Surgical Residents Surveyed; Concerns about Experience & Confidence

A recent survey of general surgery residents was published online by the Journal of the American College of Surgeons yesterday. More than 4200 residents who took the 2008 American Board of Surgery In-ServiceTraining Exam (ABSITE) responded. This accounts for 82% of all categorical (five-year) general surgery trainees. The authors of the paper represented the American Board of Surgery, Yale University and Memorial Sloan Kettering Cancer Center.

Compared to those in university programs, residents in community hospital programs had more positive responses to questions about satisfaction with their operative experience, didactic teaching and support from their programs.

But a significant number (27%) of all residents surveyed worried that they would not feel confident to perform surgery by themselves when they finished training. A similar number were not satisfied with their operative experience. Almost half of all residents were not satisfied with the level of didactic teaching being offered.

Something is wrong if over 25% of surgical residents are uncertain that they will be able to operate independently when they finish training. And just how does one identify those surgeons? Don’t say, “Check to see if they’re board-certified.” The boards don’t test operative skill.

Not long ago, I blogged about the coming shortage of general surgeons. The paper discussed above would indicate that expanding existing general surgery residency programs may not be the answer. If a quarter of all residents feel they are not getting enough operative experience and are not confident in their skills, how can programs be expanded?

Penn State Scandal: It Gets Worse

Yesterday I blogged about the many things wrong with Penn State and the way the child molestation scandal was handled. Little did I know that it would get much worse.

The Penn State Board of Trustees finally appeared to do the right thing by firing coach Joe Paterno. But according to an article in USA Today, they did it in the best interests of the school. Here’s a quote from the vice-president of the board [italics mine]: "The current situation we are in at the moment is not in the university's best interest. We believe a change is necessary to allow us to continue going forward without further damage to the university. Great difficulties have engulfed our university.” Damage to the university? Great difficulties engulfed the university? What about the children?

Speaking of children, what is going on with the students at Penn State? I realize we aren’t talking about high intellect over at Happy Valley, but the moral compass and sense of priorties seem to be missing. Someone is wasting a lot of money on tuition. Check out these quotes from some of the rioters on campus via the New York Times.

“I think the point people are trying to make is the media is responsible for JoePa going down,” said a freshman, Mike Clark. Yes, the media did it. I guess if this hadn’t been exposed by the media, everything would be just fine at PSU.

“We got rowdy, and we got maced,” Jeff Heim, 19, said rubbing his red, teary eyes. “But make no mistake, the board started this riot by firing our coach. They tarnished a legend.” Oh, the board tarnished a legend. I see.

“It’s not fair,” Mr. [Justin] Muir said hurling a white ribbon. “The board is an embarrassment to our school and a disservice to the student population.” No, the students are an embarrassment to their school.

“Of course we’re going to riot,” he [Paul Howard] said. “What do they expect when they tell us at 10 o’clock that they fired our football coach?” Of course. There’s a big game this Saturday against Nebraska. How could they fire Joe now?

“This definitely looks bad for our school,” he [Greg Becker] said sprinting away from a cloud of pepper spray. At least this guy is on to something. It does look bad for the school.

The article said, “Mixed in the crowd were a few dissenting opinions.” But it seems the vast majority of the rioters were protesting the firing of their football coach.

Meanwhile, what about the children who were the victims? Where's the outrage for them?

Pradaxa (dabigatran), a new oral anticoagulant drug: Good news and bad news

Pradaxa (dabigatran) is a new oral anticoagulant that has many advantages over Coumadin (warfarin). Unlike Coumadin, Pradaxa is a direct thrombin inhibitor. Pradaxa is much easier to use. It does not require checking of clotting studies, nor are dietary restrictions necessary. That’s the good news.

Here’s the bad news. Unlike Coumadin, which can be reversed in an emergency with fresh frozen plasma (FFP) within a few hours and vitamin K within about 24 hours, there is no known way to reverse Pradaxa. If a patient who is taking Pradaxa presents with say, severe trauma or a perforated duodenal ulcer, what is an emergency physician or surgeon to do?

