Thursday, January 29, 2015

Now I'm really worried about surgical education

Here's why.

A friend told me that a new attending on his staff was having some problems. Although the young surgeon was a graduate of five years of general surgery training plus two years of fellowship, he was unable to do an inguinal hernia or a laparoscopic cholecystectomy by himself.

This is just an anecdote, but the issue has been identified by others. Remember the paper from Annals of Surgery in September of 2013 that described a survey of fellowship directors? It stated that 66% of graduates of five-year general surgery training programs could not conduct a major case unsupervised for 30 minutes, and 30% could not independently perform a laparoscopic cholecystectomy

A study published online in JAMA Surgery last month looked at 20 years of ACGME surgical resident case logs and found that although minimally invasive surgery is being done much more frequently, it is currently performed in more than 50% of cases for only five procedures—cholecystectomy, appendectomy, adult anti-reflex surgery, partial gastric resection, and thoracic wedge resection.

In 2007, the Residency Review Committee for Surgery increased the required number of basic laparoscopic surgery cases from a minimum of 34 to 60 and from 0 to 25 for advanced . The authors expressed concern that there might not be enough minimally invasive cases for all of the residents to do. They also pointed out that there was still in need for residents to learn open surgery since all but five operation procedures are still predominantly performed that way. However, as laparoscopic cases increase, the number of open cases will decrease because the total number of cases done by graduating chief residents has not changed significantly in 20 years.

A year ago, I blogged about some potential problems that might occur when surgical residencies are expanded and new programs are begun. Specifically, I wondered if there would be enough teaching cases to go around. It is interesting to see my speculation bolstered by data.

A program director recently told me that there may be a movement afoot to start a Fundamentals of Open Surgery course.

What is going on here? There is already a Fundamentals of Laparoscopic Surgery course. Do we really need to have a separate course to teach residents open surgery? Isn't that what a "residency" is supposed to do?

How did surgeons of my generation ever learn how to operate without courses in the fundamentals of laparoscopic and open surgery?

The visionary surgeon Leo Gordon saw it coming in 2002. He predicted the need for a "macrolaparotomy" course, and it can be run by the newly created American Board of Open Surgery.

Friday, January 23, 2015

Do surgeons still do postop care?

Here's an email I received the other day (edited and posted with the author's permission):

I am a recently retired internist. I have noticed some evolving trends over time and had an interesting experience that illustrates this issue.

A 77-year-old friend went for check up due to urinary incontinence. He was found to have a large prostate and a PSA of only 2 so was given Flomax . This helped somewhat.

At the time, an asymptomatic hernia was found. He was immediately scheduled for surgery which went well. His Foley was removed, and he was sent home.

At home he could not void, called the surgeon, and was told to go to the ER, There the Foley was replaced, and he was to see his urologist in 2 days. The urologist removed the Foley. Later he was in agony and walked the floor all night. He called the urologist and the service said that the office was closed. He was told to drive to the other office in the next town only 15 miles away. They replaced his Foley again.

Wednesday, January 21, 2015


The following is based on an actual case that occurred a long time ago in a galaxy far, far away.

A 65-year-old man arrived in the emergency department by ambulance after being found unresponsive. His respiratory rate was 40/minute, heart rate was 170/minute, and temperature was 102.2°. He did not respond to Narcan or an ampule of 50% dextrose. Blood sugar was 600 mg/dL. The diagnosis of diabetic ketoacidosis was made. IV fluids and an insulin drip were given. After some hydration he became more alert and complained of abdominal pain. On examination, his abdomen was tender to palpation. Four hours after arrival, a surgical consultant was called and diagnosed an incarcerated inguinal hernia. Before the patient could be taken to surgery, he suffered a cardiac arrest and could not be resuscitated. Review of the case revealed that although blood cultures were drawn and were eventually positive, antibiotics had not been ordered.

What happened? The possibility that this patient was septic never occurred to the doctors managing the case. I am sure that if a scenario like this appeared on a test, those doctors would have immediately chosen the right antibiotics. Some doctors are "book smart" but can't deal with a real live patient.

Saturday, January 17, 2015

Going to med school and becoming a surgeon when you are older

A 34-year-old lawyer is thinking about going to medical school and becoming a surgeon He asked me for advice. Here's a link to that post.

Tuesday, January 13, 2015

Which is better for training--an academic center or a community teaching hospital?

On Ask Skeptical Scalpel, a medical student wonders if it is better to match in a community teaching hospital or an academic center for her surgical training. Here's the link.

Wednesday, January 7, 2015

How much money do journal publishers make? A lot

Many, including me, have written about who is making money in healthcare. Sure doctors do very well, but not as well as hospitals, hospital administrators, insurance companies and their corporate officers, drug companies, device manufacturers, and others.

Another lucrative area is medical journal publication, especially if you are the publisher. A researcher gets an idea, plans and carries out a study, writes a manuscript, and submits it to a journal. The research may have been funded by the government, i.e., you and me.

An associate editor or a member of the journal's editorial board looks at the manuscript, and if it is deemed worthy, it is sent out to two or more people in the same field for peer review. This process may be repeated for papers that require revision.

All of the players in the above scenario—the researchers, most of the editorial board members except maybe the editor, and the peer reviewers—are paid nothing for their work. Factor in that the cost of producing a journal has plummeted in the computer era.

How much money do journal publishers make? Here are some impressive numbers from an article that appeared on a French website called "Rue89." The figures are for the year 2011 and are in euros. They include revenue from all science publishing, not just medicine.

Friday, January 2, 2015

Can you define "professionalism"?

A while ago, I wrote about a medical student whose school tried to dismiss him just prior to graduation for unprofessional behavior.

A judge ruled that the school could not do so because it had tolerated some similar behavior earlier in his medical school career and had not considered it important enough to mention in his letters of recommendation.

In that post, I said, "'Professionalism' is difficult to define, especially when trying to do so in a courtroom."

In the comments section, a medical student wrote that he had been given a two-week suspension for unprofessional behavior for silencing his phone during an exam.

Another commenter told of several students who were caught colluding on a take-home final exam in statistics. Their punishment was that they had to agree to do their residencies at the medical school. [Digression: What does that say about the school?]

The Accreditation Council for Graduate Medical Education defines professionalism, one of its six core competencies, as follows:

"Professionalism—Demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles."

I'm always a bit confused when the definition of a term contains the term itself, and this is no exception.

Three internal medicine foundations combined to publish a somewhat clearer definition that is two pages long, but does not mention specific behaviors like cheating on a test, falsifying a medical record, or being arrested for driving under the influence of alcohol.

The American Board of Internal Medicine Foundation produced this "Word Cloud," which is supposed to help one better understand what professionalism is. But all it did was remind me why I hate word clouds.

It is said to depict "words physicians most associate with medical professionalism."

If you are having trouble reading some of them, I can help. Here are a few: "empathize, compassion, respect, responsibility, ethics, integrity, caring, honor."

Those sound pretty good, but here are some more: "tougher, smoker, diet, sick, job, prevent, financial, good insurance, disease, death." What do those words have to do with medical professionalism?

Since we have trouble defining professionalism, we can hardly blame the judge in the case I wrote about before for ruling in the student's favor.

He said, "Although courts should give almost complete deference to university judgments regarding academic issues, the same deference does not follow university character judgments, especially on character judgments only distantly related to medical education."

I disagree with the last part of his statement. I think character judgments are strongly related to medical education, but how are medical schools and residency programs supposed to teach professionalism and assess whether their trainees possess it, if it is so ill-defined?