Which type of surgery residency should I choose?

A reader asks if I have “any advice on choosing a surgery residency, e.g. academic, community, hybrid?” I’m not sure what a “hybrid” residency is, but I think he meant a university program with extensive exposure to community hospital rotations.

This is a companion piece to my recent blog “Is surgery the right career for me?”

Having been a community hospital residency program director for many years I was always partial to that type of program. I felt that we trained people who got more operative experience and were more confident in their skills.

A recent paper in the Journal of the American College of Surgeons co-authored by [believe it or not] surgeons from Yale, Memorial Sloan Kettering Cancer Center and the American Board of Surgery validated my impression.

The paper was a survey of 4282 residents, who comprised 80% of all categorical surgical residents in 2007-2008.

Table 2 of that paper shows that residents at community hospitals are statistically significantly more satisfied with their operative experience and less likely to worry that they will not be confident operating by themselves after they finish training than university trainees. [I have blogged before about resident lack of confidence.] Surprisingly, they were also happier with the level of didactic teaching than university-based residents.

Of course, the choice of where to train depends on what the prospective trainee wants to do with her career in the long term. If one wants to be an “academic surgeon,” one might overlook the above deficiencies of university residencies. However, I always told my residents that they could get their academic ticket punched by taking a fellowship in a university program.

Remember, the definition of the word “academic” is varied. One online dictionary contains the following:

-of or pertaining to a college, academy, school, or other educational institution, especially one for higher education: academic requirements.

-pertaining to areas of study that are not primarily vocational or applied, as the humanities or pure mathematics.

-theoretical or hypothetical; not practical, realistic, or directly useful: an academic question; an academic discussion of a matter already decided.

-learned or scholarly but lacking in worldliness, common sense, or practicality.

So, choose wisely, my friends.

A med student asks, “Is surgery the right career for me?”

A third-year medical student emailed me with some interesting questions asking how one can confirm whether surgery is the right career choice. She said she had just completed a two-week rotation of nights and felt that she handled it well.

How does a student know if surgery is right for her? That's a tough one. I'm afraid that working only 2 weeks of nights, while certainly hard, is a little misleading. Anyone can do 2 weeks of nights. Surgery training is 5 years with a lot of nights, weekends and long days. I think that one of the reasons there is a 25% attrition rate among general surgery residents is that their medical school experience is nothing like what residency really is. [See my blog about this.] Don't forget that it continues when you become an attending. The attending surgeons in private practice where I now work are putting in a lot of hours, sometimes more than 80/week. I'd suggest you take an elective of at least 6 weeks in general surgery as your first 4th year course. Find a good elective in a busy trauma center. If you still like surgery after 6 weeks of doing that, it might be right for you.

Here is an interesting website. It features the “Medical Specialty Aptitude Test.” I took it and here were the top 10 specialties it suggested for me.

And here are the bottom 10.

In my case, the test was pretty accurate with two exceptions. One is listing neurology and nuclear medicine in the top 10 and the other is colon and rectal surgery in the bottom 10.

What about other fourth-year electives? [I blogged about this also.] Note that my suggestions were only my suggestions. I don't know if all, some or no program directors agree with me. I'm a little out of the loop and don't know if “audition” electives [The student takes an elective at a hospital where she wants to train so that she may be seen performing well.] are still mandated by some programs.

How can I tell if I will be competitive for some of the big name surgical training programs? If you are above the 90th percentile of USMLE Parts I and II, you should be OK for all but say, the Mass Generals and Stanfords of the world. I'll tell you a secret. USMLE scores are second only to AOA in importance for surgery program directors.

By the way, most general surgeons I know like what they are doing but are discouraged about declining reimbursements, lawsuits, paperwork and more.

There is a predicted shortage of us though. [See my blog about this.] One will always be able to find work.

See also "Which type of surgery residency should I choose?

Why are recently trained residents worried about their skills?

Recent research has shown that trainees in both in the United States and the United Kingdom do not feel confident in their abilities to operate or care for critically ill patients. I have commented on this  (here and here) but haven’t discussed the possible causes.

Of course, we surgeons have been complaining about the work hours limitations for years, feeling that the education of residents will suffer. There may be some validity to this as expressed in the article about graduates of medical training in the UK, where the work hour limit is now at 48 hours per week.

Regarding surgical training, more than 25% of recent residents are worried that they will not be able to operate by themselves when they begin practice.

