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Teaching Hospital Update - March 14-18, 2011

By Adam Mingal and Leah Voigt*

Primary Care Again a Top Choice on Match Day

Family medicine residency match rates increased for the second year in a row, up 11% over 2010, according to the National Resident Matching Program. The organization said these programs continued to experience the strongest growth in the number of positions filled by U.S. seniors, who took nearly half of the 2,708 family medicine residency slots. U.S. seniors also preferred pediatrics and internal medicine, filling up 1,768 of the 2,482 pediatric slots (up 3% from last year) and 2,940 of 5,121 internal medicine positions (up 8%).

"This is good news for internal medicine and adult patient care in the U.S.," J. Fred Ralston Jr. MD, president of the American College of Physicians (ACP), said in a statement. The organization appeared guarded, however, adding that the primary care work force still has "a long way to go" to meet the needs of an aging population with various chronic diseases.

"We're cautiously optimistic and hope that the positive trend continues, but the U.S. still has to overcome a generational shift that resulted in decreased numbers of students choosing primary care as a career," Steven Weinberger, MD, executive ACP vice president and CEO, said in the statement. Weinberger noted that in 1985, nearly 4,000 medical school graduates chose internal medicine residency programs, and the 19% of seniors who matched internal medicine programs this year is the same as it was in 2007.

Overall, a total of 16,559 medical school seniors sought to be matched—489 more than in 2010. When factoring in students of osteopathic medicine and those at international medical schools, there were 37,735 applicants seeking to fill more than 26,000 positions, the total number of which increased by 638 since 2010. Just over 94% of medical school seniors matched to a first-year residency program, 81% of them nabbing one of their top three choices.

More seniors also sought positions in emergency medicine—filling 1,268 of 1,607 spots—as well as anesthesiology and neurology. The most competitive fields were dermatology, orthopedic surgery, otolaryngology, plastic surgery, radiation oncology, thoracic surgery, and vascular surgery, according to the National Resident Matching Program. The match uses an algorithm to line up applicant preferences with those of residency programs at U.S. teaching hospitals.

Kristina Fiore, Primary Care Again a Top Choice on Match Day, MedPage Today (Mar. 17, 2011).

Study: When Nurse Staffing Drops, Mortality Rates Rise

When nurse staffing levels fell below target levels in a large hospital, more patients died, a new study discovered. The finding may provide guidance in an era of nursing shortages and cost-cutting, in that the focus should shift from cost to patient safety, said the authors of the research, appearing in the March 17 issue of the New England Journal of Medicine.

"Hospitals need to know what their nursing needs are for their patients, and they need to bring staffing into line," said the study's senior author, a professor of health services at the School of Public Health of the University of California, Los Angeles. "Patients are entitled to be safe in the hospital and to have care delivered reliably and to have nurses with enough time to make sure they aren't developing avoidable complications with permanent consequences," he said.

Previous research has suggested that this might be the case, but many of those studies were dismissed in part because of methodology flaws. "People had thought maybe [adverse consequences] were due to something else, maybe the quality of the nurses, quality of the doctors, technology, equipment or the hospital doesn't have a commitment to quality," the study's senior author explained.

For this study, the authors looked at almost 200,000 admissions and about 177,000 nursing shifts at forty-three patient units at one hospital that generally had high staffing targets. Presumably, different areas of the hospital had the same quality of nurses, doctors, technology, and equipment, thus eliminating these factors as the source of problems.

Units were considered properly staffed if nursing staffing fell within eight hours of the target level. When units were understaffed, patient mortality increased by 2%. On average, a patient stayed in the hospital for three shifts and when they were all understaffed, mortality rose by 6%. And when nurses had to work harder because of high patient turnover on their unit, the mortality risk increased by 4%.

Amanda Gardner, When Nurse Staffing Drops, Mortality Rates Rise: Study, BusinessWeek (Mar. 16, 2011).

