FAQs from IMGs about applying for surgery training

Here are some of my responses to common questions from international medical graduates (IMGs) looking to match in categorical general surgery residency programs.

1. Which programs should I apply to?

You should apply to a number of second and third tier programs, especially if you USMLE Step 1 scores are not outstanding.

2. What would you consider second and third tier academic programs?

There is no short answer to this question. I suggest you go to Doximity’s residency navigator and look at their list of surgery programs. You should start at the bottom and work your way up. Doximity’s list is not perfect, but it is better than any other one I have looked at.

3. How much of a level playing field is the interview process?

I’m not sure what you mean by this question. The object is to get some interviews. Most programs will not waste their time interviewing people they have no interest in. If you are offered an interview, you should obviously make the best impression you can.

4. What about observerships?

My response to a misguided opinion piece about surgery

"There is no place for the surgeon myth in modern medicine" says writer Alexis Sobel Fitts in Aeon Magazine.

Having a sister in medical school apparently qualifies Ms. Fitts to critique the specialty of surgery.

She starts with an old joke "An internist can figure out what’s wrong with you, but he can’t fix it. A surgeon has no idea what’s wrong with you, but he’s happy to fix it." If you read it carefully, you should note that it’s not that funny, and it’s wrong on both counts. No surgeon would ever fix something unless she knew why, and internists have these things called pills which can successfully treat a number of diseases.

She goes on, "After all, fixing problems is corporeal, often removed from the more intellectually nimble task of diagnosis." Apparently she is unaware that surgeons often make diagnoses—occasionally even correct ones, and I’ve written before about the misconception that doing an operation doesn’t require thinking [here and here].

"Surgeons are descended from the barber or the butcher," she says. That was hundreds of years ago. Nowadays, surgeons complete four years of medical school just like her sister and all the other doctors.

"Any missteps might incite devastating consequences, as the surgeon navigates around the vagus nerve, which dictates facial response…" I hope her sister didn’t give her that information. The vagus innervates many structures, but the face isn't one of them.

"Before anaesthesia and antibacterials, a patient undergoing surgery could be assured of two things: immense pain and the likelihood of infection and death." That’s actually three things. Of course without surgery, patients experienced immense pain, infections, and death anyway.

"Since the 1950s, laboratory science has increasingly been the origin of medical innovation. Which is why, over the past four decades, merely a 10th of the articles published in The New England Journal of Medicine have covered surgical innovation." Or maybe it's because The New England Journal is a medically, not surgically, oriented journal.

Here’s the winner. "Surgery’s place at the bottom of the medical hierarchy can be attributed to the crude cruelty of early surgical procedures." Other than Ms. Fitts, who has placed surgery at the bottom of the medical hierarchy? It’s certainly not US medical students who make the surgical specialties among the most competitive of all.

In the 2015 resident match, surgical specialties filled their first-year positions with 80% or more US medical school graduates. In fact, orthopedics matched with 94.3% US grads. Compare those numbers to internal medicine and family medicine, which filled their first-year positions with 49% and 44% US graduates, respectively.

Here's what Wikipedia has to say about its Aeon Magazine entry:

This article has multiple issues. Please help improve it or discuss these issues on the talk page.

The neutrality of this article is disputed.

This article contains content that is written like an advertisement.

This article contains weasel words: vague phrasing that often accompanies biased or unverifiable information.

That pretty much describes the Aeon essay about surgeons too.

Electronic medical records: Documentation of care and upcoding

Electronic medical records make documentation easier and that may be a problem.

There are many interesting unintended consequences of electronic medical records (EMRs). I was reminded of this by a recent blog I wrote about what interns really do when they are on call. According to a study from a VA hospital using trained time-motion observers, interns spend 40% of their time on a computer and only 12% of their time taking care of patients. This meshes well with other reports noting that doctors are staring at screens instead of talking to patients.

Here’s the problem. The system actually rewards extensive documentation which may result in less patient contact. The saying “If you didn’t document it, you didn’t do it” has morphed into “Document it, and you can use a higher billing code.”

Here are some CPT billing codes for hospital visits.

99221 Initial Hospital Care, Physician spends 30 minutes at the bedside

99222 Initial Hospital Care, Physician spends 50 minutes at the bedside

99223 Initial Hospital Care, Physician spends 70 minutes at the bedside

Sources tell me that they know of physicians who never bill for less than 99223 or 70 minutes for a history and physical (H&P) examination. In order to do this the doctor must document such things as having reviewed at least 10 different systems (e.g., respiratory, GI, musculoskeletal etc.). This is easy to document without having actually done it. The EMR may have popup windows with lists of systems and symptoms that can be checked off as reviewed.

