Friday, March 28, 2014

A college junior wonders if she will get into med school

Over on my "Ask Skeptical Scalpel" blog, a  college junior with a few problems wonders if she will get into medical school. Did I give her the right advice? What do you think?

Thursday, March 27, 2014

Who would ask an anonymous blogger for medical advice?

I'm often asked why I use a pseudonym. When I first started blogging almost 4 years ago, I was still in practice. Some of my posts are a little edgy and my sense of humor is not for everyone. I didn't want patients to google me and have my blog come up on the first page of hits.

Now that I've been retired for over a year, I still have not revealed my true identity. You may ask, "Why not?"

I like being anonymous. I feel that I can be more honest because I am not worrying about what someone is going to think. A quote from Oscar Wilde says it all: "Man is least himself when he talks in his own person. Give him a mask, and he will tell you the truth."

Some people have questioned my credibility. They say how can anyone believe what you write when they don't know who you are? I've been referred to the UK General Medical Council's rule #17, which states "If you identify yourself as a doctor in publicly accessible social media, you should also identify yourself by name. Any material written by authors who represent themselves as doctors is likely to be taken on trust and may reasonably be taken to represent the views of the profession more widely."

Regarding the previous sentence, I agree with the first part about trust and strongly disagree with the second part. How could anyone think that what a single doctor writes is representative of the profession more widely? I am reasonably certain that is not the case in my situation.

You want credibility?

A single post of mine called "Appendicitis: Diagnosis,CT Scans and Reality," which I wrote about three weeks into my blogging career, has received almost 14,000 page views.

In the comments section of that post or via email, more than 50 people have asked me questions about their own or a family member's abdominal pain. I've had to add numerous disclaimers over the years reminding readers that I could not give medical advice without examining the patient.

Despite the disclaimers, the questions keep coming with the most recent one submitted two days ago. I can only guess that they are either reluctant to ask questions in person or not getting satisfactory answers from the doctors they are seeing.

Premed and medical students and residents frequently look to me for career counseling. Last week I even got a question from a high school student who was thinking about becoming a doctor. The students and residents occasionally preface their questions by saying that they didn't want to ask someone from their school or residency program for fear it would reflect poorly on them.

I have been amazed at how many readers seem to trust me enough to ask personal questions about their health or their career. To be able to connect with so many people despite my use of a pseudonym is rewarding.

Patients and aspiring doctors—that's who would ask an anonymous blogger for advice.

Tuesday, March 25, 2014

Gallbladder surgery: Double jeopardy

Last month, I blogged about a paper from China that advocated removing just the gallstones and leaving the gallbladder in place. I wrote that such procedures had been tried in the early days of gallbladder surgery and failed because the stones recurred. You can read that post here.

It's not often that one gets to see almost immediate follow-up on a blog post like this, but I am happy to say that I can share a brief story with you.

A 44-year-old man (who consented to my blogging about him) underwent a cholecystectomy by a friend of mine a few weeks ago. The patient presented with right upper quadrant abdominal pain. He said that he had gallbladder surgery in a South American country in 2009 and had a large right subcostal incision to show for it.

In the emergency department of the hospital, a CT scan showed a large gallstone in what appeared to be a shrunken gallbladder. My friend obtained a copy of the operative report and a handwritten note from the original surgeon. See below.
The surgery that had been performed was a partial cholecystectomy and removal of a 6 cm gallstone.

My friend (and yes, he is still my friend) performed a robotic cholecystectomy. He said the surgery was difficult due to omental adhesions and the small size of the gallbladder. The specimen contained six 2 to 3 mm stones. The patient did well and was discharged.

OK, one case is an anecdote and doesn't prove anything, but its timely appearance doesn't hurt my position that just removing the stones won't cut it. (Pun intended.)

Friday, March 21, 2014

Should medical school be shortened to 3 years?

I say, "No." Here's why.

