So you got into medical school… Now what?

"So you got into medical school… Now what?" is a book written by Dr. Daniel R. Paull, a recent med school graduate. His aim was to inform newly matriculating medical students about what to expect and how to survive. For the most part, he succeeds.

The first four chapters are a bit on the dry side because Dr. Paull tries to simplify such complex things as how to live with anxiety in the first two years of medical school. He also spends a bit too much time on how to study. I agree with him that studying in medical school differs from studying in college, and that sticking to a schedule is a sensible way to organize time. However, I think that most people will figure out what works best for them on their own.

The book picks up steam starting with Chapter 5 on how to prepare for USMLE Step 1. I get a lot of questions about USMLE, and with no recent experience, I sometimes find them difficult to answer. Dr. Paull takes care of that quite nicely.

The remaining chapters offer plenty of practical advice on transitioning to the clinical years, clerkships and how to arrange them, studying for the two parts of USMLE Step 2, the fourth year of medical school, and finally how to arrange and succeed in the all-important residency interview process.

Regarding clerkships, Dr. Paull wisely recommends that students ask their residents and attendings for feedback during the rotation instead of waiting until the end to find out that their performance was not up to par. He gives some specifics like asking for feedback about H&P's and presentations and how to improve on them.

The pros and cons of away rotations are discussed in some detail and should help any student who is conflicted about whether to do one or not.

He explains how the National Resident Matching Program works and offers some hints about ranking programs which echo similar comments I have made on this blog.

The book is in trade paperback format and inexpensive at a list price of $19.95. It's also available in a Kindle edition.

My only other criticism of the book is that Dr. Paull relies a little too much on an alarm clock about to go off or going off as a way to introduce a challenge he is trying to help students deal with.

Why should we believe anything Dr. Paull says? Well, he has a bachelor of science degree in physics from New York University, graduated from the University of Miami School of Medicine, and is currently an orthopedic resident at the University of Toledo in Ohio. In case you hadn't heard, orthopedic residencies are highly competitive.

Also, I have read the book myself and think most med students will find value in it.

Disclosure: I received a complimentary copy of the book from the author.

Is do-it-yourself surgery the future of medicine?

Once in a while, I read something on the Internet that is so silly, so outrageous that I can't help myself. I must speak up.

Such a situation occurred a few days ago when I came across an article called "DIY [do it yourself] Surgery: The Future of Medicine?" on a website called FastCompany.

An "interaction designer" named Frank Kolkman has created a robotic Open Surgery Machine which he proposes could fill in need when "middle-class" US citizens who have no access to healthcare require surgery.

My favorite line from the article is an explanation of what Mr. Kolkman's robot can do. "It's designed to perform simple surgeries like laparoscopic surgery in which three or more small keyhole incisions are made to allow a surgeon to operate inside a part of the patient's body after inflating it with CO2."

He proposes that "appendectomies, prostate operations, hysterectomies, and also colon and general inspections" could be done.

The Surgeon Scorecard: My analysis

I've got nothing against ProPublica. If a valid way to rate surgeons is ever discovered, I would support it completely. However, ProPublica's Surgeon Scorecard is not the answer.

I keep hearing its defenders say, "Some data is better than no data at all." I disagree strongly with that. To me, bad data is worse than no data at all. People with much more statistical sophistication than I have pointed out the flaws in the scorecard.

Digression: Having written many posts about statistics, I can tell you that the mere mention of the word drives readers away about as fast as if you were to yell "Fire" in a crowded theater.

I want to focus on a different area. The scorecard has created a lot of chatter on Twitter, and just about everyone I know has blogged about it.

This reminds me of a couple of posts I wrote back in 2011. [Links here and here.] I pointed out that Twitter might not be as important as those of us who use it think it is.

While we were busy arguing about the merits of the scorecard on Twitter, I'm not so sure what the general public was doing.