My colleague, Michael McGonigal MD, who blogs at Trauma Pro, posted a guideline on the emergency care of bleeding in patients on Pradaxa issued by the Institute for Clinical Systems Improvement (ISCI). A nice algorithm appears on page 2. It suggests holding the drug as step #1. [That is obvious.] Lab tests such as PT, INR, PTT and thrombin time are recommended with the caveat that they do not accurately reflect the bleeding risk or level of Pradaxa in the blood. Activated charcoal may be given if the drug was taken within two hours of arrival. FFP and vitamin K will not help as there is not a deficiency of clotting factors. Renal dialysis may be considered, but realistically, is it practical?

As a last resort, recombinant activated Factor VII (rFVIIa) or prothrombin complex concentrate (PCC) might be tried but get this: “The ICSI work group has included rFVIIa or PCC as options to help with clot formation at the site of bleeding. They do not reverse the drug, the correct dose is unknown, and there is no FDA approval for this use. Thrombosis is a known side effect of rFVIIa and PCC.”

The half-life of Pradaxa is 12-17 hours. Although the guideline does not address semi-emergency surgery, it might be wise in certain instances, such as in a patient with acute appendicitis, to wait at least 12 hours to perform the surgery. Keep in mind that laparoscopic surgery is usually done on patients with normal clotting. Unlike in open surgery, it is sometimes not possible to maintain a completely dry operative field when a laparoscopic procedure is done.

Unfortunately, the ICSI guideline is not very helpful. What it says to me is “Good luck if someone on Pradaxa comes in with head trauma or needs emergency surgery.” It’s not the ICSI’s fault. It seems like there is nothing one can do.

Since all I do is emergency surgery, I’m really looking forward to my first Pradaxa patient.

Penn State Scandal. Can Someone Dial 911?

This is away from my usual subject matter but I am so disgusted and appalled by the Penn State scandal that I must comment. The mainstream media do not seem to be asking the right questions or pointing out the obvious.

A former defensive coordinator for the Penn State football team named Jerry Sandusky was just indicted on 40 counts of child molestation spanning some 15 years. The athletic director and the head of the campus policy are facing perjury charges.

Warnings were sounded as far back as the mid-1990s and nothing was done. In 2002, then graduate assistant Mike McQueary, who is now an assistant coach there, told coach Joe Paterno that he saw Sandusky sodomizing a child in the football team’s shower. Paterno’s response was to tell his boss, the athletic director, and no law enforcement or social agency was ever contacted. The president of the school was apparently informed. Penn State’s sole action consisted of barring Sandusky from the campus, which was not enforced.

Meanwhile, Sandusky continued to run a program for at-risk [they certainly were] children, which gave him continued access to victims.

1. When he saw what was going on why didn’t McQueary simply grab Sandusky and beat the crap out of him?

2. Why didn’t the McQueary go to the authorities when it became obvious that the school was doing nothing?

3. Until a few minutes ago, the school had the audacity to tell the media that Paterno would not answer questions about the scandal during his weekly pregame press conference. They just announced that the press conference was canceled.

4. When did “We did nothing illegal” supersede “We did the right thing”?

5. Everyone involved with this [McQueary, Paterno, athletic director, campus police head, school president] is as big a scumbag as Sandusky himself. If they have not committed a crime, at least they all must lose their jobs. [Note: the head of the campus police has "retired."]

Post Script: Sandusky’s biography is entitled “Touched.” You can't make this stuff up.

What is most important to residents looking for a practice setting?

Question: What is the most important thing concerning residents finishing training and looking for a practice in 2011?

a. Feeling of insufficient medical knowledge

b. Health system reform

c. Educational debt

d. Availability of free time

e. Dealing with patients

If you said “d. Availability of free time,” you are either very perceptive and in tune with today’s young doctors or you read an article about this in American Medical News. According to survey performed by Merritt & Hawkins, a physician recruiting company, 48% of newly graduating residents are most concerned about finding a practice which will allow them adequate free time. This is up from 33% in 2008. Only 7% chose availability of free time as “least concerning.”

Insufficient medical knowledge and dealing with patients were concerns of 7% and 2% of the residents respectively. To put some perspective on that, I worry about my fund of knowledge and dealing with patients every day.

Other interesting survey findings are that almost no one wants to practice in a small town and certain “must haves” include geographic location [sic], adequate call coverage/personal time, lifestyle and good financial package. Sixth on the list of “must haves” was good medical facilities/equipment.

