he says. "Nursing homes are not just straitjacketing residents with medications as a matter of course, but because there are a host of barriers to giving them optimal care."

Suspect in child-rape scheme was never a psychologist

By Jennifer Sullivan and Bob Young
Seattle Times staff reporters


David Scratchley is not all he claimed to be, though it wouldn't be apparent if you followed his career.

The head of a Seattle drug-treatment center, Scratchley authored books, gave speeches to city employees and co-hosted a radio show. He has worked in the Seattle area at least 23 years and is regarded as a local expert on substance abuse and addictions.

David Scratchley

Scratchley, 52, flatly claimed in a recent video to be a psychologist.

He is not.

He is training to be certified by the state as a chemical-dependency counselor, according to the Department of Health.

That's just one of the mysteries and exaggerations that surround Scratchley, who was arrested early Friday and has been held without bail at the King County Jail on investigation of attempted rape of a child in the first degree and communicating with a minor for immoral purposes.

According to Seattle police, Scratchley talked with a woman about raping a 10-year-old boy at his Belltown apartment on Thursday.

The woman, who said she met Scratchley through drug treatment, contacted police Thursday afternoon after being fearful that Scratchley planned to go ahead with the sexual assault.

Police found the child inside Scratchley's apartment building and took him to Harborview Medical Center; investigators did not say whether the child had been harmed. They also found suspected cocaine in the apartment, according to a Seattle police report.

King County prosecutors said that Wednesday is their deadline to file charges against Scratchley in Superior Court.

The state Department of Health opened an investigation of Scratchley on Tuesday because of media attention surrounding his arrest, though department officials said they have never received a complaint about him.

One thing the health department will focus on is Scratchley's claim he is a psychologist.

Scratchley, clinical manager of the treatment program at the Matt Talbot New Hope Recovery Center, has never been a licensed psychologist in the state of Washington, according to Department of Health officials and records.

There is no gray area when it comes to making such a claim, said Betty Moe, a department program manager. State law prohibits anyone from calling themselves a psychologist unless they've obtained such a credential from the Department of Health.

Read the entire story here.

Nation's Jails Struggle With Mentally Ill Prisoners

By NPR staff

Three hundred and fifty thousand: That's a conservative estimate for the number of offenders with mental illness confined in America's prisons and jails.

More Americans receive mental health treatment in prisons and jails than in hospitals or treatment centers. In fact, the three largest inpatient psychiatric facilities in the country are jails: Los Angeles County Jail, Rikers Island Jail in New York City and Cook County Jail in Illinois.

"We have a criminal justice system which has a very clear purpose: You get arrested. We want justice. We try you, and justice hopefully prevails. It was never built to handle people that were very, very ill, at least with mental illness," Judge Steve Leifman tells Laura Sullivan, guest host of weekends on All Things Considered.

A failing system

When the government began closing state-run hospitals in the 1980s, people with mental illness had nowhere to turn; many ended up in jail. Leifman saw the problem first-hand decades ago in the courtroom. When individuals suffering from mental illness came before him accused of petty crimes, he didn't have many options.

"What we used to do, which I tell people was the definition of insanity [...] was they would commit an offense, the police would arrest them, they'd come to court, they'd be acting out so we would order two or three psychological evaluations at great expense, we would determine that they were incompetent to stand trial and we'd re-release them back to the community and kind of held our breath and crossed our fingers and hoped that somehow they'd get better and come back and we could try them," he says.

Instead, many disappeared and got re-arrested. Sometimes within minutes.

"They'd walk out the door, they were ill, they'd act out, because [the jail] is next to the courthouse there are several officers out there, and they'd get re-arrested," he says.

Not only was the system inefficient, it was costly as well. When Leifman asked the University of South Florida to look at who the highest users of criminal justice and mental health services in Miami-Dade County, researchers found the prime users were 97 people, individuals diagnosed primarily with schizophrenia.

"Over a five-year period, these 97 individuals were arrested almost 2,200 times and spent 27,000 days in the Miami-Dade Jail," Leifman says. "It cost the tax payers $13 million."

More information can be found here.

As military struggles with suicides, a push for seeking help

By Adam Ashton
Tacoma News Tribune

A Washington state social worker is circulating a petition urging federal lawmakers and the military to adopt a policy declaring that service members shouldn't be punished if they seek help for behavioral health issues, such as post-traumatic stress.

Patricia Bailey, 45, believes the lack of a firm policy on whether service members could be held back in their careers for seeking counseling is one of the main obstacles keeping people in the military from pursuing treatment.