For example, ProPublica says the Surgeon Scorecard has had over 1 million visitors since its launch. That sounds like a lot until you consider that the current population of the United States is estimated at 321 million. So 1 million people would be 0.3%. We do not know how many of those 1 million were unique visitors. It could be that many of them were doctors looking for their own statistics and bloggers looking for ideas.

That the public may not care was reinforced by a rather tepid response to the ProPublica AMA (Ask Me Anything) on Reddit today.

By 1:00 PM EDT, which was two hours into the AMA, there were 80 comments, 31 of which were by ProPublica staff or the spine surgeon who had consulted on the scorecard's methods.

Just to give you some perspective, an AMA last year by a guy with two penises drew 17,134 comments.

Because the demographic is skewed toward younger people, perhaps Reddit may not have been the right venue. Although Reddit boasts 169 million unique visitors per month, the most recent figures show that 33% of the Reddit users are mostly men between 18 and 49 years old. Those under 18 are not counted but represent "a substantial percentage of Reddit users."

My two favorite questions asked of ProPublica were "How can I tell if my doctor is capable of making an error?" and "Do you fix the leg which is broken completely?" [Did the question refer to a leg that was completely broken, or did it mean should the leg be completely fixed?]

What have we learned here? It's hard to say.

If you want to read a measured critique of the scorecard, go to Dr. John Mandrola's piece on Medscape.

Take lecture notes on a laptop computer or use old fashioned longhand?

A paper published last year in Psychological Science suggests that taking notes in longhand is the better choice.

The authors, from Princeton University and UCLA, performed three studies on college students. They found that even if multitasking and distractions were eliminated, “students who took notes on laptops performed worse on conceptual questions than students who took notes longhand.”

Previous research has shown that note taking enhances learning by both providing external storage of information for later review and “encoding,” that is, processing information and reframing it in one’s own words.

Although significantly more notes were taken by laptop users, they tended to be more like transcriptionists instead of thinking about and summarizing what they heard.

Review courses and board exams

Four years ago, I wrote a post called "Hints for new residents." Among my 15 tips was this: "Read, read, read. This isn't like school. You can't cram for your boards. You can’t learn 4 or 5 years’ worth of material in a one-week review course. You have to learn it as you go along."

Just published online in the journal Surgery is a paper entitled "Review courses for the American Board of Surgery certifying examination do not provide an advantage" by four officials from the board.

They surveyed new surgeons who took the certifying (oral) exam, 1067 for the first time and 329 who had previously failed the test, during the time period from October 2012 through June 2013. The overall response rate was 90%.

The pass rate for first-time takers was significantly better than that of repeaters, 82.1% and 72.6% respectively, p < 0.001; 77.9% of all examinees took a review course—76.1% were first-time takers compared to 84.6% of those repeating the exam, p = 0.002.

Which is better—an electronic or a paper progress note?

It depends on whom you ask.

A new study says internal medicine house staff generally feel that the quality of progress notes is unchanged or better since the implementation of an electronic medical record, but the attendings feel that progress note quality is unchanged or worse.

Over 400 interns, residents, and attending internists at four university hospitals were surveyed. The paper appears online in the Journal of Hospital Medicine.

Specifically, 50% of residents felt that the quality of notes was unchanged and 39% thought the quality was better or much better. Conversely, 39% of the attendings felt the note quality was unchanged, and another 39% felt that it was worse or much worse.

From the paper: Half of interns and residents rated their own progress notes as “very good” or “excellent.” A total of 44% percent of interns and 24% of residents rated their peers’ notes as “very good” or “excellent,” whereas only 15% of attending physicians rated housestaff notes as “very good” or “excellent.”

When the 9-item Physician Documentation Quality Instrument was used to evaluate notes, attending perceptions of housestaff notes were significantly lower than housestaff perceptions of their own notes, p < 0.001. One of the PDQI items asked for a rating of how succinct resident notes were. That feature was rated lowest by attendings and residents alike. I can think of a lot of words to describe electronic progress notes, but "succinct" isn't one of them.

