Surgical training is different in Japan

Quite different than what we are used to in the United States as a paper published online in the American Journal of Surgery explains.

In the US, all residency programs are vetted by the Accreditation Council for Graduate Medical Education (ACGME). Japan has no central accrediting organization. Each hospital establishes its own training program without any national standardization.

Medical school graduates in Japan take a national practitioner examination and then complete a two-year rotating internship. Specialization in general surgery residency takes three more years after which the residents may obtain board certification.

The authors surveyed 76 teaching hospitals in Hokkaido, a prefecture in the north of Japan, and 49 (64.5%) responded.

Program directors were in place in 81% of the residency programs. Of that number, 79.3% devoted less than 5 hours per week to education [compared to an ACGME mandate that 30% of a program director’s time must be devoted to education], and 72.4% had dialogues with residents only when necessary.

Of those responding to the question, 31/36 (86%) "had teaching activities outside of clinical settings," but no program had protected time dedicated to teaching.

Fewer than half of the programs had skills or simulation laboratories, with 12.5% having formal simulation training as part of their educational agenda.

Only 55.6% of the programs evaluated the competency of their trainees in knowledge, skills, or scholarly activities.

Not surprisingly, only 8.6% of program directors were satisfied with the way their programs functioned.

To become board-certified in Japan, residency graduates must take a written exam for which the pass rate is 82.1% and an oral examination which has a pass rate of 100%. The pass rate for the oral exam has been an issue. A medical specialty board was established in 2014 and is preparing to oversee the quality of resident education and certification.

Lead author Dr. Yo Kurashima, Director of Surgical Education Research at Hokkaido University Graduate School of Medicine, answered a few questions via email. He said some of the hospitals limit resident work hours and allow residents to go home after call. However, "most do not define work hour limitations, so residents usually work from early in the morning to midnight every day."

No universal surgical residency curriculum exists in Japan, but a national surgical society recently listed criteria that must be achieved prior to board certification.

Dr. Kurashima did some training in Canada where he became familiar with North American residency methods.

For his next project, he said, "We are just starting a national survey which will investigate resident satisfaction regarding their residency.”

I suspect the residents might raise some concerns. I wonder if they will have time to respond.

Misconceptions about oxygen by alternative medicine practitioners

An article called “Simple ‘4-7-8′ breathing trick can induce sleep in 60 seconds” claims that this trick can get you to go to sleep within 60 seconds. All you have to do is the following:

♦ Exhale completely through your mouth, making a whoosh sound.
♦ Close your mouth and inhale quietly through your nose to a mental count of four.
♦ Hold your breath for a count of seven.
♦ Exhale completely through your mouth, making a whoosh sound to a count of eight.
♦ This is one breath. Now inhale again and repeat the cycle three more times for a total of four breaths

An integrative medicine expert, Dr. Andrew Weil, said it works because it allows the lungs to become fully charged with air, allowing more oxygen into the body, which promotes a state of calm.

“Promotes a state of calm” is nonsense. Let’s concentrate on the science. Does it allow more oxygen into the body? Ich don't think so.

The air we breathe contains about 21% oxygen. Nearly all oxygen in the blood is carried by hemoglobin. No matter how many deep breaths you take, you cannot get the oxygen saturation of hemoglobin (normally > 92%, closer to 98% in healthy people) above 100%. This is explained in more detail in a previous post of mine about why athletes don’t benefit from breathing pure oxygen after exertion.

This simple trick would be hard to remember but might work through the power of suggestion. It doesn’t cost anything, and unless you hyperventilate and pass out (but you'll be in bed anyway), it is harmless.

The next misconception about oxygen is neither inexpensive nor harmless.

Two naturopathic “doctors” have been accused of injecting a woman with oxygen or perhaps purified water that had been taken from an Octozone machine. The oxygen was supposed to destroy any pathogens in the woman’s blood. In the process of trying to kill the pathogens, the injection killed the patient who paid $500 for the treatment.

The naturopathic duo left town and were at large for several months before eventually being caught and charged with homicide.

An autopsy found her death was due to an air embolism.

According to a recent review of the subject, “Traditionally, it has been estimated that more than 5 mL/kg of air displaced into the intravenous space is required for significant injury (shock or cardiac arrest) to occur. However, complications have been reported with as little as 20 mL of air (the length of an unprimed IV infusion tubing) that was injected intravenously.”

Pure water should never be injected IV either because it causes blood cells to die from hemolysis.

How about we just take our oxygen the old-fashioned way—normal breaths and never intravenously?

Do doctors charge too much?

We all know that some doctors’ fees are excessive. I have blogged about this myself citing a neurosurgeon’s $117,000 charge for assisting on a case.