This problem is more prevalent among the so-called “cognitive” specialties like internal medicine and primary care because for procedure-based specialties like surgery, the H&P is usually “bundled” (included) as part of the fee for the surgery.

Now that it is so easy to write a very detailed H&P, it must be tempting to bill every encounter at the maximum level. However, this may come back to bite those who try it. Medicare has been known to audit hospital charts and office records. They have profiles of what the distribution of the various levels of care should be.

Also, there are only so many hours in a day. Let’s say you are working a 12-hour shift and bill for eight 75 minute H&Ps and ten 25 minute subsequent visits. That’s 600 + 250 = 850 minutes or over 14 hours. If you are audited, you will have some explaining to do.

You may think that I am exaggerating but I am not the only one to raise this issue.

A recent long-read from the Center for Public Integrity confirms my thoughts. Here’s a quote from that piece, “And Medicare regulators worry that the coding levels may be accelerating in part because of increased use of electronic health records, which make it easy to create detailed patient files with just a few mouse clicks.”

The article points out that billing for higher codes has risen over the last several years and it’s costing the taxpayers over $6 billion. It warns that Medicare audits might be forthcoming, but some feel that audits might cost more to perform than the revenue they generate.

We will see.

What do interns do when they're on call?

You may be surprised and dismayed when you find out.

A study in the Journal of General Internal Medicine from a VA hospital affiliated with the University of Wisconsin reveals some startling facts.

During a 14-hour call period of 3 pm to 5 am, medical interns spent 40% of their time on computer work and 30% on “non-patient communication,” such as clinical conversations with team members, other physicians and nurses among other things. Direct patient care accounted for a whopping 12% of their time.

What about teaching and learning? Would you believe 2% of the time?

The study was conducted using observers trained in time-motion research. They followed the 25 interns who volunteered for the project, but did not interact with them or influence them in any way. The study was likely much more accurate than most previous research on this topic, which was based on self-reported surveys of house staff.

Other interesting tidbits from the paper were that the on-call intern cross-covered an average of 27 patients per night, which seems like a lot to me. The amount of time spent on “sign out” or “hand offs” was not stated. They averaged 4 admissions per night. Only 93 minutes [11% of the total time on call] were devoted to “downtime,” that is sleeping, eating and recreational computer time.

So it looks like internal medicine interns at the VA in Wisconsin do a lot of “scut work” and don’t have much time for learning or sleeping. With only 4 admissions per night, you would think there might be more opportunity for sleep, but since this was internal medicine, each admission probably took two hours.

The interns in the study worked every fourth night. Ironically, in the good old days when we worked every second or third night, we cross-covered far fewer patients because there were more of us on call each night. Therefore, we got more sleep and were less tired the next day.

When one looks at the small amount of time allotted to patient care and teaching and learning, one is not shocked that many graduates of residency these days are not confident about starting independent practice.

I suspect the results would be similar if surgical residents were observed.

What do you think about this?

A version of this appeared on Sermo yesterday and most agreed that interns are not being properly trained.

Unprofessional behavior by medical hospitalists

By their own admission, medical hospitalists are guilty of many types of unprofessional behavior says a recent paper published ahead of print in the Journal of Hospital Medicine. A group of researchers from the University of Chicago surveyed medical hospitalists from three major Chicago area teaching institutions. The respondents themselves rated each listed behavior on a professionalism scale. There were 77 responses from pool of 101 hospitalists who were sent the questionnaires. The study asked respondents to state whether they had either engaged in and/or observed unprofessional conduct.

The key findings were as follows:

• Most of the respondents had engaged in at least one unprofessional behavior.
• The most common unprofessional behavior was [I hope you are sitting down.] having non-medical/personal conversations, such as discussing plans for the evening, in hospital corridors. [Gasp!]
• Over 60% of these doctors admitted that they ordered a routine test as “urgent” as a way of obtaining results more quickly. [Can you believe it?]
• My favorite is that 40% confessed that they had made fun of or disparaged the emergency department team for missing findings. [Unreported but very likely true is that 60% of those questioned committed another unprofessional act, which was lying by claiming they had never made fun of or disparaged any ED MDs. The only physicians I know who do not routinely make fun of the ED staff are pathologists because they never deal directly with the ED. Before all you ED docs get your panties in a knot, I am certain all of you disparage all of us too.]
• Other alleged unprofessional behaviors were celebrating a blocked admission, going to working when ill and texting during conferences.

