Tuesday, March 24, 2015

2015 Match Review

Continuing grim news for international med school grads and some US grads too

There were a lot of happy faces on March 20th as depicted in this brief video of the excitement on the campus of the University of Rochester School of Medicine. Similar scenes took place at every US medical school because 93.9% of the 18,025 graduates of US allopathic medical schools matched in a specialty.

But for the 1093 (6.1%) US graduates who didn't match things were not so bright. These applicants had to go through the Supplemental Offer and Acceptance Program (SOAP) which connects unfilled programs with unmatched students.

Because there were over 8600 unmatched graduates from schools all over the world vying for about 1200 unfilled first-year residency positions, even some US med school grads did not secure a position. One of these unfortunate souls tells her story in this blog.

The 7400 or so new MDs left out in the cold will not be able to pursue their careers. They will not progress into any specialty, nor will they be able to obtain licenses to practice medicine anywhere in this country. Those with substantial tuition debt will have no way to pay off their loans.

The percentage of unmatched US graduates has been relatively stable over the last five years, ranging from 4.9% to 6.3% while the number of first-year residency positions offered has steadily increased by nearly 4000 from 23,420 in 2011 to 27,293 this year.

Graduates of osteopathic medical schools didn't fare quite as well. Of the 2949 osteopathic school applicants, 610 (20.7%) went unmatched, but this percentage has steadily declined from a high of 28.3% in 2011.

International med school grads were much worse off; 2354 (46.9%) US citizens and 3725 (50.6%) non-US citizen graduates of international medical schools did not match. Both of these groups also had declining percentages of unmatched applicants. In addition, about 1900 US citizen graduates of offshore schools either withdrew or did not submit a rank list compared to almost 2700 non-US citizen international graduates who did likewise.

Reentering the match next year is an option, but spending a year outside of clinical medicine greatly reduces one's chances of finding an accredited position.

If you factor in the number of applicants who either withdrew from the match for did not submit a rank list. graduates of international medical schools have well below a 50% chance of matching.

In previous posts here and here, I have warned about the risks involved with attending an offshore medical school. If you are considering attending such a school, I urge you to look at the numbers and think long and hard about your decision.

Source: Advance Data Tables 2015 Residency Match

Thursday, March 19, 2015

Patients vs. doctors

A JAMA Viewpoint article suggests that doctors should be aware that patients may be surreptitiously recording their conversations. The author, a neurosurgeon, takes a very benign view of this issue and recommends that if a doctor suspects that patient is recording a conversation, "the physician can express assent, note constructive uses of such recordings, and educate the patient about the privacy rights of other patients so as to avoid any violations."

He also says this would show that the physician was open and strengthen the relationship between the doctor and the patient. I'm not so sure.

Here's a different perspective. If a patient is secretly recording a conversation, the relationship between him and the doctor is already in serious trouble. What I would do is to tell that patient to find another doctor.

If a patient asked me if it was OK to record our conversation, I would agree, but I would also want to record it to preserve a complete copy.

This comes on the heels of another privacy and trust question—should doctors google their patients? There is no consensus on this, but having read several discussions on the topic, most writers feel that googling patients should only be done for certain narrow reasons which you can read here.

Most medical societies have not weighed in on the subject, but I would guess when guidelines are published, they will discourage the practice. But of course, patients may google physicians at will.

Taking it to another level, Dr. Jeremy Brown, Director of the Office of Emergency Care Research at the National Institutes of Health, recently proposed that emergency physicians should be equipped with body cameras to record audio and video of patient encounters.

Leaving aside such questions as who owns the videos, how to store the vast amount of data, and what impact this would have on the performance of the individual physicians, body cameras would establish an adversarial relationship that is unnecessary for the overwhelming majority of doctors and patients.

A physician interaction with a patient begins on terms quite different from those of a police officer interacting with a suspect in which the adversarial relationship is already established. The increasing number of controversial and highly publicized cases involving police and suspects has resulted in a need to protect both parties. This need seems much less pressing in medicine.

Where does this end? Should all patients be equipped with body cameras too in case the physician copy "gets lost"?

It is sad to realize how far we have sunk as a profession.

Wednesday, March 11, 2015

Blame the patient

The other day some cardiologists on Twitter were discussing whether a patient should be blamed if a permanent pacemaker lead became displaced. The consensus seemed to be that it was probably poor placement (i.e., operator error), rather than patient behavior that caused leads to dislodge.

The discussion reminded me of an attending plastic surgeon of mine during my resident days. He was one of the most obsessive-compulsive people I ever met. When he applied a dressing, he always cut the tape with scissors instead of tearing it. He felt that torn tape looked sloppy, and that if a patient saw a ragged edged of torn tape, she might think that the surgical procedure itself had been done without meticulous care too.

When he wrapped a hand, he used a very bulky dressing with yards and yards of carefully cut, not torn, tape over the ace bandage to prevent from slipping or unraveling.

But my favorite eccentricity was what he told patients who had any sort of facial surgery. He had a thing about the role of movement of skin possibly causing scars to separate and permanently widen.

