What's with pre-med students "shadowing a doctor"?

Many medical schools are either requiring or highly recommending that applicants show evidence of “shadowing” [following a doctor around] for varying periods of time. This supposedly gives a pre-med student an idea of what doctors do. I guess the schools assume that if someone has shadowed a doctor and still wants to become one, that individual is a better candidate for medical school than someone who hasn't done any shadowing.

A recent incident at a hospital in Syracuse, New York raised some serious concerns about shadowing. An anesthesiologist allowed a college student to endotracheally intubate a patient in the operating room. This was a problem on many levels. Students who are shadowing are not supposed to touch or examine patients. The patient who was intubated likely did not know that an unlicensed college student would be doing a procedure on him. And of course, there's HIPAA.

According to the article, the director of Consumers Union's Safe Patient Project, called the incident an "egregious violation of patient-doctor trust."

I've had a problem with shadowing for many years, and I'm not the first to say so. Dr. Elizabeth Kitsis, director of bioethics education at Albert Einstein College of Medicine in New York, has blogged about the topic.

She told of a male pre-med student who was introduced to patients as a "student doctor" and watched a gynecologist perform pelvic exams. The student himself said he felt a little awkward. One wonders how the unsuspecting patients would have felt had it been known he was a college student thinking about becoming a doctor.

There were many comments pro and con on both Dr. Kitsis's blog and a follow-up piece that appeared on another Einstein blog.

Dr. Kitsis co-authored a paper which found that few studies have looked at shadowing by pre-med students. She called for guidelines and a code of conduct for this activity.

Several questions come to mind.

With all the information available on the Internet, is shadowing really an effective way for college students to decide whether to become physicians or not?

Is there any research comparing career outcomes of pre-med students who shadowed doctors to those who did not?

What about the patients? Do they have any say in this? Are students who shadow introduced as who they really are?

How does a student choose a doctor to shadow? As far as I can tell, there is no quality control for this aspect of shadowing.

Is shadowing mandatory in other fields? Must one shadow before becoming an engineer [civil, railroad, or sanitation], an accountant, a fighter pilot, a shepherd, or an exotic dancer?

Applicants, want to be a resident but don’t write good? Here’s help

Thanks to a spammer trying to comment on some of my posts, I have been introduced to the world of online personal statement services.

On a website called internalmedicineresidency.biz, $54.09 (discounted to $43.27 if you order by June 30) will get you a 275-word personal statement. As the website points out, “Coming up with a personal statement internal medicine of this quality is far from easy, but it’s what our professional service is here to help you achieve.”

Under the heading “How to create a killer statement, item #2 is “Argue why you suit for the course.”

The site offers a sample personal statement that begins, “I’ve always admired those who work in the health care industry not only because my mother was one but the fact that these people are the ones who care for our well being.”

In case you are after bigger game, the same company offers similar services for obtaining a neurosurgical residency. This site says, “Getting a neurosurgery residency can give your career a boost which can have a positive effect at your future in this field.”

I must agree that if you want to become a neurosurgeon, failure to obtain a neurosurgical residency position is a definite disadvantage. In fact, I think it would pretty much preclude your becoming a neurosurgeon.

It may be more difficult to obtain a neurosurgical residency than one in internal medicine, but the price for a neurosurgery personal statement, at a mere $27.19, is much lower.

For some reason when you click on the Sample tab, the site displays a “Pre Med Personal Statement” followed by this paragraph:

Pre Med personal statement writing is nowadays proven as beneficial using online services. Nowadays, students are showing more interest for the pre-med programs because of its value and prospective value for the future medicine studies. There is a great competition every year for this program and thousands of students applying every year too. Here, it is indicating, how important it is to add your application with a personal statement. If you fail to satiate this factor, then admission success is hard to expect. Our service is definitely wise option here to come up with a neurosurgery residency personal statement and any winning personal statement.

If that doesn’t convince you to try this service, I don’t know what will.

A USMLE Forum lists 18 other websites that provide personal statement writing services. I wish I had time to check out all of them.

Questions about antibiotics vs. surgery for acute appendicitis

A study from Finland suggesting that antibiotics may be a viable alternative to surgery for acute appendicitis has created a stir. As you might have expected, I had some concerns about the paper which you can read in my blog post here.

On Twitter, many surgeons have commented on both the paper and my post. Several interesting questions come to mind.

Based on this and other similar studies, is the treatment of acute appendicitis with antibiotics now a mainstream alternative to surgery?