AMedNews cites an Association of American Medical Colleges report showing that 28% of medical school graduates owe more than $200,000 in student loans. Despite all the concern about educational debt, only 12% considered loan forgiveness important, a finding with implications for those dreamers who think that loan forgiveness will entice doctors to practice in unglamorous locations.

Does all this bother anyone else? I wonder what people expected? Did they not know that being a doctor involves commitment and self-sacrifice? Apparently not for at least one, as a revealing blogger wrote a few months ago. See my comments about that here.

The future of medicine is not looking too good to me right now.

Related posts:

Medical student whining and work hours
Now is the best time to be a doctor
Is medical school tuition debt deterring students?
Night call.

Is now the best time to be a doctor? I think not.

Those of you who are physicians will be interested to learn that according to Dr. Bryan Vartabedian, who blogs at “33 Charts,” there’s never been a better time to be a doctor.

I won’t quote the post. It’s not very long and you can read it yourself.

I will admit that there are some things about being a doctor that are good today. Access to information has never been better. Communication is easier. New treatments are emerging.

But to say that there’s never been a better time to be a doctor than right now is ludicrous.

Where shall I begin? Let’s start with government and third-party interference, regulations, inspections, unfunded mandates, cutbacks, rollbacks and so on. Reimbursements for services are declining while the amount of non-clinical work is increasing.

How about the malpractice insurance situation? Neurosurgeons in parts of New York are paying premiums of over $300,000 per year.[See what any MD pays in NY here.]

Many are predicting the imminent demise of private practice.

Medical education is under fire with ratcheting down of work hours. Yesterday, I heard a Congressman speak at a surgical conference. He is sympathetic to physicians but predicts a 30% to 50% reduction in graduate medical education funding this year.

A shortage of physicians is on the horizon. Will anyone want to become a doctor?

I would like to see a poll of doctors on the subject of whether they think there’s never been a better time to be a doctor than right now.

I can think of a better time—the early 1970s. Doctors were respected. The cost for malpractice insurance for general surgeons was under $500 per year. Most people had medical insurance and the payments were based on fee-for-service. Charity care was undertaken willingly with because doctors were satisfied with what their incomes from insured patients. Was it perfect? Of course not. Are patients better off now? I don’t know. The news is full of stories about how doctors and hospitals are killing people every day. Medical errors are occurring in record numbers. Panic in the streets.

You tell me; is now the best time to be a doctor?

11 things to ponder about a power failure in winter

In case you haven’t heard, we had a freak snowstorm in the Northeast on Saturday. Over 1,000,000 people have no electricity. [See outage map for Connecticut.] There are some things that are obvious when the power goes out. When it’s dark, you can’t see anything in your house and the refrigerator doesn’t work. But here are some things you may not appreciate unless you are living through a major power outage in cold weather.

1. Even if you have a gas furnace, it does not work because the thermostat is electric. Unlike the power failure that followed Hurricane Irene in August, it’s very cold right now. For example, it’s 48° in my house.

2. This leads to an issue with sleeping. You can’t stay in your house. There aren’t enough blankets to make 48° comfortable. Even if you could sleep, try taking a shower in the morning.

3. Check into a hotel? Not so fast. Most have no power either. And the hotels that have it are full with people who thought of that option before you.

4. The food will stay cold in the refrigerator because the house is so cold, but you can’t cook it with a microwave or an electric stove.

5. So just go out to eat? Most of the restaurants are closed due to lack of electricity too.

6. It takes at least a day or two to stop turning on light switches.

7. There’s no Wi-Fi, no internet.

8. Most of the traffic lights in town are not working. A pleasant surprise is that drivers are being patient and courteous. The problem is that the flow of traffic is not very smooth. This results in significant delays.

9. Most of the gas stations do not have power to run the pumps. This leads to long lines at the few stations that do have working pumps. It’s reminiscent of the initial gas crises of the 1970s. The lines spill over on to the streets, causing more traffic delays.

10. Outpatient and walk-in clinics are closed because of lack of electricity.

11. Our emergency department is swamped with people who have no heat in their homes or electricity to run their home oxygen equipment. More and more people are getting sick because of the cold.

A power failure in winter is not fun.