There is way too much to learn in 3 years. Unless medical education is radically changed, it will be impossible for students to memorize all the unnecessary stuff they still have to memorize, complete all their clerkships, and move onto the next phase—residency training.

I do not see how medical students can choose a career path before they have had experience with rotations in all of the major specialties. I have had numerous queries from students in four-year schools who do not know what they want to specialize in even by the first part of their fourth year.

Yes, the fourth year of medical school currently is not productive. However, the amount of time needed for students to choose their specialties and interview at 15 or more different residency programs could not possibly be squeezed into the third year of a three-year program.

Some have said that shortening medical school to three years would increase the number of doctors produced. That would be true for one year when schools would graduate two classes, the three-year and four-year groups. But after that year, the same number of students would graduate from school as did so when the length of time was four years.

By the way, that year with the double graduating classes would be difficult to manage because there is already a predicted shortage of residency positions by 2015. This is due to the federal government's cap on the funding of resident positions. Graduating more than 40,000 medical students at the same time when only about 25,000 residency slots are available would be chaotic.

Here's a better solution.

The length of time it takes to become a doctor could be shortened by simply not mandating that every medical student have a four-year undergraduate degree before starting medical school.

Who says that medical students need to have a bachelor's degree in anything? If for some reason that is still desired, students could attend college through the summers to pick up enough credits for a degree.

A few medical schools in the United States have had accelerated programs in place for many years. For example, a program jointly run by Penn State University and Jefferson Medical College graduates doctors with both BS and MD degrees in six or seven years. It's been around since 1964. A longitudinal study over 26 years showed that doctors who completed that accelerated program performed at a level indistinguishable from traditional eight-year graduates.

A recent compilation lists several colleges/medical schools (of 140 or so MD-granting medical schools in the US) with similar accelerated programs.

Several European countries use similar models and seem to have healthy citizens.

Shortening or accelerating the undergraduate experience would save a year or two of tuition expense, accomplish the desired saving of time, and not disrupt the four-year med school cycle.

Of course, this will not get any further than this blog because I am not a "good old boy" with any influence on those who run medical education.

Wednesday, March 19, 2014

A study says you can trust online physician ratings

This abstract comes from the Social Science Research Network:

Despite heated debate about the pros and cons of online physician ratings, very little systematic work examines the correlation between physicians’ online ratings and their actual medical performance. Using patients’ ratings of physicians at RateMDs website and the Florida Hospital Discharge data, we investigate whether online ratings reflect physicians’ medical skill by means of a two-stage model that takes into account patients’ ratings-based selection of cardiac surgeons. Estimation results suggest that five-star surgeons perform significantly better and are more likely to be selected by sicker patients than lower-rated surgeons. Our findings suggest that we can trust online physician reviews, at least of cardiac surgeons.

You won't be surprised to learn that I don't believe it. As is my custom, I decided to read the entire paper the full text of which can be found here. At 37 pages, the raw manuscript is rather lengthy. As a public service, I waded through it.

The authors, non-MD faculty from the William E. Simon Graduate School of Business Administration at the University of Rochester, in New York, combed the ratings for Florida cardiac surgeons on the website and classified surgeons into three categories—five-star surgeons, non-five-star surgeons, and those with no ratings at all.

They looked at 799 quarterly opportunities for ratings over a 9-year period and found that 21% of surgeons had an average of 1.9 online ratings. The 79% of surgeons who did not have an online rating performed 79% of the total surgeries in 2012, the year that the authors analyzed for patient results.

The five-star surgeons had a mean of 1.8 reviews each, and only 10% had more than 2 reviews.

The average mortality rate for coronary artery bypass grafting (CABG) among the Florida cardiac surgeons was 1.8% in 2012. The five-star surgeons with multiple reviews had the highest mortality rates at 3.3%.

I could find no evidence that patient mortality rates were adjusted for risk. But a lot of statistical manipulations took place. It's all explained by this simple equation—one of many.