Should surgeons now mention the Finnish study results during their informed consent discussions with patients?

Antibiotics for appendicitis? No thanks

The long-awaited Finnish randomized controlled trial of antibiotics vs. surgery for appendicitis was just published in JAMA. Depending on your perspective, 73% of patients were successfully treated with antibiotics or 27% of patients failed antibiotics and needed surgery.

The good news is that it was a large multicenter study involving 273 patients randomized to surgery and 257 to antibiotics. Patients included in the study had uncomplicated appendicitis as diagnosed by CT scan.

The bad news is that the paper has many limitations.

Of the patients who underwent appendectomy as the primary treatment, only 15 (5.5%) had laparoscopic surgery. The authors state that open appendectomy was selected as the protocol operative technique because laparoscopic instruments may not be available worldwide and apparently many surgeons in Finland are not experienced in performing laparoscopic appendectomies.

It wasn't like this in my med school

When I was a medical student, we had to practice drawing blood on our lab partners. I remember the first day we did it. One guy fainted as he was having his blood drawn, and another fainted while he was drawing someone else's blood.

We've made a lot of progress in medical education since then. In 2015, teaching blood drawing, which is going to eventually be taken over by robots anyway, is passé.

Students are suing a Florida sonography school because they were forced to perform transvaginal ultrasounds on each other almost every week. Those who complained were allegedly told to “find another school if they did not wish to be probed” said an article in the Washington Post.

While that seems out of line, it pales in comparison to allegations lodged against a former US Army doctor who ran a company that taught battlefield medicine to soldiers and made more than $10.5 million in the process.

According to Reuters, he gave students alcohol and drugs, including ketamine, a powerful hypnotic used as an anesthetic. Sometimes alcohol and ketamine were given at the same time.

Trainees were told to insert urinary catheters into each other, and two students underwent penile nerve blocks. On another occasion, when students balked at receiving penile blocks, the doctor had the students perform a penile nerve block on him. It's not clear what a penile nerve block has to do with treating wartime casualties.

If that's not troubling enough, he supposedly ran what he called "shock labs," during which he drew blood from trainees, observed them, and gave their blood back to them.

But wait, there's more. The doctor is alleged to have had a few beers with a student and examined, manipulated, and photographed the student's uncircumcised penis.

The doctor's claim that his methods are standard in Virginia medical schools was refuted by experts quoted in the Reuters piece.

The Virginia Medical Board has suspended the doctor's license and will hold a hearing on June 19.

And we thought sticking each other with needles was traumatic.

Narcotic addicts can sue doctors and pharmacies for "enabling" them

In a 3-2 decision, the Supreme Court of West Virginia ruled that narcotic addicts may sue pharmacies and physicians for facilitating their addictions.

A suit was brought on behalf of 29 pain center patients who had been treated with narcotics for various injuries and became addicted. One article quoted the Chief Justice's explanation: "A plaintiff’s wrongful or immoral conduct does not prohibit them from seeking damages as the result of the actions of others."

The court recognized that most of the plaintiffs "admitted their abuse of controlled substances occurred before they sought help "at the pain clinic.

Another story said, "The justices paved the way for people to claim damages for allegedly causing or contributing to their addictions of controlled substances—even if they broke the law by doctor shopping."

In a dissenting opinion, one justice wrote that the decision “requires hardworking West Virginians to immerse themselves in the sordid details of the parties’ enterprise in an attempt to determine who is the least culpable—a drug addict or his dealer.”

In response to the ruling, the West Virginia Medical Association issued a statement: "It may cause some physicians to curb or stop treating pain altogether for fear of retribution should treatment lead to patient addiction and/or criminal behavior. It may create additional barriers for patients seeking treatment for legitimate chronic pain due to reduced access to physicians. It would allow criminals to potentially profit for their wrongful conduct by taking doctors and pharmacists to court."

A post on the American Pharmacists Association website explained that pharmacists were included in the ruling "because they were aware of the 'pill mill' activities of the medical providers. The plaintiffs said these pharmacies refilled the controlled substances too early, refilled them for excessive periods of time, filled contraindicated controlled substances, and filled 'synergistic' controlled substances."