Numbers collected by the American Board of Surgery and the Residency Review Committee for Surgery and published in Annals of Surgery show that for many operations the operative experience of residents is ominously low. For example of the 121 types of cases considered by program directors to be absolutely essential, the mode (most common number) reported by graduating residents for 63 of those case types was none.

This may not strictly be due to work hours limitations. There are conflicting studies on the impact of those restrictions on case volumes.

Resident insecurity is related to a number of factors. To me, the most important of these is that residents almost never operate independently in the 21^st century. There is much more supervision than there was in the past. This may be because of increased regulatory scrutiny, medicolegal considerations and patient demand.

For those who like the pilot/surgeon analogy [I don’t but use it when it supports my biases], would you like to fly with a pilot who had never soloed before? Better for a young surgeon to solo during residency when help is readily available than when she is in practice, don’t you think?

How journal articles are peer-reviewed: Part 2

Based on my experience as an associate editor of a journal, I recently blogged about the current mechanism of peer-review that most medical journals use and pointed out that it doesn't work very well.

Here is a story that illustrates some of the problems with the peer-review process.

A journal editor sent a manuscript to three peer-reviewers.

Of the three reviews returned, one recommendation was to “accept,” one said “accept with minor revision” and one said “accept with major revision.” Two of the reviews were 2-3 sentences long. One simply complimented the authors on a “nice paper.” The other pointed out two trivial areas needing revision.

The third review raised a couple of major points questioning the methods used by the authors. These were significant issues suggesting that the paper was unsalvageable.

Conflicting opinions are not that unusual. I have seen three reviews returned which had three even more diverse opinions such as, accept, accept with revision and reject. Based on that input, how does an editor decide the fate of a paper?

Perhaps you have read a paper and wondered, as I have, how did this ever see the light of day? Heck, I’ve even written a few papers like that myself. There used to be a saying, "If you have enough stamps, you can eventually get anything published." Now you don't even need the stamps.

Bottom line for me is that the peer-review process is very weak at the level of the peer-reviewers themselves. The reviews are not standardized and the quality is inconsistent.

Coincidentally, the New York Times ran a piece today mentioning some other problems with conventional journals such as “Peer review can take months, journal subscriptions can be prohibitively costly, and a handful of gatekeepers limit the flow of information.” The new wave seems to be “open science.” It will be interesting to see how this evolves.

I may be out of a job as an unpaid associate editor soon.

How are journal articles peer-reviewed?

There is a possibly some misunderstanding among science journalists regarding the process that the term “peer-review” encompasses.

I am an associate editor (AE) of a medical journal with a respectable impact factor. I also am or have been a manuscript reviewer for five different journals. I feel qualified to describe how manuscripts are reviewed and published.

In 2012, authors submit a manuscript electronically to the journal. It is assigned to an AE who screens it for appropriateness, format and, on occasion, readability in the English language. Manuscripts are not blinded. AEs and reviewers are aware of the authors’ names and their institutions.

The AE emails prospective peer-reviewers asking if they are willing to review the submission. Reviewers are chosen based on their self-reported areas of interest. They become listed as peer-reviewers by demonstrating expertise, usually having submitted papers of their own. They may also be well-known experts through society memberships or familiarity with the journal’s editorial board members. I once became a peer-reviewer for a journal after writing a letter to the editor pointing out a statistical flaw in a published paper. Although seen by many as a career-enhancing, the jobs of AE and peer-reviewer are not compensated.

If all goes well, the peer-reviewers return their recommendations in a timely way. Unfortunately, being a peer, an expert or an author in a field related to the manuscript’s topic does not necessarily mean that one can review a research paper competently. Most journals have guidelines for reviewers but no way to tell if the reviewer has read them. We often receive “two-sentence” reviews of 25-30 page (double-spaced) manuscripts.

A manuscript would have to be quite extraordinary to elicit only a two-sentence review. The reviewer may have been too busy, disinterested, incapable or not motivated to do a thorough job. But then why would he have accepted the assignment? That’s one of life’s great mysteries. The AE may have to become a peer-reviewer at times.

Assuming the AE receives two or three adequate reviews, he decides to accept, accept with revisions or reject the paper and forwards it to the editor for a final decision.

Here is what we cannot do. We cannot verify that

1. the data are not fabricated;

2. all authors deserve to have their names listed on the paper;

3. no plagiarism has occurred;

4. the paper is not an attempted duplicate publication.