So he gave this written instruction to every patient who had so little as a facial mole removed, "Do not talk or chew for 10 days."

Think about it. Could any patient possibly comply with that? Some of us more cynical types figured that should a scar not have turned out perfectly, the conversation might have gone like this.

Surgeon: "About your scar, you must have talked or chewed during the first 10 days after surgery."
Patient (sheepishly): "Well doc, I must admit I did say a few words, and I had to eat something."

Monday, March 9, 2015

Why I blog and tweet

I have reached a new milestone. My work has been published in a a real journal, the Canadian Journal of Anesthesia. I was asked to write an editorial about social media--"Why I blog and tweet."

If you would like to read it, the full text is available here.

Sunday, February 22, 2015

Dr. Topol's bad day

Dr. Eric Topol is a cardiologist, author, editor-in-chief of Medscape, and genomics professor. In 2009, he was named one of the 12 Rock Stars of Science by none other than GQ magazine.

But even rock stars occasionally have a bad day. After blogging for almost 5 years, I sometimes have trouble thinking of things to write about. This apparently happened to Dr. Topol the other day. He published a Medscape article with an accompanying video about how doctors are being squeezed by many outside forces that require them to do things they don't want to do.

It was kind of a rambling discourse in which he suggested that doctors should offload the responsibility to do these "more mundane aspects of care" to the patients. He thinks this would make medicine more exciting "the way it used to be."

Dr. Topol offered this cartoon to illustrate the outside forces that are squeezing doctors.

Genomics is a focus of Dr. Topol's research, but I don't think a lot of doctors are concerned that they lack knowledge about it.

His post created a lot of controversy prompting Medscape to take down all of the comments.

With great foresight, one physician, Dr. Kristin Held, preserved her comment with a screenshot which I have thoughtfully provided for you below.

What do you think she really wanted to say with the start of her second paragraph? Could it have been "How about growing a _ _ _ _ of _ _ _ _s?

Like Dr. Held, I have no idea which of the "mundane aspects of this new world" Dr. Topol had in mind to offload on the patients. Of the 16 forces squeezing doctors that he illustrated, I don't see many of them being taken over by patients. They already control patient satisfaction and what's written on Yelp. Maybe they can cover the lack of genomic knowledge too.

It's sad that an influential doctor like Topol is so lost in the woods. However, the bright side is that gave me something to write about.

Thursday, February 19, 2015

Don't trust the abstract; read the whole paper

Above are the results and conclusion from an abstract of a paper called "Single-Incision Laparoscopic Cholecystectomy: Will It Succeed as the Future Leading Technique for Gallbladder Removal?" It appears online in the journal Surgical Laparoscopy, Endoscopy & Percutaneous Techniques.

It is another great example of why you need to read the entire paper and not just the abstract.

The methods section says that the study involved 875 patients with prospectively collected data. Don’t be fooled by prospectively collected data. This research is retrospective.

Here are some issues.

Monday, February 16, 2015

Medicare is changing the way it pays surgeons

Starting in 2017, Medicare will end global payments for operations. The current payment scheme combines preoperative, operative, and postoperative care into one fee. When the change occurs, each of those events will have to be billed separately—otherwise known as “unbundling.”

I missed this news when it first appeared late last year and thank one of my blog followers who calls himself Artiger for bringing it to my attention. An Advisory Board piece summarized the situation.

After analyzing a number of claims, Medicare came to the conclusion that it was paying for duplicate services. What a revelation! I could have told them that without a claims analysis.

For many years, certain surgical specialists have been delegating preoperative evaluations for “medical clearance” and postoperative management of everything but the incision to internists and hospitalists. Since the global fee was meant to include pre-and postop care, Medicare was indeed paying twice for the same service.

Representatives of the American College of Surgeons expressed concern that sicker patients would need more in-hospital postoperative visits thereby incurring more bills. [If they receive more care, maybe they should pay more.] They also worried that since postoperative care was covered under the global fee, patients might forgo office visits after surgery because of increased costs.

The unbundling of the global fee may have other unintended consequences. Since preoperative and postoperative care reimbursement will be separated from the fee for the operation itself, surgeons will be paid less for performing surgery.

Most surgeons would rather operate than make rounds and may look to perform more surgery to make up for the loss of income. This could end up costing Medicare more money.

With global payments, there is no incentive for a surgeon to keep a patient in the hospital longer than absolutely necessary. When the payment method changes, the exact opposite will exist. And surgeons who aren’t very busy might schedule more postoperative office visits to make up the difference caused by the reduction in the surgical fee.

This might all become moot anyway because Health and Human Services Secretary Sylvia Matthews Burwell has proposed that 30% of Medicare payments be converted to a non-fee-for-service model by the end of next year rising to 50% by the end of 2018.

According to a news@JAMA article, doctors may be given incentives to join Accountable Care Organizations. Quality indicators such as readmissions and infections currently applied to hospital fees might be imposed on doctors too. More bundled payments for acute care illnesses may be created. [This of course is the exact opposite of the plan to unbundle global surgery fees. I'm getting confused].

One thing I'm sure of is that none of this is making me regret that I retired.