One newspaper summarized the public reaction to the ruling in an editorial stating, "Those who are illegally abusing prescription narcotics should be prosecuted to the fullest extent of the law. The same goes for medical professionals who are found guilty of committing a criminal act. But telling a drug addict or someone who is illegally abusing prescription narcotics that it is OK to go to court and file what could very well be a frivolous lawsuit is both baffling and shameful. This ruling by the Supreme Court justices is a clear back eye for West Virginia. And it does nothing to help West Virginia’s rampant drug problem."

As I wrote last year, I think the prescription drug abuse epidemic all stems from a 15-year campaign that declared pain is the fifth vital sign—a concept which is both untrue and as we have come to learn, harmful.

I agree with the WVMA. If I were practicing in West Virginia, I would be very reluctant to prescribe narcotic pain medication to any patient.

What do you think?

Warning. Beware of misleading medical information on the Internet

While doing some research for another blog post, I came across a website for a company that makes private-label bottled water. One section of the site described the different kinds of bacteria such as aerobes which need oxygen to survive, strict anaerobes which are killed in the presence of oxygen, and facultative anaerobes which usually prefer oxygen but can survive without it if necessary.

So far so good. However, the next paragraph reads as follows:

The most virulent and destructive pathogens that affect mankind generally fall into the “strict anaerobe” category. They include bacteria like Staphylococcus aureus, Streptococcus pneumoniae, Clostridium botulinum and Escherichia coli.

This is wrong. Except for Clostridium botulinum, the organism that causes botulism, the other bacteria are aerobic. Staphylococcus aureus can be nasty, particularly if it's methicillin-resistant (MRSA), but Streptococcus pneumoniae is not particularly virulent, and Escherichia coli, while a common cause of wound infections after bowel surgery, is part of the normal flora of the large intestine.

As wrong as that bacteriology lesson was, it pales in comparison to a more than 700 word essay on why you should drink warm water instead of cold.

If you have a few minutes, you should read it because nearly every sentence contains misinformation. Let me share a few of the highlights with you.

Can a surgeon who is sitting perform abdominal operations?

A loyal reader alerted me to news of a lawsuit brought by an obstetrician in South Carolina who is suing a hospital for suspending his privileges. He had performed a cesarean section while sitting on a stool because he had a foot fracture secondary to diabetes. Several witnesses said that the doctor "had been unable to properly view the surgical field, unable to properly handle the baby and unable to address hemorrhaging." The patient later developed a serious infection.

A seated surgeon can operate on the hand and arm. In fact, that's the way everyone does it. The surgeon's knees easily fit under the small table holding the outstretched arm. Certain anorectal operations and gynecologic procedures done through the vagina can be done by a surgeon who is sitting, but abdominal and pelvic operations done via laparotomy can't be safely done that way.

The problem is that when a surgeon is sitting, she can't get close enough to the OR table and the patient to see way down into the abdomen and pelvis. If bleeding occurs deep in the wound, controlling it would be challenging to a surgeon who is sitting. Tying a secure knot in the pelvis while sitting might even be impossible.

With the exception of robot-assisted surgery where the surgeon sits a console remote from the operating table, a seated surgeon would have trouble doing both open and laparoscopic procedures. Even with a robotic operation, there can be problems. If the surgeon can't stand, an assistant would have to help insert the robotic ports. What if something went wrong and the abdomen had to be opened?

In a laparoscopic case, the video monitor could be seen by a sitting surgeon, but manipulating the rigid instruments would be difficult because of the angles created by the locations of the ports through which the instruments are passed.

As a retired surgeon, I sympathize with anyone who might be forced to quit operating because of illness or disability, but the safety of the patient comes first.

I hope that the suit is resolved quickly and we learn what the outcome is.

Book review: Operation Health—Surgical Care in the Developing World

The Lancet Commission on Global Surgery recently reported that “5 billion people do not have access to safe, affordable surgical and anesthesia care when needed. Access is worst in low-income and lower-middle-income countries, where nine of ten people cannot access basic surgical care.”
This timely book, edited by Adam L. Kushner, MD, MPH who is on the faculty of both Columbia University and the Johns Hopkins and is a director of the Society of International Humanitarian Surgeons/Surgeons OverSeas (SOS), explains many of the important issues.

In 100 pages and 11 chapters, the assembled international contributors cover such diverse topics as assessing the needs of low-and middle-income countries (LMICs) worldwide, HIV, trauma, women’s health, and process improvement.

The chapters are brief, but packed with useful information most of which is based on research carried out in the field.

Each chapter is introduced by a personal vignette that highlights the importance of the work that Dr. Kushner and his colleagues have been doing.