Journals have no resources to investigate any of these issues. We must accept the word of those submitting. Among other causes, pressure on faculty to publish and/or greed may promote scientific misconduct.

Is this a good system? No. What are the alternatives? I don’t know. I pointed out in a previous post that many more people have read my blog than ever read my research publications. One day, every paper may be posted and critiqued by the scientific public, a movement that has already begun on websites such as Faculty of 1000.

Meanwhile, expect to see more publications retracted as internet users discover and expose fraud and duplicate publications. For more on retractions, follow the blog Retraction Watch for interesting insights into the process.

Older surgeons may not be better surgeons, but….READ THE WHOLE PAPER

The internet was abuzz yesterday with headlines like these.

Healthfinder/HealthDay: Surgeons in mid-career have fewest complications

MedPage Today: Best surgeons are not too young or too old

Discovery: Older surgeons may not be better surgeons

The story was tweeted widely.

This is yet another instance where one must read the entire paper to see what the facts are.

What the headlines don’t mention are the following:

Only 28 surgeons were studied. The study is about thyroid surgery only. Age did not matter in the incidence of recurrent laryngeal nerve injury. There was a statistically significant difference in the rate of postoperative hypoparathyroidism depending on the length of experience and age of the surgeon. But the figure below shows that only 5 surgeons above the age of 50 experienced this complication. 

Dotted lines are Confidence Intervals; Ordinate is predicted complication rate.

 The manner in which surgeons were grouped by length of experience was odd. Wouldn’t it be logical to divide them by years such as <5, 5-10, 11-15, 16-20 and >20? The authors divided the surgeons by length of experience this way: <2 years, 8 surgeons; 2-4 years, 7 surgeons; 5-19 years, 6 surgeons; ≥20 years, 7 surgeons.

The authors admit that their study has limitations. Here are some of them. The study is not applicable to other types of surgery. There were few middle-aged surgeons. Despite attempting to adjust for risk, complexity of surgery might not have been accurately defined. [Older surgeons might have been referred harder cases.] Not mentioned was that the number of thyroidectomies for each experience or age group was not stated.

The overall incidence of complications was quite acceptable with recurrent laryngeal nerve palsy occurring in 2.1% of patients and hypoparathyroidism in 2.7%.

A 2006 study published in Annals of Surgery looked at outcomes for 461,000 Medicare patients. They divided surgeons [logically] into groups by age (≤40 years, 41-50 years, 51-60 years, and >60 years). They concluded, “For some complex procedures, surgeons older than 60 years, particularly those with low procedure volumes, have higher operative mortality rates than their younger counterparts. For most procedures, however, surgeon age is not an important predictor of operative risk.”

Bottom line: It’s OK if you are operated on by an older surgeon.

Occupations more stressful than being an MD

I usually enjoy things posted by "The Consumerist," but its writers missed the mark on a recent post entitled "Here are 5 jobs more stressful than yours." The 5 jobs purported to be more stressful than mine are enlisted soldier, firefighter, airline pilot, police officer and event coordinator. Yes, you read it correctly, event coordinator.

The article had a link to the source of the information, a site called CareerCast. It turns out that CareerCast actually had ranked the Top 10 most stressful jobs. The other 5 are military general, public relations executive, corporate executive, photojournalist and taxi driver.

The methodology of the rankings was described but it does not say how the ratings were decided or who did the rating.

I concede that enlisted soldiers, firefighters, airline pilots and police officers are putting their own lives on the line as well as being responsible for the lives of others, although I would say that airline pilots are no more likely to be killed on the job than non-pilots. To my knowledge, they do not pay extra for life insurance.

With the exception of military general, the other 5 jobs do not involve life-and-death decisions. [OK, if you've ever ridden in a New York City taxi, you might argue that some taxi drivers do put their lives and the lives of their passengers in peril.] Does anyone seriously believe that event coordinators, public relations executives, corporate executives, photojournalists and taxi drivers really have more stressful jobs than physicians?

The "methodology" includes 11 stress factors, including hazards encountered 0-5 possble points, own life at risk 0-8 points and others lives at risk 0-10 points. This means that an event coordinator or public relations executive, who would score 0 points for the 3 stress factors noted above [except for a potential hazard like a paper cut], still has so much stress that she exceeds the stress risk of, say, a surgeon.

I'm not buying it.

