EM Resident Career Path Often Influenced by Crippling Student Debt

LOMA LINDA, CA – Back in the day, emergency medicine physicians were just overwhelmed with work. Now, according to a new study, residents are likely to be buried in educational debt, as well.

A presentation at the recent Society for Academic Emergency Medicine annual meeting in San Diego notes that, in 2001, less than 20% of emergency medicine residents had more than $150,000 of educational debt.

Now, however, emergency medicine residents anecdotally report much larger debt loads, which affect their career and life choices, according to the Loma Linda University Medical Center and Children’s Hospital-led research.

Background information in the report notes that debt can limit medical school graduates’ ability or desire to pursue the career of their choosing. That, in turn, decreases the number of physicians pursuing lower-paying specialties or willing to extend their training by obtaining specialized training.

The study team sought to gain a better understanding of how emergency medicine residents experience debt by conducting individual semi-structured interviews at the healthcare system. Collecting self-reported data related to educational debt, researchers conducted 48 interviews with 98% of the residents in a single program, asking open-ended questions about how the amount of money owed influences career choices, personal life, future plans, and financial decisions.

Results indicate that median educational debt was $212,000. Study authors listed six themes they said emerged from the analysis:

  • Debt influenced career and life decisions by altering priorities.
  • Residents experienced debt as a persistent source of background stress and felt powerless to change it.
  • Residents made use of various techniques to negotiate debt to focus on day-to-day work.
  • Personal debt philosophy, based on individual values and obtained from family, shaped how debt affected each individual.
  • Debt had a normative effect and was acculturated in residency.
  • Residents reported a wide range of financial knowledge, but recognized its importance to career success.

Study authors explain that emergency medicine is a young and growing specialty with increasing subspecialty options and is near the middle of the compensation spectrum for physicians.

“Our emergency medicine residents’ debt experience is complex and involves multiple dimensions,” the researchers write. “Given our current understanding, simple solutions are unlikely to be effective in adequately addressing this issue.”



Pediatric Concussions Undercounted; Most Don’t Present at EDsCRC- ED Push Ad

PHILADELPHIA – While some children who suffer concussions — primarily those who are younger and covered by Medicaid — end up in the emergency department, the vast majority do not, according to a new study.

More than 82% of children in a study recently published in JAMA Pediatrics had their first concussion visit in a primary care setting, while 11.7% presented to an ED. Another 5% sought specialty care (sports medicine, neurology, trauma), and 1% were directly admitted to the hospital, according to the report.

The problem, according to a study team involving researchers from the Children’s Hospital of Philadelphia (CHOP) and the national Centers for Disease Control and Prevention in Atlanta, is that counts of concussion injury among children often are solely based on ED visits or on organized high school and college athletics data.

The result likely is an undercount of the incidence of concussions.

"We learned two really important things about pediatric concussion healthcare practices," recounted lead author Kristy Arbogast, PhD, co-scientific director of CHOP's Center for Injury Research and Prevention. "First, four in five of this diverse group of children were diagnosed at a primary care practice — not the emergency department. Second, one-third were under age 12, and therefore represent an important part of the concussion population that is missed by existing surveillance systems that focus on high school athletes."

Noting that concussion diagnosis is symptom-based and does not require advanced diagnostic tools such as imaging, the researchers sought to gain a better understanding of who treats children with the condition to more accurately target training and resources.

For the study, the investigative team used CHOP’s electronic health record system to describe the healthcare point of entry for concussion from 2010 to 2014. The network includes more than 50 locations throughout southeastern Pennsylvania and southern New Jersey, including 31 primary care centers, 14 specialty care centers, an inpatient hospital, two EDs, and two urgent care centers, that support more than 1 million annual visits.

During that time period, 8,083 children ages 17 years and younger — median age 13 years, mostly white, and with private insurance — had an initial in-person clinical visit for concussion. While 52% of children up to age 4 years were taken to the ED, more than three-quarters of the patients 5 to 17 years old initially visited a primary care provider. The ED also was used more often for concussion care if children were covered by Medicaid, according to the results.

"Efforts to measure the incidence of concussion cannot solely be based on emergency department visits, and primary care clinicians must be trained in concussion diagnosis and management," the study concludes.


Urine Tests Not Accurate for Water-loss Dehydration in Elderly

NORWICH, UK – In emergency departments and elsewhere, urine tests are widely employed to help determine dehydration in older patients. The problem, according to a new British study? They aren’t always very accurate.

The report was published recently in the American Journal of Clinical Nutrition.

“Although USG, urine color, and urinary osmolality have been widely advocated for screening for dehydration in older adults, we show, in the largest study to date to our knowledge, that their diagnostic accuracy is too low to be useful, and these measures should not be used to indicate hydration status in older people (either alone or as part of a wider tranche of tests),” assert study authors, led by researchers from the University of East Anglia.

