Thursday, October 1, 2015

“Code Black” should be pronounced dead

A new television series called “Code Black” debuted last night on CBS. The show’s name supposedly means the emergency department has too many patients and not enough staff. In my over 40 years in medicine, I’ve seen many busy, understaffed EDs but never heard anyone call it a "Code Black."

There is the usual array of standard medical characters—the inexperienced new residents on their first day at work, the savvy nurses, and the cocky, overconfident attendings. This one has a few twists. The world-weary head nurse is a Hispanic man, and the headstrong know-it-all attending is a woman, Dr. Leanne Rorish. She has early conflict with the handsome, more cautious Dr. Neal Hudson, but I see romance in the future should this show manage to stay on the air.

It takes 5 people to push an empty gurney at Angels Memorial
The show started off with a gunshot wound to the neck that the docs had to retrieve from a car which had been abandoned in the hospital parking lot. Although no one had been putting pressure on the damaged carotid artery for an undetermined period of time and blood was visibly spurting out of the wound, the patient pulled through the resuscitation thanks to Dr. Rorish who replaced all his blood with cold IV fluid. She spiced up the resuscitation by asking the new residents questions about what she was doing.

Sunday, September 27, 2015

Another Caribbean med school graduate needs advice

I did not attend St. George's, Ross, or Saba. I chose my school because it has a premed program which leads to an MD program. My USMLE Scores on Step 1 and Step 2 CK are above 230.

I did not apply for the 2015 match because I did not have my step 2 CK results until November. It would have been too late. I could have rushed my step 2 but I wanted to get a good score and be a solid applicant. Also I would not have been able to complete my surgical electives in time to get letters of recommendation. At some point, I will be doing research at [a very well-known medical school]. I felt that for these reasons this would make me a better applicant the next year.

Since graduating I have been trying to find a medical related job (scribe) but have had no success. I have reached out to many institutions regarding research opportunities but have come up dry. I may be able to secure a volunteer research position by next month. Do you have any suggestions for me? I knew I would hate being out of the medical field for this long but this was my best bet. Does this gap hurt my chances?

I am concerned that despite your excellent USMLE scores, taking a year off from clinical medicine may cause your application to be rejected immediately. I do not know if a 9 week research elective, even at a premier med school, would be enough to offset your lack of clinical experience over the entire year. Acting as a scribe would not be considered clinical experience.

Another issue is what is the record of your school regarding matching graduates into surgical programs? Since you didn’t tell me your school’s name, I cannot give you any insight into that situation. Even if I did know the school’s name, it may not have published its match results.

To answer your specific questions:

How many gen surg programs should I apply to? I was thinking ~100. That seems reasonable. You should be able to gauge your chances better after you see if you receive any offers for interviews from the 100 programs.

During a gen surg interview, should I be open about my backup specialty? I would advise you to say that you would take a preliminary spot in general surgery if you didn’t match in a categorical position. Admitting that you would do internal medicine is often seen as a lack of commitment to surgery.

Most hospitals I am looking to apply are IMG friendly. Which means the surgery and medicine programs are both IMG friendly. Would it be a bad idea to apply to different specialties at the same hospital? I think it would be a bad idea. I suggest you wait and see if you get interviews from the general surgery programs. If you don’t, then there would be no problem applying to internal medicine at the same place. I doubt very much that the two services would talk about any specific applicants. Most surgery programs get hundreds of applications and those applicants who are not offered interviews are not remembered.

Some readers may have other opinions. I hope they will comment.

Monday, September 21, 2015

Gladwell says just about any college grad could become a cardiac surgeon

"I honestly think that…the overwhelming majority of college grads, given the opportunity, could be better-than-average cardiac surgeons," said pop author Malcolm Gladwell in a discussion with David Epstein. Gladwell qualified his astonishing statement by stipulating that it could only occur with 10,000 hours of deliberate, highly structured practice by very motivated people.

Epstein, author of "The Sports Gene," challenged Gladwell to produce some evidence to support his opinion regarding cardiac surgeons. Instead of evidence, Gladwell replied, "I have a very low opinion of the difficulty of cardiac surgery" and equated the complexity of cardiac surgery with that of driving a car.

If you don't believe me, watch a few minutes of this video, which I have cued to the start of his comments about cardiac surgery.

Both Gladwell and Epstein are somewhat off base. While there is no question that doing operations on the heart requires psychomotor skills, there is much more to it.

Like all procedural specialties, cardiac surgery involves deciding who would benefit from an operation, when should the operation be done, who would be better served without an operation, and what should be done if an unexpected finding or a complication occurs either during surgery or in the postoperative period.

Equating driving a car with performing cardiac surgery is absurd. Most of the time, driving does not require intense concentration. Nearly everyone has had the experience of driving a car on a highway for several miles and realizing that they have no recollection of the scenery or any other vehicles that may have passed going the other way.