"It will give reassurance to him that if he seeks mental health counseling nothing will be in jeopardy," said Bailey, whose 13-year marriage to a Joint Base Lewis-McChord soldier ended in 2008 as stress built during his deployments to Iraq.

She's targeting a gray area in the military's evolving suicide prevention and post-traumatic stress programs. Leaders at the Pentagon and at Lewis-McChord insist service members won't face professional repercussions for seeking counseling, but it's not clear how well that message reaches down the ranks.

An April study on military suicides released by the nonprofit RAND Corporation pointed out that the Defense Department hasn't taken concrete steps to reverse a perception that service members might be retired for medical reasons or lose out on a promotion if they ask for counseling. The study received funding from the Defense Department.

Bailey got a close view of Lewis-McChord's behavioral health services both as a part-time counselor between 2002 and 2004 and as someone who later reached out for help in keeping her marriage together. She'd like to see a greater emphasis on preventive programs instead of ones that kick in after an outburst, such as an arrest.

"When my husband and I were going through everything, I asked people for help," she said. "I wasn't shy. And they said 'We can't do anything for you.' You're frustrated because you can't do anything. I didn't want my marriage to end."

She's one of many people in the South Sound who are raising their voices to draw attention to the psychological toll 10 years of warfare have taken on military families. In the past year, service clubs have organized retreats for Army couples and the United Way of Pierce County put forward a proposal to deliver more resources to military families.

The military, likewise, is looking for new approaches. Madigan Army Medical Center increased its ranks of behavioral health specialists last year. Lewis-McChord recently hired a new suicide prevention officer.
Yet the Army and the base continue to struggle with how to reach distressed service members.

The Army reported that it was investigating 32 possible suicides in July, the most in any month over the past two years. Lewis-McChord officials told Sen. Patty Murray, D-Wash., that nine soldiers took their lives this year.

Read more here.

DOD, Services Work to Prevent Suicides

By Karen Parrish
American Forces Press Service

WASHINGTON, Sept. 9, 2011 – Officials know the facts about suicide in the military services, but the causes and best means of prevention are more elusive, a senior Defense Department official said today.

In testimony before the House Armed Services committee, Dr. Jonathan Woodson, the assistant secretary of defense for health affairs and director of the TRICARE Management Activity, said DOD has invested “tremendous resources” to better understand how to identify those at risk of suicide, treat at-risk people, and prevent suicide.

“We continue to seek the best minds from both within our ranks, from academia, other federal health partners, and the private sector to further our understanding of this complex set of issues,” Woodson said.

The overall rate of suicide among service members has risen steadily for a decade, he said, and DOD and the services are taking a multidisciplinary approach in their efforts to save lives.

The Defense and Veterans Affairs Departments are developing shared clinical practice guidelines that health care providers in both agencies will use to assess suicide risk and help prevent suicide attempts, Woodson said.

DOD also is working with the Department of Health and Human Services and the Substance Abuse and Mental Health Services Administration to offer critical mental health services to National Guard and Reserve members, who often don’t live close to military medical facilities, he added.

Woodson acknowledged much work remains.

“We have identified risk factors for suicide, and factors that appear to protect an individual from suicide,” he said. “As you well understand, the interplay of these factors is very complex. Our efforts are focused on addressing solutions in a comprehensive and holistic manner.”

Defense suicide prevention research includes Army ‘STARS,’ a study to assess risk and resilience in service members, Woodson said.

“This is the largest single epidemiologic research effort ever undertaken by the Army, and is designed to examine mental health, psychological resilience, suicide risk, suicide-related behaviors and suicide deaths,” the assistant secretary said.

The study, he said, involves experts from the Uniform Services University of the Health Sciences, University of California, University of Michigan, Harvard University, and the National Institute of Mental Health.

STARS is examining past data on about 90,000 active-duty soldiers, evaluating soldiers' characteristics and experiences as they relate to subsequent psychological health issues, suicidal behavior and other relevant outcomes, he said.

DOD has added more than 200 mental health professionals from the Public Health Service to medical facilities’ staffs, and is expanding access to services in civilian communities, Woodson said.

“Within the department, we have amended medical doctrine and embedded our mental health professionals far forward … to provide care in theaters of operation,” he added.

The department also has worked to collect, analyze and share data more effectively “so that the entire care team understands the diagnosis and treatment plan,” he said.

“As important as any step, we have also made great attempts to remove stigma from seeking mental health services, a stigma that is common throughout society, and not just in the military,” Woodson continued. “This is a long-term effort, but both senior officers and enlisted leaders are speaking out with a common message.”

Defense leaders are encouraged that service members increasingly now seek professional help when it is recommended, he said.

The entire article can be found here.