In all, 16% of interns, 22% of residents, and 55% of attendings reported that copy forward [copy and paste] had a “somewhat negative” or “very negative” impact on critical thinking, p < 0.001. Auto population of fields in notes was judged similarly.

The authors felt that these differences could be explained because Attendings may expect notes to reflect synthesis and analysis, whereas trainees may be satisfied with the data gathering that an EHR facilitates. I agree.

Can all this be remedied?

Dr. Daniel Sexton, a Duke University internist, authored a three page guide [link is safe] on how to write effective progress notes. Here are just a few excerpts:

DO NOT TRANSCRIBE LAB DATA INTO THE PROGRESS NOTES UNLESS YOU INTEND TO COMMENT UPON IT. [All caps by Dr. Sexton]

It is often good and useful to explain your thinking in the chart.

Do not mindlessly repeat yourself in daily notes. [That goes for "copy and paste" too (my extension of this recommendation)]

LENGTH OF NOTES DOES NOT RELATE TO RELEVANCE OF NOTES. [All caps by Dr. Sexton]

I have written about the pitfalls of electronic medical records several times. In my blog's search field to your upper right, insert "electronic medical record" or "EMR" and click "Search This Blog" to see my other posts.

It's early in the academic year. Start writing better notes now. And please don't copy and paste.

That time Skeptical Scalpel wasn’t skeptical enough

Yesterday I retweeted a link to “Live Action News,” a website with a video claiming that Planned Parenthood was selling fetal organs.

I had watched the video and read the accompanying article but failed to engage my skeptical radar. It turns out that the video was maliciously edited to portray Dr. Deborah Nucatola, Senior Director of Medical Services for Planned Parenthood, in the worst possible way. The video showed her “having lunch with actors posing as buyers who are interested in purchasing the body parts of babies who have been aborted” and discussing prices.

The website Media Matters describes some of the edits and explains why they are deceptive. It turns out that of the 150 minutes of the original footage, only 8 minutes were used in the "Live Action News" clip.

If I had watched the video more closely, I wouldn’t have needed Media Matters or the 150 minutes of original footage to see the flaws.

First of all, it begins with an introduction by a former ABC News anchor Connie Chung promising something shocking. But as you can see in the screen shot below in the lower left corner, it clearly says “ABC News 20/20 March 8, 2000.”

Another obvious clue is that the date and time stamp in the lower left-hand corner of the edited video itself is “2014 07 25.” In retrospect, it does not seem plausible that an anti-abortion organization would have sat on this inflammatory story for almost a year before releasing it.

In addition, the times differ greatly as the video progresses which obviously should have told me that major editing had taken place.





The "Live Action News website looks pretty bogus too.


I am very disappointed in myself for having fallen for this dishonest garbage.

It won’t happen again.

Big data is not big enough

Today ProPublica released its “Surgeon Scorecard” touting it as the best way to pick the right surgeon.

It took me less than a minute to discover some interesting omissions from the application.

For laparoscopic cholecystectomy, the only general surgery procedure listed, the app omits approximately one-third of the hospitals in my state including two where I have practiced.

It looks like the problem is that using Medicare fee-for-service data does not yield enough surgeons performing 20 or more cases in some categories such as laparoscopic cholecystectomy for the five years included in the database.

At one of the biggest hospitals in my state, apparently only one surgeon performed 20 laparoscopic cholecystectomies on fee-for-service Medicare patients in the five years studied; 23 other surgeons were listed as having performed fewer than 20 laparoscopic cholecystectomies on patients in the target population. I don’t see how patients who want to use that hospital for their gallbladder surgery will benefit from the Surgeon Scorecard.