Not so with cardiac surgeons, who do not have the luxury of "zoning out."

The "10,000 hours" rule has been challenged by many including David Epstein in his book. If you don't have time to read that book, here is a link to a blog called "The Science of Sport" by Ross Tucker, a PhD in exercise physiology. Do not be put off by the length of the piece, which is worth the few minutes spent reading it. He explains how the original research on the topic of 10,000 hours by psychologist Anders Ericsson was flawed.

And here's an article from Salon called " Ditch the 10,000 hour rule!" that says approaches to learning other than massed practice yield better results.

Finally if hard work and time expended is all it takes to be an expert, my tennis game should be a lot better than it is.

One true statement Gladwell made in the video was, "This is going to offend all medical doctors in the room." But he should have added that it would also offend anyone who is a rational thinker.

This post originally appeared on Physician's Weekly on 11/3/14. It has been revised and updated.

Thursday, September 17, 2015

What comes after the Heimlich maneuver?

At the end of an otherwise informative article about the nuances of performing a Heimlich maneuver, New York Times science reporter Jane E. Brody recommends that if all else fails, a cricothyrotomy should be attempted.

She goes on to briefly explain how the procedure is done. In the right hands, a cricothyrotomy is safer and easier to perform than a formal tracheostomy. However, for a layperson who has never seen either procedure done, does not know the relevant anatomy, and has never put a knife to anyone's skin, it is highly unlikely to be successful.

Ms. Brody includes a link to website with some static drawings of the procedure. The site is called Aaron's Tracheostomy Page and it bills itself as "The Internet's leading tracheostomy resource since 1996."

Here's an excerpt from that description of the operation:

"3. Take the razor blade or knife and make a half-inch horizontal incision. The cut should be about half an inch deep. There should not be too much blood." Yes, there should not be too much blood, but sometimes there is.

Both the Times article and the reference repeat the medical urban legend that the barrel of a ballpoint pen can be used as a breathing tube.

A 2010 paper found that due to high resistance to airflow, most ballpoint pens are not adequate airways, and the two that were acceptable (the Baron retractable ballpoint and the BIC Soft Feel Jumbo) are unlikely to be on hand. An earlier paper also reported similar high airflow resistance with ballpoint pens.

A small study involving inexperienced junior doctors and medical students found that they were able to successfully perform cricothyrotomies in only 8 of 14 cadavers. Injuries to the thyroid and cricoid cartilages were common.

Remember these important points—cadavers don't need an airway in a hurry and they don't bleed.

Evidence of successful cricothyrotomy by bystanders is lacking. A 2010 review of American soldiers killed in Iraq between 2003 and 2006 noted that five of those who died appeared to have had attempts at cricothyrotomy, all of which failed.

I once was asked to see a patient whose "cricothyrotomy" done in an ED by an experienced emergency physician and a resident turned out to be a laryngotomy. The tube was inserted directly into the larynx.

To the uninitiated, surgery looks easy. Last year I blogged about Malcolm Gladwell's outrageous claim that just about any college graduate could become a cardiac surgeon.

I suppose one might say "What have you got to lose? The patient is dying. Try the cricothyrotomy." I can’t stop you. But be certain it is necessary, and realize your chances of success are extremely low.

If you’re considering it, at least look at some of the many instructional videos available online.

Warning: Graphic. There is some blood. Here’s one by an ED doc. In a non-hospital setting, you would not have all the help and equipment he had. Here’s another, this time by a surgeon—with lots of help and equipment. Both patients were relatively thin.

Now imagine doing it with a pocket knife and a ballpoint pen on an obese person. Still think it’s easy?

Monday, September 14, 2015

Is obesity a disease, a disability, both, or neither?

In 2013, the American Medical Association recognized obesity as a disease. Dr. Peter Ubel, writing in his blog on the Forbes website, thought this was a bad idea. He feared that calling obesity a disease will result in people having less motivation to lose weight and cited a study which found that people who were told that obesity is a disease tended to be less concerned about their weight and when offered a sandwich for a hypothetical lunch, chose less healthy food.

Although he gave good reasons why obesity should not be considered a disease, he favored retaining the disease label because it would help reduce the stigma attached to obesity and build public support for programs to conquer obesity. I am not sure about that.

Back in December, the BBC reported that the European Court of Justice heard the case of a 352 lb Danish childcare worker who was fired from his job because he couldn't bend down to tie children's shoelaces. He denied the allegation.

The European Court "ruled that if the obesity of the worker 'hinders the full and effective participation of that person in professional life on an equal basis with other workers,' then obesity can fall within the concept of 'disability.'" Danish courts need to hear the case and decide if the worker is truly disabled. The ruling affects all other countries in the European Union.

