A Critical Look at Medical Education

Medical students may be subject to "unrecognized influence" by the marketing efforts of drug companies and medical residents who consistently work long hours suffer impairment that is comparable to if they worked half the number of hours but had an alcoholic drink or two, according to two studies published Tuesday in the Journal of the American Medical Association.

The studies were among numerous papers and editorials included in JAMA's start of the academic year "theme" issue, which touches on some of the most pressing and contentious issues related to medical education.

Drug Companies’ Influence

One study examined the extent to which medical students are exposed to, and influenced by, the pharmaceutical industry. The authors posit, based on previous studies, that interactions with drug companies “increase the likelihood of physicians making formulary requests for drugs with no clear advantage over existing ones, prescribing nonrationally, prescribing costlier drugs, and prescribing fewer generic drugs.”

But because studies of medical students have been sparse, the authors surveyed third-year students at eight medical schools and found that they received, on average, one gift or attended one activity sponsored by a drug company each week. Most of the students believed they were entitled to gifts; two-thirds said they did not believe such gifts would influence their own practices, and 58 percent said they did not think drug company gifts would influence their colleagues.

Three in five of the students surveyed believed that grand rounds (meetings at which doctors discuss clinical cases of patients) that are sponsored by drug companies were both educationally helpful and likely to be biased in favor of the companies’ products.

A separate survey by the authors of student affairs deans at medical schools found that only 1 in 10 of those who were aware of their policies reported having schoolwide policies governing interactions between students and drug companies.

Medical students’ significant interaction with drug companies and their perceptions that their peers are more likely than they themselves to be influenced by such interactions “suggests that as a group they are at risk for unrecognized influence by marketing efforts,” the authors conclude.

'Heavy Call' and Alcohol

Another study in the JAMA special issue seeks to shed some quantitative light on the contentious issue of work-related fatigue in medical training.

To try to gauge the effects that working long hospital rotations for an extended period of time has on the neurobehavioral performance of medical residents, the researchers put four small groups of residents through a battery of tests right after they had finished work. One group was tested after “light call” (four-week rotations averaging 44 hours per week); one was tested after heavy call (an average of 80 to 90 hours per week, working through the night every fourth or fifth night); one was tested after “light call” and having been given alcohol to raise their blood alcohol concentrations to 0.04 or 0.05 grams; and one was tested after working heavy call and being given a placebo.

The researchers found that the residents who worked heavy call had reaction times that were 7 percent slower than those who worked light call, and had similar reaction times and made similar numbers of errors on various tests to those residents who had worked light call and had an elevated blood alcohol level.

The study also found that the residents generally were not aware that their performance was hurt.

“Residents must be aware of post-call performance impairment and the potential riskk to personal and patient safety,” the researchers wrote. “Because sleepy residents may have limited ability to recognize the degree to which they are impaired, residency programs should consider these risks when designing work schedules and develop risk management strategies for residents.”

Cross-Cultural Care

A third study in the JAMA issue reveals that many medical residents feel unprepared to deal fully with patients from other cultures. About a quarter of medical residents feel unprepared to care for patients whose health beliefs are at odds with Western medicine and with new immigrants, while 20 percent say they aren’t well-prepared to treat patients whose religious beliefs affect treatment.

About a quarter of residents surveyed also said they “lacked the skills to identify relevant cultural customs that impact medical care,” the researchers found.

While the residents reported receiving some instruction in “cross-cultural care” in medical school, most said they had received little or no evaluation in it during their residencies.

“These mixed educational messages indicate the need for significant improvement in cross-cultural education to help eliminate racial and ethnic disparities in health care,” the researchers conclude.

Among the other elements of the issue are:

• An editorial calling for "separate and equitable" promotion tracks for clinician-educators in medical schools.
• A study concluding that most research on the quality and nature of medical education is not formally funded, and that such research will be improved only if more funds are made available for it.