We also know that doctor bashing is a popular sport right now.

In an otherwise reasonable article about high-deductible health insurance on Vox.com, reporter Sarah Kliff’s second paragraph read as follows:

The bolded text was hyperlinked to a Washington Post piece about a study that showed wide variations in hospital charges for appendectomies in California. The study was not about physician fees. No matter how difficult the case was, no surgeon would ever have been paid $186,955 for performing an appendectomy.

Yesterday, I twice asked Ms. Kliff to please correct this grossly misleading paragraph. She acknowledged my request that evening, but as of 9 AM today, nothing had been changed.

Even if Ms. Kliff had correctly identified the hospitals as the culprits, using appendectomy as an example of why patients should shop for the lowest prices was a poor choice.

Nearly every patient with appendicitis does not know he has it until he has gone to an emergency room, seen an ED physician, and had some tests. I doubt most people in this situation would A) ask how much it’s going to cost to have an appendectomy and B) decide to go to another hospital for care. The fact is, hospitals are so secretive about their charges that a patient would be unable to comparison shop especially if the emergency department visit occurred outside of normal working hours.

Even trying to find out the charges for elective surgery remains difficult in 2015.

Physicians—particularly surgeons—have taken a lot of heat recently. We don’t need articles like this to inflame patients (and journalists) even more than they already are.

ADDENDUM 9:45 AM 10/15/15

The article was just changed. The bolded mistaken passage was corrected, but the next sentence (underlined in red) remains the same. Still blaming those "really expensive doctors."

Code Black Part II: "It gets worse"

Last week, I reviewed the premier of the new medical television series "Code Black" and pointed out several flawed or impossible scenarios. I didn't think I'd watch another episode.

But I was alerted to a rather shocking error on last week's installment. I had to see it for myself.

On this typically chaotic day in the emergency department, a young woman was brought in after a car crash which occurred while she was in her way to the ED because of abdominal pain. A CT scan of her abdomen and pelvis was negative, but her serum lactate level was elevated. They then decided to examine her abdomen and noted tenderness. A bedside ultrasound done in the ED revealed a left ovarian torsion (twisting of the blood supply to the ovary which if not rapidly corrected, could cause irreversible damage). The patient had already had her right ovary removed. Further heightening the drama was that her husband died of lymphoma but had banked his sperm, and the patient wanted to have his baby.

She needed immediate surgery, but all of the hospital's operating rooms were busy. As the window of opportunity to correct the problem was closing, an operating room opened up. But alas, there was not a single gynecologist or surgeon available to do the case. According to the back story about Dr. Neil Hudson, he's a fully trained surgeon who decided to work in emergency medicine. One of the new ED residents begged Dr. Hudson to do the case, and he resisted for a while until it was almost too late.

Live tweeting from #ACSCC15

As many of you know, I have not been a fan of live tweeting conferences. I blogged about the issue last year (here and here) and received a lot of feedback about the posts, most of it strongly opposing my views.

Vigorous live tweeting from the American College of Surgeons Clinical Congress (#ACSCC15) in Chicago is underway. Here are a couple of examples of tweets from that meeting. Twitter handles are blocked to protect the innocent (or guilty).

First, the good. Here is a nice montage showing what surgical program directors are looking for in residency applicants.

The photos are in focus and well-positioned. Anyone not in the audience for the talk can get something useful from this tweet. My one complaint -- we do not know who the speaker is. That information may have been provided in an earlier tweet, but this retweet is the only one I saw.

OR tech: "How do I deal with an abusive surgeon?"

Have you ever come across problems with rage and temperament issues in the OR. I have been an operating room tech for many years and have been in a variety of surgical settings.

A certain surgeon brings in a lot of money to the hospital, but he is terrible. I have been called things no one has ever called me. He throws instruments on my table and mayo stand, screams, and implies that I and my colleagues have no idea what we are doing. I have reported him to my manager and the OR director, but nothing ever comes of it.

Other surgeons have witnessed his behavior and have said something, but nothing was ever done. I understand the OR is a beast of its own, but the culture has to change with these newer guys coming out of residency. The mindset of the surgeon being our 'customer,' which is being rolled out to us now, is not reason for us to put up with abuse. What have you encountered on a peer-to-peer level on how to handle such demeaning behavior? I trained and worked at a level 1 trauma center with emotions that constantly ran high, and still it was less stressful than this particular surgeon. Thank you for your advice. 

A recent paper in the American Journal of Surgery addressed this topic. The authors interviewed 19 OR personnel including nurses, medical students, surgical residents, anesthesiologists, and 2 scrub technicians. Dr. Amalia Cochran, the paper's lead author, told me the reason there weren't more scrub techs was that they were reluctant to participate.

“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.