In general, the complication rate for laparoscopic cholecystectomy is low, but I think I understand why ProPublica chose that procedure to review. They needed to select a procedure that was done frequently enough to yield a sufficient number of cases for analysis. Unfortunately, because of the limitations of the Medicare fee-for-service data and the low complication rate of the procedure, the Surgeon Scorecard is useless for anyone looking to compare general surgeons.

Similar problems with the scorecard may be in play for prostate surgery. Again, the procedure was chosen because of its high frequency, but in quickly looking through some searches in that area, I note that a number of urologists I know also did not perform 20 cases on fee-for-service Medicare patients.

Perhaps the next iteration of the scorecard will utilize a data set that contains enough patient and surgeon records to make a meaningful comparison.

Until then, general surgeons can relax. They will not have to explain away their complications but will simply have to explain why they aren’t listed in the Surgeon Scorecard.

How to pick the leading physicians of the world

 

My "real life" self has been selected as a Top Surgeon in my city by the International Association of Healthcare Professionals (IAHCP). I will be spotlighted in the renowned publication “The Leading Physicians of the World.” Can you imagine?

As you can see, my candidacy [which I did not know was even a remote possibility] was approved on June 11.

The letter goes on to state that the IAHCP highlights and profiles the world’s Top Surgeons. The association features physicians who have demonstrated success and leadership in their profession. It even provides an opportunity to network, collaborate, and share information with other medical professionals from around the globe. [Just what I need—another social network of physicians.]

Inclusion in the book “The Leading Physicians of the World” is not only a tribute to my success, but is also a valuable resource for potential patients who are looking for a Top Surgeon in their area.

There is no charge for this honor.

I’m sure the organization did a lot of research before it approved my candidacy. I wonder how they missed that I’ve been retired from the practice of surgery for more than two years?

I thought this was remarkable, but last year New York Times writer Dr. Abigail Zuger easily topped me.

Last year, she wrote that a relative of hers had been named one of the world’s top physicians. All he had to do was to verify his biographical information, and he would be included in the same book and online reference mentioned above.

The good doctor wasn’t able to do so because unfortunately, he died 16 years ago.

What have we learned here?

As I have said on many occasions [e.g., here and here], one must take all ratings with a pinch of salt. 

Physician ratings? A truckload of salt.

What about a rural track surgical residency program?

Here's an email from someone interested in rural surgery:

I am a senior medical student planning on going in to general surgery and practicing in a moderate sized city (~70k people), but would also like to do some medical missions. I currently do not plan on doing a fellowship after residency, and would like to go directly into practice. I have seen a growing trend of "rural programs” popping up including Mayo starting a rural track this year, Wisconsin has one rural spot, and Gundersen is another notable program. For many of these programs you leave your primary training hospital during PGY3-4 and go train rural hospital, you may also spend more time doing OB/GYN cases or other surgical specialties. How do you think this affects the preparedness of the residents leaving these programs vs a community program with a high case load or university program? Most of these programs advertise all the “extra” skills acquired from participating in their rural tracks but don’t discuss what that means you will miss.

Great question. I have no personal experience with rural track surgical programs. From what I have read, most residents who go this route emerge satisfied.

I think you need to speak to a few residents who have done it and see if they feel they missed anything. It probably wouldn't be too hard to get some names from coordinators in programs that have the rural option.

My concern for your situation is that if you plan to practice in a city of about 70,000, it is highly unlikely that you will be doing C-sections, orthopedics, or G.I. endoscopy. This would negate much of the value of doing a rural track. I have a few former residents who practice in small towns and do C-sections and endoscopies, but those locations have fewer than 10,000 people. My program provided a decent endoscopy experience, but since we had an OB/GYN residency, I think my graduates learned to do C-sections after they left the program.

Since you are planning to practice in a community hospital, you may want to consider training in a busy community hospital residency program. The way things are going in general surgery, case volume is becoming more and more important. As a general surgeon in a city of 70,000, you will probably not be doing big cases such as Whipples and major vascular surgery anyway.

Can any of my readers offer you more advice?