February 14, 2011

Internal med residents graduate unprepared for primary care

Doctors who have completed training in internal medicine are in general poorly prepared for jobs as primary care physicians, most notably lacking the knowledge to best care for patients with chronic conditions such as diabetes, hypertension and high cholesterol, a new Johns Hopkins study suggests.

The researchers also found, however, that physicians who completed internal medicine residency programs at community hospitals were significantly better prepared to treat patients in an outpatient setting than physicians who trained at academic medical centers.

One likely reason for the gaps in knowledge is the focus in medical training on inpatient care at the expense of outpatient care, the bread and butter of any physician, the researchers say. Ninety percent of all doctor-patient visits are outpatient, even in specialty care.

“When I graduated from residency here, I knew much more about how to ventilate a patient on a machine than how to control somebody’s blood sugar, and that’s a problem,” said general internist Stephen Sisson, an associate professor of medicine at the Johns Hopkins University School of Medicine and leader of the study published in the January issue of The American Journal of Medicine. “The average resident doesn’t know what the goal for normal fasting blood sugar should be. If you don’t know what it has to be, how are you going to guide your diabetes management with patients?”

The need for primary care doctors is growing. And as the population ages, there is a greater need for physicians to manage chronic diseases for the long term. Studies have shown that populations with better access to good internists spend less time in the hospital and cost less to treat. Experts have long been concerned that residents are leaving training unprepared to face the sort of patients who will walk into their examination rooms, Sisson says. One-third of internal medicine residency is supposed to be devoted to outpatient care, but not all of that time is spent on primary care. Some is spent on outpatient specialty care, and some is even spent rotating through the emergency department, he adds.

“We need to change the way we teach residents,” he said. “If the mission of internal medicine residency programs is to meet society’s health care needs, then our results suggest that these training programs are failing.”

Sisson’s study looked at the performance of internal medicine residents on a curriculum created by the Johns Hopkins Internet Learning Center and used during the 2006–2007 academic year by 67 medical residency programs in the United States. The Johns Hopkins curriculum is now used by twice that many programs, serving 10,000 residents. There are 38 online training modules, in topics from cancer screening to headaches to depression, designed to supplement the lectures and clinical care of residency. Each module is written on the level of a practicing internist and the pretest, lesson and post-test take approximately 45 minutes to complete.

Sisson looked at the performance of residents at the end of the first, second and third years. At the beginning, residents from academic medical centers and community hospitals performed equally poorly. But by the end of the third year, there was a much wider knowledge gap, with community hospital residents doing better, particularly in acute care areas such as the treatment of pneumonia, dizziness and gastroesophageal reflux disease.

Still, residents at both kinds of hospitals failed to score more than 55 percent overall on topics such as chronic disease management, preventive care and acute care—exactly the type of cases a primary care doctor would encounter in private practice. Chronic disease management was the worst across the board, with neither resident type scoring above 50 percent.

The data suggest a drop-off in learning between the end of the second and third years of residency. Sisson says that some of that could be attributed to residents who have decided to pursue fellowships in specialty areas and may not try as hard to learn concepts that won’t apply to those specialties. He says that more community hospital residents tend to go into primary care, which could explain why they do better on tests of internal medicine knowledge.

Deepan Dalal also worked on the study.