How should residents spend their time?

As everyone knows, residents are now restricted to working 80 hours per week. One of the lesser known side effects of this work hours limitation is the drastic loss of educational conference time.

Since at least one third of the residents must now go home after morning rounds, afternoon conferences are no longer possible. Most residency programs now devote part of at least one morning per week to dedicated educational time.

A new paper from JAMA Surgery describes how one program chose to comply with the mandate to teach some of the more fuzzy resident core competencies. Their weekly didactic schedule of 1 hour of grand rounds and 1 hour of small group learning now includes 10 hours per year [representing 10% of the 100 hours allotted to formal teaching] on practice-based learning and improvement, interpersonal and communication skills, systems-based practice, and professionalism.

From the paper's Table 3, the specific topics are structure and policy of US health care, advocacy, medical economics and finance, history and consequences of major legislation, innovation in health care, health information technology, comparative effectiveness, health care disparities, basic management principles, quality, performance improvement, patient safety, coding and billing compliance, legal issues, litigation, risk management, clinical practice models, contracts, relative value units (RVUs), personal leadership styles, power and influence: organization psychology, negotiation and conflict resolution, communication, ethics, and last but certainly not least, one of my favorites—Six Sigma. [What, no mention of "Lean"?]

I don't mean to disparage the authors of this paper. They're only trying to follow the rules. I'm just glad I'm no longer a residency program director having to commit 10% of my program's precious educational time to things like organization psychology, history and consequences of major legislation, and Six freakin' Sigma.

But I guess it could be worse. At this year's meeting of the Association of Program Directors in Internal Medicine, the following slide suggesting books that should be read by every chief resident was shown.

I would love to meet the chief resident who had not only the time, but also the inclination to read all 17 of these books.

Will automation affect surgeons' skills?

Although it has been known for over two years, news outlets are again reporting that automation is degrading pilots' skills. Links are here and here. I blogged about this back then as part of a comparison of pilots to surgeons. My point was that surgeons did not have autopilots to rely on in the operating room.

This new report has prompted some to wonder whether robotic surgery will lead to deterioration of surgeons' skills.

In my opinion, that is not likely at this time because the robot is not really doing the surgery by itself. It is simply a tool that helps the surgeon and is under the surgeon's complete control at all times (except when it runs amok).

However, ever since the advent of laparoscopic surgery over 20 years ago and its popularity for many of the common procedures surgeons do, there has been concern that surgeons may eventually lose proficiency for open procedures. And a number of other open operations have been done less frequently due to alternate ways of treating patients such as non-operative or interventional radiologic techniques.

Here are some examples from the ACGME resident log data for the academic years 1999-2000 and 2011-2012.



We are approaching the critical lower limit for open gallbladder surgery expertise especially when you consider that only the most difficult cholecystectomies will be done as open cases from now on.

What will happen in 20 years when few surgeons will have sufficient skill to do a very inflamed open gallbladder?

Does anyone really believe that a surgeon can confidently remove an enlarged spleen having done fewer than 2 such cases during training?

This is a bigger problem and far more pressing than the possibility that automation will render human surgeons obsolete.

There's another issue too, which is the predicted shortage of general surgeons in the near future. How are more surgeons going to be trained if there are not enough open cases to train the current number of graduating residents, of which there were 1092 in 2012?

Has anyone else thought about these questions?

Vacation

I'm on vacation until April 29th. Please use the search field to take a look at some of my previous posts. Thank you.

A medical student says to abandon the match

A blog post entitled "How a Nobel Economist Ruined the Residency Matching System for Newly Minted MDs" appeared on the Forbes website. In it, Amy Ho, the medical student author, lists all the things she considers wrong with the National Resident Matching Program (the "Match").

I would have commented about this on the site itself except that I have a lot to say, and in order to post a comment, I would have had to agree to allow Forbes to post tweets in my name. No, thanks.