Background information in the article points out that water-loss dehydration — hypertonic, hyperosmotic, or intracellular dehydration — is caused by insufficient fluid intake and is different from hypovolemia due to excess fluid losses.

Adding that water-loss dehydration is associated with poor health outcomes such as disability and mortality in older patients, study authors explain that urine specific gravity (USG), urine color, and urine osmolality have been widely advocated for screening for dehydration in older adults.

"Around 20% of older people living in residential care don't drink enough fluid, so are dehydrated. This figure rises to around 40% among older adults admitted to hospital,” added lead researcher Lee Hooper, PhD, RD. "Dehydration often goes unnoticed by carers, but it can lead to increased risk of hospital admission, urinary tract infections, disability and even death.”

For the study, researchers assessed 383 men and women aged 65 years or older living in residential care, nursing homes, or in their own homes in Norfolk and Suffolk. They measured serum osmolality to assess whether the patients were drinking enough to stay hydrated — and compared the results with urine samples taken at the same time, testing for color, cloudiness, specific gravity, osmolality, volume, glucose, and pH.

Reviewed for the study were participants in the DRIE (Dehydration Recognition In our Elders; living in long-term care) or NU-AGE (Dietary Strategies for Healthy Aging in Europe; living in the community) studies. While 19% of DRIE participants and 22% of NU-AGE participants were dehydrated with serum osmolality greater than 300 mOsm/kg, neither the USG, nor any other potential urinary tests, were found to be accurately diagnostic for water-loss dehydration.

"Assessing a urine sample is simple and cheap. But our research shows that urine tests for dehydration are not fit for purpose — either alone or as part of a wider tranche of tests,” Hooper emphasized. “They are not sensitive or specific enough. Urine tests will indicate that some people are dehydrated when they are not, but the urine tests also miss some older adults who really are dehydrated.”

The study notes that urine color can be altered by medical conditions, drugs such as warfarin, and by eating certain foods such as beetroot or blackberries. Hooper added that urinary tests “rely on normal kidney function. While urine tests do seem to be able to indicate hydration status in children and younger adults, aging is associated with impaired kidney function. As we get older we cannot concentrate our urine as well as younger people — so urine tests are not useful in older adults for indicating hydration.”

"There is a great need to develop simple, inexpensive and noninvasive tools for the assessment of dehydration in older people,” study authors conclude.


Long-term Costs to Diagnose Coronary Artery Disease Similar Despite Method

DURHAM, NC – Emergency physicians are under constant pressure to control costs, especially when using diagnostics for conditions such as heart disease.

So, which is less expensive for assessing patients with suspected coronary artery disease (CAD)? Computed tomographic angiography (CTA) or functional diagnostic testing?

A study published online recently by Annals of Internal Medicine provides an answer, suggesting that costs are similar over three years of follow-up. The Duke Clinical Research Institute-led study also included investigators from Duke University Medical Center in Durham; Massachusetts General Hospital and Harvard Medical School in Boston; and the National Heart, Lung, and Blood Institute in Bethesda, MD.

Background information in the article notes that chest pain is a common reason for patients to seek medical care. Usually clinicians rely on health history and noninvasive tests to assess for CAD, such as CTA and functional stress tests.

The recent PROspective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) trial examined the effect of these different diagnostic testing strategies for CAD on patient outcomes and found little difference between them. In a planned secondary aim of PROMISE, researchers conducted an economic analysis to assess cost differences between the two approaches.

To do so, the study team analyzed economic data for 9,649 patients enrolled in PROMISE between July 2010 and September 2013, looking at the costs of the initial outpatient testing strategy, hospital-based costs, and physician fees for the first 90 days. After estimating out for three years, data showed that an initial CTA strategy had costs similar to those of a functional stress testing strategy, although patterns of care differed.

Mean initial testing costs were:

  • $174 for exercise electrocardiography;
  • $404 for CTA;
  • $501 to $514 for pharmacologic and exercise stress echocardiography, respectively; and
  • $946 to $1,132 for exercise and pharmacologic stress nuclear testing, respectively.

At 90 days, mean costs were $2,494 for the CTA strategy vs. $2,240 for the functional strategy. Patients in the CTA group were found to have had less follow-up noninvasive testing and more invasive catheterization and revascularization. Still, after 90 days, the choice of test made little difference in costs.

An accompanying editorial from Emory University’s Clinical Cardiovascular Research Institute notes, however, that healthcare care cost comparisons "are difficult to interpret without supplemental clinical data," calling index procedure costs an "incomplete snapshot."


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