Another interesting finding was that for every one of the over 30 unprofessional behaviors listed in the questionnaire, hospitalists said they had observed many more such behaviors than they admitted to participating in.

Despite what many surgeons may have believed, this survey shows that medical hospitalists are really pretty normal. 

But I suspect there will be corrective actions for these doctors at the three hospitals. A curriculum will be developed and monitoring metrics will be established. Maybe listening devices will be placed in hallways. These scandalous behaviors must be stopped.

A final note—this study was supported by grants from two different sources.

Why I am I so grumpy?

Patient information and situations have been slightly altered for privacy reasons, but the essence of the stories is true.

A middle-aged woman was admitted to the medical service for symptoms of alcohol withdrawal. Her liver function tests were abnormal. Despite the fact that she had no abdominal pain, an ultrasound was ordered and showed a gallstone. The cognitive doctor called me and said he didn't think the gallstones were significant but would like me to see the patient and confirm his feeling. Asymptomatic gallstones do not require surgical intervention. Why can’t a cognitive doctor deal with this himself?

An emergency physician had a woman in the ED who had fallen down some steps and fractured her right humerus, clavicle and a rib. There was no history of loss of consciousness. Her total body CT scans were otherwise negative. He consulted me to "clear" her regarding possible other injuries before deciding on her disposition. Are ED MDs capable of assessing and "clearing" trauma patients or not?

A man was admitted to the medical service with gallstone pancreatitis. [Whether such patients should be admitted to medicine or surgery will be the subject of another discussion.] I was called for a consult at 2:00 a.m. Think about it. How likely was it that I was going to operate on this patient in the middle of the night? Hint: Not very.

The answering service of a surgeon I was covering for called me at 5:00 on a Sunday morning to tell me that a woman had called to say her husband, who had undergone surgery a few weeks before, was having pain. I called the number I was given, and the call went straight to voice mail. Through clenched teeth, I left a message stating I was returning her call and that if she wanted to talk to me she should leave her phone on and call the service back. When she called back a while later, I learned that the pain had been going on for more than 24 hours. Why couldn’t they have waited two more hours to call? And how about leaving the phone on to receive the call-back?

A patient of another surgeon I was covering for called me at 6:00 p.m. on a Friday to tell me he had just run out of pain medication. Wouldn’t it make more sense to call the doctor for a refill when one was down to say, two or three pills? By the way, this happens all too frequently. It always makes me suspicious that the patient is drug-seeking. They get just enough pills to last the weekend.

I was called to the ED to see a morbidly obese woman with an incarcerated ventral hernia. While taking a history, I learned that she had diabetes, hypertension, asthma, sleep apnea, hypercholesterolemia, arthritis, atrial fibrillation and was taking prednisone and Coumadin, as well as 15 other medications. Her primary care physician, all of her specialists and the surgeon who had performed all of her previous operations practiced at another hospital. Why did she come to my hospital? She said she knew she wouldn’t be kept waiting as long in our ED.

Horace Greeley: “Common sense is uncommon.”
Skeptical Scalpel: “Common sense cannot be taught.”

Finally, an internist discovers some pitfalls of the ACGME work hours restrictions

In a blog post, noted patient safety expert and hospitalist movement founder Bob Wachter discussed some new realities in resident education as a result of the recent [July, 2011] ratcheting down of resident work hours by the Accreditation Council for Graduate Medical Education [ACGME]. While applauding the more humane conditions under which residents now labor, he noticed disturbing changes in the way residents are being trained. The issues he raised have been well-known to surgical educators since the institution of the 80-hour work week in 2003.

He unknowingly agreed with something I wrote recently about today’s residents lacking opportunities to function independently, which leads them to worry about their competence after graduation. Wachter wrote: “Learning from one’s mistakes is fundamentally unethical when you have a human life in your hands. But an environment in which the housestaff are trained to read the attending’s body language before making a tough call can’t be right either, particularly when our third-year residents morph from resident to attending on June 30th each year.”

Continuity of care is another issue. Wachter: “A second worry is the relative dearth of patients being followed by a single resident from admission to denouement. Our teams inherited nearly half their patients as handoffs from night admitters.”

He stated the problem very well. “So many emergency admissions traverse a trajectory in which an early assessment is followed by a period of data gathering (tests, consults), followed by an initial patient response, which is evaluated in context. In a system in which half the patients are cared for by two sets of doctors during these crucial stages, neither group fully sees this arc play out, and their education suffers.”