The title of the post is misleading. As the author noted, the Match as been around since 1952. It was established to make the process of finding a residency position fair for all graduating medical students. Alvin Roth, the economist who shared a Nobel Prize based in part on his work with the Match algorithm, simply refined the process in the 1980s and 1990s to make it even more fair. Roth didn't ruin the Match; he made it better.

Why aren't all board recertification exams oral?

A loyal reader, who agrees with me that we may be teaching and testing medical students and residents the wrong way, asks why aren't all board recertification examinations given orally. She correctly asserts that oral examinations are better because they assess how people think rather than how much they have memorized.

Here's why it would be difficult to do.

The initial surgery board exam is given in two parts. First a written exam must be passed. Those who pass it are tested orally at one of four or five different times and locations within the following year. Oral exams are quite labor intensive.

Each candidate is examined by three pairs of surgeons, consisting of a senior examiner who is a member of the board itself and a surgeon from the local area. Each session lasts 30 minutes per pair for a total of 90 minutes. Multiply that by 1300+ examinees per year.

I had the privilege of serving as an examiner on one occasion. It's very stressful because one wants to be fair but also not let incompetent surgeons become certified. It's also much harder to standardize oral exams. Scenarios used in the exam are chosen by the board each year, but the individual examiners may have different approaches to the way the questions are asked and answered. For a number of surgical diagnoses, there may be more than one correct way to handle a problem, which makes creating a written exam difficult too.

About 1800 to 2000 general surgeons take the recertifying exams every year. To give each one of them a 90 minute oral exam would be very expensive and time consuming. It would be hard to find practicing surgeons willing to give up so much time to be examiners.

Many surgeons and other specialists are complaining about the cost of maintaining board certification. Taking a written recertification exam now involves going to a testing center and sitting in front of a computer. Many such centers exist, and traveling to them is much less complicated than going to one of the four or five cities where the oral examinations are held every year.

I do not see any way that recertification exams can ever be even partially oral. Until someone finds a way to make computer-based exams more clinically oriented, the ability to memorize facts will remain the basis for all recertification testing. 

There are other issues such as how to deal with surgeons who have specialized in a narrow area of surgery for many years, which is becoming more prevalent with so many graduates of residencies taking fellowships.

I addressed the other maintenance of certification components in a post last year. The concept of maintenance of certification is noble, but the execution is not working for those subjected to the process.

If anyone has a better idea, please comment.

What are the residency prospects for graduates of offshore medical schools?

Note: I updated this information in a new post on 7/26/16.

A year ago in a post about law school applications decreasing, I speculated about whether a similar phenomenon would occur with medical schools.

In that post, I commented on the impending problem of too many medical school graduates and not enough residency training positions. I cited an article that appeared in the New England Journal of Medicine in 2011 in which the CEO of the Accreditation Council for Graduate Medical Education predicted that by 2015 or sooner there would be more graduates of US medical schools than residency positions leading to specialty certification.

The data for the 2014 residency match have not been released publicly so the outcomes for graduates of US med schools are unknown.

However, the Educational Commission for Foreign Medical Graduates says [here] that of the 26,678 residency positions offered, only 53% of US citizen graduates of offshore medical schools (US-IMGs) and 49.5% of non-US citizen offshore grads matched.

My blog is now being cited as evidence

That is a scary thought.

Some people on Twitter were questioning the rationale for the UK's "Bare below the Elbows" infection control policy which says that all hospital personnel who are in contact with patients must wear short sleeve shirts, no lab coats, no watches, and no ties.

A medical student from the UK who follows me posted this tweet:

In a recent post on anonymity, I tried to justify my existence by referring to a post that I wrote about CT scans and appendicitis noting that I have received many questions from patients asking for advice. This suggested I had credibility despite using a pseudonym.

But I think being cited as evidence tops any previous attempts to claim that my writings can be trusted.

Here's the med student on how the Brits feel about "Bare below the Elbows:" He said they are ambivalent and in his experience the policy results in "infection control people chasing people round for long sleeves/watches and missing the real problems!"

I told him that we have legions of clipboard carriers in our hospitals too.

He added, "Antibiotic stewardship is a far more pressing issue than length of my sleeves."

