One-Tenth Of Medical Residents Unprepared To Manage Clinical Issues They Will Likely Face In Practice

More than one in ten medical residents say they feel unprepared to handle certain treatments and procedures relative to their specialties despite years of solid training, according to a new study released today in the Journal of the American Medical Association. While residents in all eight specialties represented in the study felt prepared to handle most of the common conditions they would encounter in their clinical careers, a surprising one-tenth said they felt unprepared to deal with such tasks as the treatment of HIV/AIDS, substance abuse, nursing home patients, management of chronic pain, counseling patients about domestic violence as well as about depression, and certain procedures, such as spinal or cancer-related surgery. The study, conducted with support from the Commonwealth Fund Task Force on Academic Health Centers, is the first comprehensive analysis of resident preparedness in more than a decade. The findings suggest that gaps exist in the preparedness of physicians to manage the full range of patients, procedures and problems they may encounter. Residents reported a very positive view of their training to handle most common clinical problems, but expressed concern regarding the adequacy of their training for handling non-traditional patient populations, such as patients with substance abuse problems or patients in non-traditional settings such as nursing homes. "This survey tells us that residency programs may not be changing quickly enough to keep up with the reality of medical practice today. We may be seeing a residency-practice mismatch," said David Blumenthal, M.D., M.P.P., lead study author, and director of the Institute for Health Policy, Massachusetts General Hospital/Partners HealthCare System. "Teaching hospitals and medical schools need to provide residents with quality training that reflects the diversity of the patients they will one day treat." Conducted in 1998, the survey provides benchmark data from 4,832 residents in 632 graduate medical education programs across the country and assesses resident preparedness in eight specialties: internal medicine, pediatrics, family practice, obstetrics/gynecology, psychiatry, general surgery, orthopedic surgery, and anesthesiology. It was conducted by Blumenthal, Manjusha Gokhale, M.A., Eric G. Campbell, Ph.D. and Joel S. Weissman, Ph.D.of the Institute for Health Policy at Massachusetts General Hospital and Partners HealthCare System. Among the findings of the study:

• 42 percent of internal medicine residents feel unprepared to provide patients domestic violence counseling.
• More than 20 percent of primary care residents feel unprepared to handle nursing home patients, HIV/AIDS patients and substance abuse patients.
• 32 percent of anesthesiology residents feel unprepared to manage chronic pain.
• 19 percent of obstetrics and gynecology residents feel unprepared to counsel patients about depression.
• More than 10 percent of psychiatry residents were unprepared to treat borderline personality, substance abuse, provide short-term or long-term psychotherapy, diagnose and treat patients with loss/bereavement issues, treat somatization, or to diagnose and treat eating disorders.
• 38 percent of orthopedic surgery residents feel unprepared to perform spinal surgery.

The authors note that the complexity of modern medicine makes it difficult to gain equal competence in all areas, and some residents will go on to get additional training that will prepare them better for some conditions, such as pain management among anesthesiologists, vascular surgery among general surgeons, or spinal surgery among orthopedists. "Undoubtedly, some future physicians will avoid treating problems they feel unprepared to manage," said Blumenthal. "And the high level of preparedness shown by residents in most areas should provide reassurance to those concerned about the overall quality of graduate medical education in the United States." Blumenthal notes that given the impact of market pressures and other stresses on academic health centers, the research provides a more positive picture than anticipated of how well these institutions are doing at protecting their educational missions.