More on selecting and teaching residents

A resident emailed me with some questions about surgical residency programs and education. For space considerations, his queries are incorporated with my answers.

Thanks for sending the link to the paper on selecting residents. Many surgeons feel that choosing athletes who played a varsity sport—team or individual—in college is a good way to pick residents. With one notable exception, my limited experience is consistent with that idea. It's limited because there are not enough applicants (at least not to programs I ran) who are athletes. I have a post coming out soon about the subject of "grit" or conscientiousness and selecting residents who have high grit levels. A recent paper suggests that residents who drop out of surgical programs might have low grit levels.

The resident who wrote to me suggested trying to choose applicants who fit in. At first glance, the idea is appealing. However, the matching process can thwart that goal because the people you think will fit in may not rank the program highly. If everyone based their selections on who fit in best, there might not be women or minorities in many programs.

Teaching residents how to dictate operative notes is important for residents. The problem with allowing a resident to dictate a case is that the dictation is a legal document and cannot be removed from the chart, particularly if it is an electronic medical record. I have always felt that if a resident cannot coherently dictate a case, she probably did not learn how to do it and would not be able to do it by herself. Practicing off-line using speech recognition technology could overcome this problem. The resident could dictate a draft which then could be gone over with the attending thereby achieving the feedback which is a very important part of learning.

Regarding the best use of limited didactic time, I have no brilliant answers. In fact, I'm glad I'm no longer a program director and don't have to deal with this difficult question. One often overlooked factor in work hours limits discussions is that conference time has been quite negatively impacted since 2003.

Because about one-third of residents must go home early every morning means that there are no longer any afternoon conferences or rounds. Cramming 2 or 3 hours of didactic time into a single morning goes against many principles of learning especially if the sessions are boring lectures which do not engage the audience. Intermittent bursts of teaching and/or practice have been found to be better for learning than long single sessions. In addition, there is so much more to learn because of the expanding body of knowledge and mandates from the RRC and other regulatory entities.

I have written several posts advocating teaching residents how to think rather than memorize facts which are available on a smartphone. Here's one from 2012. However, this will require a top to bottom reorganization of not only the way residents are taught, but also the way they are tested.

Please comment if you disagree or have something to add.

Dictations can be tricky, Part 2

A while back I wrote a blog about a resident’s operative dictation that was incoherent and the pitfalls of dictating. Here is another example.

The switch to electronic medical records has brought some unintended consequences. We now have rapid turnaround of dictations at my hospital. They appear in the electronic record within a couple of hours and require verification by electronic signature. As is true of many documents that appear on computers and the Internet, they sometimes are not read carefully.

It was electronically signed by the physician who dictated it. I’m guessing that he did not proofread it. At least I hope not.

The name was changed to protect the innocent.

Dr. Balotelli found on endoscopy a stomach full liquid with esophagitis. There was a 3 orifices in the distal esophagus. There is a hiatal hernia sac, actually 2 of them; 1 led to the antrum. Pylorus and duodenum of the hernia sacs are full with dark liquid which were suctioned. The third compartment led to the small bowel. It did not contain any contents.  The hernia sacs were friable and ulcerated. The mucosa in the antrum and pylorus were widely open. The duodenum appeared normal. Since then, the patient is no longer nauseated or vomiting. His NG output is minimal.

As far as I know, I am the only person who has actually read this note. The entry was made a while ago and has not been corrected.

I used to use Dragon dictation. You must take great care when proofreading because you tend to read what you meant to say, rather than what Dragon thought it heard. I once dictated a letter of recommendation for a student. Instead of Dragon typing "she is confident and poised," it came out "she is confident and moist."

Does anyone really read electronic progress notes?

Do you know of any examples of dictations gone astray like this? If so, please describe.

A slightly different version of this post appeared on Sermo yesterday. Most of the comments suggested that the EMR would be the downfall of society as we know it.

Dictations can be tricky

I was a surgical residency program director for many years. Not long before I left medical education, I had to stop allowing residents to dictate cases they did. It began to take me longer to proofread and correct their dictation than the time it would have taken for me to dictate them myself.

Here are two examples. The first is from the dictation of an open cholecystectomy.

The next one is the actual dictation of a tracheostomy in its entirety. Parts that are inaccurate and/or incomprehensible are underlined in red. 

I think I was correct in my decision to take over the dictating duties, don't you?