Not news: Shorter hospital lengths of stay = higher readmission rates

A study in the Journal of the American Medical Association from researchers at Duke University reveals that 14.5% of American patients who were admitted for acute myocardial infarction were readmitted within 30 days. Patients in other countries were readmitted only 9.9% of the time, a significant difference. (p = 0.001)

Patients in the US had significantly shorter initial hospitalization lengths of stay [LOS], 3 days vs. 6 days. The authors concluded that the short initial hospitalization LOS is highly likely to be the cause of the increased rate of readmission.

Why are patients being readmitted in such high numbers? In a press release the senior author of the MI study, Dr. Manesh R. Patel said, “In the United States, care is episodic, not always coordinated, and it's not clear in many cases whether the patient is seen again by the same doctor or care team within the first seven days after discharge.” Can you say “hospitalist”? The same doctor may not even see the patient every day in the hospital. That’s how the hospitalist model works.

Here’s an interesting fact. The 30-day readmission rate of 14.5% for US MI patients is actually less than that of all medical discharges (21.0%) found in a large study of Medicare patients published in the New England Journal of Medicine in 2009. That study also showed that readmissions are very costly.

I’m a mere surgeon, not a statistician or epidemiologist, but I can tell you that it is not surprising that the shorter an initial hospital stay is, the higher the readmission rate will be.

Here’s my theory on this subject. In case you haven’t heard, we are under tremendous pressure to discharge patients quickly. In every hospital, utilization review [UR] is conducted by squads of clipboard-wielding nurses, who are trained to prod doctors into sending patients home as soon as possible. Third party payers demand short LOSs. Digression: Lengths of stay are often based on the Milliman care guidelines. But remember, guidelines are just that. They aren’t meant to apply to 100% of patients.

I used to be intimidated by the pressure to send patients home. It was very uncomfortable to go into a patient’s room and explain to him that he had to be discharged because the some arbitrary authority had mandated it. No matter how I spun it, the patient felt that I was the villain for “kicking him out” before he was ready.

I have reached an age where I really don’t care what the UR nurse says. I refuse to jeopardize my relationship with a patient to please the bureaucrats. When I feel a patient is medically ready, I discharge him, but I do listen to the patient. If he has a valid reason for not wanting to go home, I will usually acquiesce.

I advise my medical colleagues to keep their MI patients in the hospital for what they believe is a reasonable time, UR be damned. Show them the JAMA article if they give you a hard time.

It’s always someone else’s fault

Here’s a story about a 15-year-old boy who was traveling alone on a Southwest Airlines flight from Phoenix to Tulsa. When the plane arrived at his destination, the boy was sleeping with headphones on and didn’t hear the announcements or notice that passengers were disembarking. He slept through the ensuing take-off and landing as well as the litany of annoying announcements that accompany those events.

The plane continued to its next and final stop, St. Louis. The boy awakened and noticed that St. Louis is not Tulsa.

For 24 hours, he wandered around St. Louis until finally a kind person helped him call home.

The boy’s mother was not happy with the airline saying, "The child wakes up in St. Louis with no family, no money, no cell phone and no help,"

Southwest apologized and refunded the cost of the ticket. Yes, they should have noticed the sleeping boy, and they need to figure out how this could have happened. [System error or human error? I say “human,” but Southwest will probably say “system” and develop a new policy. See my previous blog on system vs. human error.]

But wait a second. I have three sons, who thankfully all are no longer teenagers. What parent in her right mind would send a 15-year-old boy alone on a plane with no money? What if weather or equipment trouble had forced the plane to divert from Tulsa? I guess mom assumed that Southwest would notify whoever was meeting him in Tulsa and feed the child until his journey resumed. Also, he must be the last 15-year-old boy in the United States without a cell phone.

Did he even know who was picking him up in Tulsa? Did he speak to any Southwest employee in St. Louis? Did anyone report him missing? Was there an “Amber Alert”? The plane had to have been on the ground in Tulsa for at least 45 minutes. Did the person who was to meet him in Tulsa call the mother and say he didn’t show up or better yet, ask someone at Southwest in Tulsa where he was?

So let’s list the stupid people in this drama—the mother, the boy, the person picking him up in Tulsa, unknown numbers of Southwest employees [cleaning people, flight attendants] and KPHO-TV in Phoenix for its “blame the airline” slant on the story.

This country is circling the drain right now. The future is grim. God help us all.