This Monday the 21st is the shortest day of the year and the beginning of winter. It will be very cold and very dark. On this occasion I want to call attention to something just as cold, dark, and frightening in the December issue of Academic Medicine.
It is an outstanding paper by Lorna Lynn, MD, and colleagues at the American Board of Internal Medicine reporting on the findings of a study funded by the Josiah Macy, Jr. Foundation.
The project used the evidence-based criteria for quality of care developed in the decade-long Assessing Care of Vulnerable Elders initiative conducted by the RAND Corporation and researchers at UCLA to assess the performance of resident physicians in internal and family medicine.
The results truly are terrifying. Chart audits were performed by research teams on 2,216 older adult patients seen in 52 residency clinics. Documentation of evaluations of things like gait (in the case of reported falls) averaged 28.4 % of patients in the residency clinics. Rates of screening for falls risk or cognitive impairment were under 20%. Even something as basic as recording mobility/functional status only happened 34.8% of the time.
It just gets worse. Part of the study was to assess the quality of the practice support system in the clinics (e.g., reminder systems, electronic medical records) and found that the frequency of their presence in resident clinics was very low (50% had reminders for vaccinations, 7.7% had reminders to screen for falls or falls risk, a whopping 1 practice had reminders to screen for urinary incontinence, 2 had reminders to screen for memory problems).
You might say that these are physicians in training - what do you expect? On the other hand as taxpayers we are funding graduate medical education to the tune of more than $10,000,000,000 and I believe appropriate supervision is supposed to be part of the deal. Moreover, I think the quality one sees delivered in training at least sets some standards for later practice. There can be no better way to ensure that trainees avoid primary care medicine than to allow this quality of practice to persist.
It gets even worse. If you have heard presentations on this study in various venues, you know that the other shoe still to drop in print is that there was an intervention included in the study in which residencies chose a particular area of practice for improvement (as in the PIM process) and used something like the maintenance of certification quality improvement process to try to get better. It didn't work.
The authors conclude, "The U.S. health care system is currently not meeting the needs of older adults, and it will be ill prepared to meet the needs of their rapidly increasing numbers in the coming decades unless steps are taken on several levels." Looking to the quality of care provided by future practitioners, they write, "It will be difficult for residents to be prepared to care for the elderly when they are practicing in settings that neither support nor deliver good geriatric care."
All I can say is that after Monday, the days start getting lighter. The New Year is coming. This study gives us all superb evidence to argue for real attention to the quality of training provided in the primary care disciplines. It is up to us to use it.