 The authors say, "For a representative patient who is severely ill, being treated by a five-star surgeon can reduce the in-hospital mortality by 55% compared with being treated by a non-five-star surgeon. [I have no idea how they determined that figure.] Moreover, the negative and significant coefficient of no-ratings suggests that patients treated by surgeons without ratings also have a lower mortality rate than those treated by non-five-star surgeons, all else being equal." Huh?

And this, "Patients with private insurance are less likely to select the surgeons without ratings than patients with Medicare. We suspect that patients with private insurance have to use search engines to figure out whether a surgeon is within the network that an insurance plan covers, while government patients enjoy a large physician network." I question that assumption. My experience is that patients with Medicare sometimes have problems finding anyone to care for them, let alone the best surgeons.

It turns out that half of the five-star surgeons had only one review. In one iteration of the study model, five-star surgeons with multiple reviews had higher mortality rates than those with only one review, but then they also say, "One surprising finding is that five-star surgeons with a single review show no statistical difference in performance from those with multiple reviews."

Are you as confused as I?

The paper makes no mention of the possibility that some of the online ratings could be fake. Recent articles [here and here] suggest that one-fifth to one-third of such reviews are phony.

You can manipulate the statistics all you want, but you won't convince me that one or two or even 20 online ratings are valid or useful in choosing a surgeon.

Tuesday, March 18, 2014

What happens if you don't match in your chosen specialty?

On my other blog Ask Skeptical Scalpel, a med student writes about a friend who failed to match in orthopedics for two years in a row.

To read that post entitled "Help! My friend didn't match in orthopedics ... again," click here.

Monday, March 17, 2014

A med student asks about preparing to be a rural surgeon

On my other blog "Ask Skeptical Scalpel," a medical student asks about the best way to train to be a rural surgeon. You can read it here.

Friday, March 14, 2014

Can dreaming about exercising lead to weight loss?

I was about to write one of my infrequent but famous spoof articles, and the subject was going to be losing weight by dreaming about exercising. For fun, I decided to search the Internet to see if anyone else might have had the same notion. To my surprise, they had. Here's what I discovered.

To be able to exercise while asleep, one must be able to have a so-called "lucid dream," which is described as being aware that one is dreaming while dreaming. According to a paper by Daniel Erlacher, 51% of 919 Germans who were questioned said they had experienced at least one lucid dream.

Apparently some lucid dreamers can also control the content of their dreams.

In the Harvard Business Review, Erlacher says, "In one experiment we asked participants to dream about doing deep knee bends. Even though their bodies weren’t moving, their heart and respiration rates increased slightly as if they were exercising."

We need to find a group of overweight people who are also lucid dreamers. Finding the former should be easy. If there aren't enough of the latter, subjects can be taught how to have lucid dreams in only 16 simple steps.

After explaining what a triathlon is, we tell them to dream about doing one every night for the next, say, 10 years. Would that work?

Probably not. A more scientific discussion of whether calories are actually burned while dreaming appeared in a blog called "The Naked Scientists." Someone asked whether running in a dream burned calories. They explained that while brain metabolic activity increases and a few calories are expended while dreaming, they doubt that there would be any meaningful effects on fitness levels or weight loss. Unless sleepwalking occurred, one of them said, with tongue-in-cheek.

I think the dream scenario is too complicated anyway.

Here's another potential solution.

An article on CNET is headlined "You could lose weight while your avatar exercises." Although that sounds like an exercise program that most couch potatoes could embrace, the study it refers to didn't exactly show what the headline said.

What it did show was that 8 women were recruited to watch animated avatars that they created exercise and eat reasonable portions of food. The women then "set their own weight loss and exercise goals, tracked their progress using some old-fashioned food and exercise logs" and lost an average of 3.5 lbs. over a 1-month period. Whether that weight loss continued for more months or was even maintained was not stated.

So do these shortcuts to weight loss really work? It's doubtful.

Dreaming about exercising or watching your avatar exercise probably isn't going to do it. I'm afraid you're just going to have to eat fewer calories than you burn.