That's a pretty astute observation for a medical student to have made.

I thank him for considering my blog post as evidence. If you too want to find evidence, here's a link to that post.

Can I apply to be listed in PubMed?

Doctors should be more like…

A while ago, Atul Gawande, the noted surgeon-author, wrote a long piece in the New Yorker on why healthcare should look to a restaurant called the Cheesecake Factory for some guidance on how to standardize things.

This was met with some derision by a number of physicians who pointed out, among other things, that the food at the Cheesecake Factory is not great and is loaded with calories. But I guess it's at least it’s "standardized" mediocre and unhealthy food.

Then a doctor named Peter Ubel wrote in Forbes magazine that doctors should take a cue from Starbucks about how to deal with people. He went so far as to say that baristas have more emotional intelligence than physicians.

He says the Starbucks staff are trained to placate angry customers using the mnemonic “LATTE,” which stands for “Listen to the customer, Acknowledge their complaint, Take action by solving the problem, Thank them, and then Explain why the problem occurred.”

I have never worked at Starbucks, but when I was a surgical chairman, I unknowingly used most of their principles in dealing with patient complaints about my attending and resident staffs. I could add another. I used to ask the dissatisfied patients and families "What can I do to make you happy?"

I was surprised that in many cases, the complainants could not think of a single thing that would make them happy. The question often completely diffused the confrontational nature of the encounter. You might want to try it sometime.

Another way of looking at this issue was suggested by a Twitter colleague, Dr. Edward J. Schloss, who tweeted that we work for the government, and we should be compared to the Bureau of Motor Vehicles or the post office, not Starbucks.

Since doctors are already notorious for making people wait, comparisons to the BMV would seem appropriate. And some docs also take forever to return phone calls, similar to the post office's habit of delaying the mail.

Surely physicians look better when compared to another government agency, the Internal Revenue Service, especially now that the IRS has been accused of selectively harassing certain political groups and spend lavish amounts of money on conferences.

At least no one has suggested comparing us to pilots lately. I have dealt with that analogy decisively in the past here.

Why should practicing medicine be compared to any other occupation?

Doctors are unique. None of us is perfect, but despite the occasional bad apple, most of us are doing the best we can for our patients under difficult circumstances.

A match-day lament: "We will rank you very highly"

A medical student and I were discussing his experience with this year's resident matching process. He told me he had interviewed at 18 programs and ranked 17 of them. He matched to a categorical five-year general surgery position at his sixth choice hospital and was satisfied.

His assessment of the situation was that his somewhat below average USMLE Step 1 score might have affected his chances at his first five choices. [See my previous post on how residents are selected here.]

Then he said, "I was a little surprised as I had some really positive correspondence with programs at the top of the list with one even telling me they were ranking me very highly."

Even though he had been warned that this type of thing might happen, he said, "It is so hard to not fall into the trap. It feels so good to hear 'you're ranked highly.'"

He was disappointed that a program would tell him this and not follow through. He planned to tell future applicants to beware.

"I almost wish there was a 'no contact' policy," he said.

Other than hurt feelings, no real harm was done. The match algorithm favors the student. The fact that a program director would tell an applicant that he was ranked highly and then not do so does not affect the way the match process works.

The applicant's rank order list is queried sequentially by the computer until the first unfilled program that ranked him is identified, and that's where he will end up.

Having been out of the program director business for a few years, I'm sorry to see that this sort of thing still goes on.

It works both ways. On numerous occasions, applicants would call or email me to say they were ranking my program highly, only to go elsewhere come match day. I assume that these applicants thought their chances would be improved and I might rank them higher if they expressed greater interest. After being burned a few times, I learned to disregard any such statements.

I agree with my young friend. There should be no contact after the interview including the obligatory waste of time "BS" thank you email from both sides. If there is contact, both parties should take whatever is said with a grain or two of salt.

Should ratings of airline pilots be made public?

A news story has just appeared about a plan to publish ratings of airline pilots by passengers. I think it is worth considering. You can read it here.