Two recent studies in the Journal of the American Medical Association report troubling news for U.S. academic health centers regarding medical residents' preparedness and the status of clinical research. While one study reveals significant gaps in medical residents' reported ability to treat certain types of patients, the other finds there is substantial concern over the health and quality of clinical research conducted in medical schools. Both studies were supported by The Commonwealth Fund Task Force on Academic Health Centers.
In "Preparedness for Clinical Practice: Reports of Final-Year Residents at Academic Health Centers" (JAMA, Sept. 15), authors David Blumenthal, M.D., Manjusha Gokhale, Eric G. Campbell, Ph.D., and Joel S. Weissman, Ph.D., report that more than one of 10 medical residents feel unprepared to handle certain treatments or procedures related to their specialties, despite years of solid training. The study, the first comprehensive analysis of resident preparedness in more than a decade, involved more than 4,800 residents in over 630 graduate medical education programs across the country.
While residents from eight specialties surveyed for the study felt prepared to handle most of the common conditions they would likely encounter in their clinical careers, surprising percentages reported they were not confident in treating less-traditional categories of patients. For example, almost a third (32%) of anesthesiology residents said they were not equipped to manage chronic pain, 19 percent of obstetrics and gynecology residents did not feel able to counsel patients about depression, and 42 percent of internal medicine residents lacked the confidence to counsel patients about domestic violence.
Among primary care residents (internal medicine, family practice, and obstetrics/ gynecology), 96 percent were "very prepared" or "somewhat prepared" to counsel patients about smoking, 94 percent about HIV testing, 91 percent about diet and exercise, 89 percent about compliance-with-care issues, 85 percent about substance abuse and depression, 74 percent about pain management, and 67 percent about domestic violence.
The authors say the implications of these reported gaps in preparedness are unclear, noting that modern medicine is complex and it is difficult to be equally competent in all areas. They also point out that there are several limitations to their study, the most important being its reliance on reports of residents to assess their preparedness for practice. Although it is possible that self-perceived preparedness has little correlation with actual competency, student perceptions are widely used in academia as an indicator of the quality of educational experience.
Overall, the data suggest that in 1998 residents finishing their training programs were satisfied with their preparedness for clinical practice. Gaps may still exist, however, in physicians' ability to manage the full range of patients, problems, and procedures they may confront as practitioners. These findings, the authors say, suggest the need for ongoing monitoring of how prepared residents are to practice medicine at the end their graduate medical education.
In the other study, "Status of Clinical Research in Academic Health Centers: Views from the Research Leadership" (JAMA, Aug. 15), Drs. Campbell, Weissman, Blumenthal, and Ernest Moy, M.D., provide the first systematic, national data on how leaders in the medical and scientific community view the quality and well-being of clinical research at these institutions. The authors find that barely more than half (52%) of research leaders at U.S. medical schools rated the health of their clinical research enterprise as good or excellent, compared with 63 percent for nonclinical research.
The study, which involved 712 department chairmen and senior research administrators at 122 accredited medical schools, also revealed prevalent concerns with the quality of clinical research being conducted at academic health centers. Respondents to the survey were most likely to rate nonclinical research as high in quality (79%), compared with 70 percent for phase 3 clinical trials, 67 percent for translational research, 65 percent for phase 1 and 2 trials, and 57 percent for health services research.
Overall, four of five research leaders considered the challenges facing clinical research at medical schools to be urgent or extremely urgent. Only half of respondents said their institutions had strategies in place to respond to these challenges.
The survey found that financial pressures are perceived as having a significant impact on academic health centers' clinical research mission. Nine of 10 of the leaders surveyed said clinical professors were being pressured to treat more patients, giving them less time to do research. The same proportion said research was being hampered by insufficient clinical revenue. These perceptions were greatest among those located in areas with high managed care penetration.
Three-fourths of respondents also cited problems recruiting trained clinical researchers, and about half said research was being threatened by competition from commercial and other nonacademic research groups. Despite health leaders' widespread concern, two-thirds of them gave positive marks to the research conducted on their own campuses.
The study's authors assert that their findings support the view that the clinical research workforce and infrastructure may need to be expanded and strengthened to keep pace with advances in basic research.
Facts and Figures
- Eighty-one percent of research leaders at academic health centers consider the challenges confronting clinical research enterprises to be urgent.
- At research-intensive centers, 72 percent of respondents said the overall health and robustness of their clinical research enterprise was good or excellent, compared with 35 percent in less research-intensive schools.
- More than 20 percent of primary care residents feel unprepared to handle nursing home, HIV/AIDS, and substance abuse patients.
- More than 10 percent of psychiatry residents feel unprepared to treat borderline personality or substance abuse, or to diagnose eating disorders.