And regarding hand-offs. “While some trainees forced themselves to rethink their patients’ problems and actively ward off anchoring bias, others didn’t, accepting what they were told as gospel and never coming to know the handed-off patients as well as those they admitted themselves.” This happens a lot more often than most people think.

He wondered how this fragmentation of care could be ameliorated but did not offer any solutions. Fragmentation of care during resident training will at least prepare internal medicine residents to become hospitalists, since lack of continuity permeates most hospitalist services that I am aware of.

Wachter has also just noticed that formal educational conferences are another casualty of the time limitations. He said: “The other thing that worries me about the new schedules is the palpably limited time available for education. In the 16 days I spent as attending in January, I recall only two in which the entire team was available for our traditional hour-long teaching rounds.” Bob, this has been a significant problem since 2003. It didn’t start last July. There is no such thing as an afternoon educational conference any more.

It’s nice to know that someone else is at least concerned about this. Neither Wachter nor I have any answers. I will just echo what many doctors of my generation are saying. We hope we still can figure out who the good MDs are by the time we need care for ourselves.

Thanks to Susan Carr for tweeting a link to Dr. Wachter’s blog.

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.

How many medications can a patient take?

Here is a list of medications that a 75-year-old patient is taking at home. All are orally taken except where noted.

Acidophilus 2 twice a day

Colace 100 mg twice a day

Coumadin 5 mg once a day

Detrol 4 mg once a day

Diflucan 50 mg once a day

Duragesic 12 ug transdermal patch every 3 days

Klor-Con 10 meq once a day

Lactulose 30 mL twice a day

Lantus 15 units subcutaneously once a day

Lasix 40 mg alternating with 20 mg every other day

Lisinopril 2.5 mg once a day

Metoprolol 25 mg twice a day

Multivitamin 1 tab once a day

Novolog Sliding Scale subcutaneously with meals [dose varies according to blood sugar]

Oxycontin 20 mg every 12 hours

Prilosec 20 mg once a day

Reglan 5 mg before each meal

Vitamin A 25,000 units once a day

Zoloft 50 mg once a day

Docusate 100 mg twice a day as needed

Hyoscyamine 0.25 mg sublingual every 4 hours as needed

Oxycodone 5 mg every 8 hours as needed

That’s 22 different drugs with a minimum of 24 pills per day and a maximum of 35.

With the Lasix and the sliding scale Novolog, do you think she ever misses a dose or takes a wrong dose?

The above patient is on three narcotics Duragesic, Oxycontin and as needed oxycodone. Add to those meds Zoloft and Reglan. I wonder if she’s drowsy or confused? I bet it will be a big mystery when she falls and breaks her hip.

What effect do you suppose 10 meq of oral potassium per day is having on her total body potassium [total body contains some 3000 meq of potassium] or even serum potassium?

This is not close to the record. I once was consulted on a patient who was on 31 different medications at home. I’m sure that someone has seen a patient taking more than 31 medications. Have you?

Preoperative Medical Consultation May Increase Risk

Attention readers: Unlike my previous post on the reasons medical students do not choose primary care careers, this post is serious. I feel I have to explain because when my blog on primary care appeared as a guest post on the blog KevinMD, someone commented that I should have said up front that it was satire. I found that hard to believe.

Similarly hard to believe, but appearing in the current issue (August 9/23, 2010) of Archives of Internal Medicine is an article that has the following conclusions: “Medical consultation before major elective noncardiac surgery is associated with increased mortality and hospital stay, as well as increases in preoperative pharmacologic interventions and testing.”

The study was a retrospective cohort study of 269,000 patients who underwent intermediate and high-risk noncardiac surgery in Ontario, Canada. Over 90% of the more than 104,000 patients who underwent preoperative medical consultation were matched to similar patients who did not have a consult. While the increases in mortality rates and length of stay are small, they are real. In addition to the increased 30-day and one-year mortality rates and length of stay, patients receiving consults had more preoperative testing such as unnecessary echocardiograms and were given more drugs including beta-blockers. The beta-blockers were probably not indicated and were associated with increased rates of postoperative stroke in abdominal and thoracic surgery patients. Interestingly, consults with specialists such as cardiologists led to higher mortality rates.

In fairness, the authors mentioned several limitations of the study including the fact that they used an administrative database which did not include certain complications and that it was a retrospective study. But evidence is evidence, and a prospective study on this topic would be impossible due to ethical considerations. Reminder: This is factual information from an internal medicine journal. I leave you to ponder the implications of this study.