Tufts Nurses Protest Over Hospital Staffing

Tufts Medical Center nurses are ratcheting up their heated contract dispute with the Boston teaching hospital. Nurses say that recent cuts in staff and other changes in how they deliver care mean that nurses are caring for more patients at one time on nearly every unit. These changes, they say, have transformed the hospital from one of the best staffed in Boston to the worst.

For example, according to figures derived from a public database posted by the Massachusetts Hospital Association, each Tufts nurse in pediatrics cares for at least 1.4 critical care patients, compared with 1.03 patients at Massachusetts General Hospital, the nurses union says.

To compensate for chronic understaffing, Tufts is forcing nurses to work overtime and to "float" from one area of the hospital to another, where they might not be competent, according to the Massachusetts Nurses Association. The group represents 1,200 nurses at the hospital and is trying to prohibit these practices in a new contract. Even so, nurses said that there are delays in assessing patients, giving them medications and tests, and in changing bed linens, as well as more falls because nurses cannot get to the bedside as quickly to help patients walk.

Liz Kowalczyk, Tufts Nurses Protest Over Hospital Staffing, Boston Globe (Mar. 16, 2011).

Report: State Boards Don't Punish All Doctors Sanctioned by Hospitals

State medical boards have failed to discipline 55% of the nation's doctors who were sanctioned by the hospitals where they worked, according to a report released this week by Public Citizen. The consumer advocacy group analyzed data in a federal clearinghouse from 1990-2009 for disciplinary action and medical malpractice payments against doctors.

Of 10,672 physicians listed in the National Practitioner Data Bank (NPDB), about 55%, or 5,887 doctors, had been disciplined by hospitals but escaped any licensing action by the state during the entire twenty-year period. The hospital discipline was to restrict or revoke the physicians' clinical privileges. Among the most serious violations, which involved 2,071 of the 5,887 physicians who were not disciplined, were doctors who posed an immediate threat to health or safety, were incompetent or negligent, or provided substandard care, the study found.

Other categories that triggered hospital action serious enough to be reported to the federal data bank included sexual misconduct, fraud, and narcotics violations. Less serious disciplinary violations included alcohol or other substance abuse, and practicing beyond the scope of privileges.

Lena H. Sun, Report: State Boards Don't Punish All Doctors Sanctioned by Hospitals, Washington Post (Mar. 16, 2011).

Patients Trust Physicians Most to Protect Personal Data

Patients trust their doctors over other parties, such as insurers, the government, and employers, to protect their health information. But some believe electronic medical records (EMR) may make their data less secure, according to a survey.

In late January, CDW Healthcare surveyed 1,000 American adults who had visited a physician or hospital in the past eighteen months. Sixty-eight percent said their physician office was responsible for protecting their personal health information, and 67% trusted their doctor's office the most to maintain that information. Employers were least trusted, at 7%.

In addition to health information, the majority of survey respondents 79% said they believed their doctors' offices were responsible for protecting their financial information, 91% said personal identifying information, and 94% said family information. When asked what impact EMRs would have on privacy protections, 40% said they would have a somewhat negative effect, and 9% said they would have a significantly negative impact. Only 27% said EMRs would have a somewhat or significantly positive effect.

Even though physicians are the most trusted, "they have to be aware that right now your patients have a big, big concern about going to the electronic medical record, and I think part of the onus is on the physician to ease those feelings for their patients," said CDW Healthcare vice president.

Pamela Lewis Dolan, Patients Trust Physicians Most to Protect Personal Data, Am. Med. Ass'n (Mar. 15, 2011).

AHLA Teaching Hospital Updates are intended to provide quick summaries of cutting-edge issues of interest to teaching hospitals and their counsel. Additional information and more in-depth coverage on these topics may be available from AHLA Health Lawyers weekly and appropriate AHLA Practice Groups.

*We would like to thank Adam Mingal, JD (Washington, DC), and Leah Voigt, Esquire (Squire Sanders & Dempsey LLP, Washington, DC), for providing this week's update.

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