The Editorial Board of the Chicago Tribune commented on the issue in a piece entitled "the dangers of treating obesity as a disability." It mentioned a Texas case in which a court said a company that dismissed a 600 lb materials handler could not do so because they had not tried to "find ways to help him perform his duties."

The Tribune article pointed out that one-third of Americans are obese with 15 million (7% of the population) classified as morbidly obese. The board felt that this was a potentially very costly expansion of the Americans with Disabilities Act, which they say was intended to help those who were disabled not by individual decisions, but rather were "victims of fate." It did not address the fact that many are disabled from smoking-related emphysema. Are they victims of fate or poor choices?

A recent editorial [full-text here] in the American Journal of Medicine took it up another notch. The author, Dr. Robert M. Doroghazi blamed obesity on eating more calories than one burns—a hypothesis held by many. Regarding the war on obesity, he said, "We will not make progress until we tell obese patients they eat too much, and it is their personal responsibility to eat less." Too harsh?

Disease, disability, both, or neither? What's your opinion?

Tuesday, September 8, 2015

In what specialties can a surgeon be autonomous?

I am a medical student who is trying to decide on a field. I am not chasing money but rather autonomy; thus I would prefer to work for myself rather than a hospital. So my question is, which fields of surgery are more amenable to private practice, and which fields tend to require the resources of a hospital or don't work as well without a hospital?

The way things are going; future use of the words “autonomous” and “physician” in the same sentence will be rare, if not unheard of.

Here are some figures from a July 2015 American Medical Association report.
  • Younger physicians were more likely than older physicians to be employed. About 59% of physicians under the age of 40 were employed, versus 46.0% of physicians aged 40-54 and 33.3% of physicians 55 and above.
  • Nearly one-third of physicians are in practices with more than 10 physicians, including 13.5 percent in practices with 50 or more physicians.
  • Multi-specialty practice physicians were more likely than single-specialty practice physicians to report that their practices were hospital owned—44.6% compared to 23.0%.
Who knows what the percentage of employed physicians will be by 2020, but it surely will be higher.

I can think of only two surgical specialties that can be mostly independent of hospitals, otolaryngology and plastic surgery. I am not including ophthalmology because it isn’t really a classic surgical specialty.

The only way otolaryngologists and plastic surgeons can be autonomous is by concentrating solely on cosmetic surgery or working only in an ambulatory surgery center.

Otherwise, you would need a complete operating room—staffed by a nurse, an operating room technician and for some cases, an anesthesiologist—in your office.

Very few surgeons are able to limit their practices to cosmetic surgery directly out of residency or fellowship. Unless you join an established cosmetic surgeon in practice, which would of course limit your autonomy, you will need to be on call for trauma and be available for consults involving problems like pressure sores in hospitals to pay the bills.

My observation as a surgical chairman in community hospitals was that it takes years before the average plastic surgeon is able to develop a reputation and focus solely on cosmetic surgery.

You should also be aware that both of those specialties are highly competitive. In this year's match, only 1 of 299 ENT positions went unfilled, and 364 US seniors had ranked ENT as their preferred choice. For plastics, there are two ways to obtain a position. The NRMP handles an integrated match which filled 144 of 148 positions. There were 162 US seniors who listed Integrated plastics as their preferred choice. The other match is independent of the NRMP and takes residents who have done varying years of general surgery. For that 2015 match, which placed applicants in positions starting in July 2016, 85 applicants submitted rank lists, and 68 of 70 positions were filled. That left 17 candidates unmatched.

Additional reading: A post on KevinMD entitled “So doctor, who’s your boss?

Wednesday, September 2, 2015

Variation is not causation

I made a rookie mistake in statistics of the “correlation is causation” genre by confusing variation for causation in the recent JAMA Surgery paper referred to in my last post. I contacted Dr. Timothy M. Pawlik, the lead author of the Johns Hopkins study, who said the following:

"The model is explaining and attributing variation in readmission and not attributing readmission itself to the different domains. The model suggested that only 2.8% of the variation in readmissions was attributable to surgeons. This is different than saying that only 2.8% were the 'fault' of surgeons. A more accurate interpretation would be that only 2.8% of the variation seen in readmissions was attributable to provider level factors. The majority of the variation in readmission was due to patient factors."

He added that some of the 82.8% variation in readmissions attributable (note: attributable doesn’t mean it’s the patient’s fault) to the patient could be modified by better medically managing patients' comorbidities or not operating on some of these patients.

That readmissions can be explained by a single domain or a single person is simplistic. Dr. Pawlik's clarification confirms my original concern that attributing differences in patient outcomes solely to differences in technical quality of surgeons is probably inaccurate, statistically speaking.

Variation is not causation but variation is still a call to action. Regardless of who is to blame for unfavorable outcomes, surgery is a team sport. The incision is just as important as the community care. In this regard, I am certain that ProPublica and I are on the same side. Let’s work together so that we see the whole story behind the numbers.