Thursday, July 31, 2014

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.

Wednesday, July 30, 2014

Ultrasound selfies? How surveys can mislead

Do you believe that traditional hospitals will be obsolete in the future? A recent survey found that 57% of those polled believed that would happen.

The survey, sponsored by the Intel Corporation, involved 12,000 subjects from the United States and seven other countries around the world.

Here are some other revelations from that survey:
  • 84% said they would be willing to share their personal health information to advance and lower costs in the health care system.
  • 70% said they were receptive to using toilet sensors, prescription bottle sensors, and swallowed health monitors.
  • 53% said they would trust a test they personally administered as much or more than if that same test was performed by a doctor
  • 30% of people would trust themselves to perform their own ultrasound. 
That made me laugh. Ultrasonography is one of the most operator-dependent tests in use today. It is not easy to perform, nor is it easy to interpret.
I then began to wonder about the credibility of this survey. Before I retired, I practiced in a typical small town in the northeastern United States. Some patients googled me, and a few searched the Internet for information about their illnesses. But for the most part, it was a technologically unsophisticated population.

I just can't envision most of my patients wanting to share their personal health information, use toilet sensors, or trust tests they did at home. Do their own ultrasounds? Not likely. Many of them did not even know what medications they were on.

After rereading the article about the survey, it occurred to me that the sample may have been flawed.

This sentence stood out. "[The] Intel Health Innovation Barometer was conducted online by Penn Schoen Berland in Brazil, China, France, India, Indonesia, Italy, Japan and the United States." The key word is "online."

This reminded me of a famous survey conducted by a magazine called The Literary Digest, which polled 10 million people and had a response of 2.4 million just before the 1936 presidential election. The magazine had correctly called the previous four presidential winners.

The names of the 10 million people queried were drawn from lists of the magazine's subscribers, owners of automobiles, and those with telephones. The survey predicted a crushing defeat for President Franklin D. Roosevelt at the hands of the Republican nominee, Alf Landon.

Of course, the opposite occurred. Roosevelt won all but 8 electoral vote, a huge landslide. What went wrong? Unlike the prior years, 1936 was the middle of the Great Depression, and this time those who had enough money to subscribe to The Literary Digest, own cars, and have telephones were not a representative sample of those who voted.

Do you think maybe the 12,000 people polled online might not be a representative sample of the general population of the world?

I'm not expecting patients to do their own ultrasounds anytime soon. I think hospitals will be around for a while too.

Friday, July 25, 2014

The best general surgery residency programs for clinical training?

I've received a couple of emails from Doximity [A closed medical "community" of > 280,000 doctors] reminding me to complete a survey which they are sponsoring jointly with U.S. News & World Report. They are asking members, possibly only surgeons, to name the best general surgery training programs in the country.

Not mentioned in the email but stated at the beginning of the survey is that they want respondents to name the 5 best programs for clinical training.

I have a feeling that not everyone will notice the part about clinical training, and we will get a list of the usual suspects just as we do every year with the U.S. News best hospitals survey.

For several reasons, the survey is fundamentally flawed.

There are 240 general surgery residency programs in the country. Unless one is personally involved with a program, it is impossible to judge the competency of its graduates. How would I or anyone else who does not work there know whether residents training at UCLA or Baylor or Lehigh Valley are clinically competent?

There are no accepted ways to judge the clinical skills of any surgeon. Video recording of procedures with judging by peers can assess technical ability, and as shown in the recent New England Journal paper from Michigan, there is some correlation with outcomes.

The American Board of Surgery publishes first attempt board passage rates for all programs, but passing the boards does not necessarily equate to clinical skill.

Most surgeons have probably encountered only one or two graduates of any of surgical residency. Even if the ones we have seen were great, they may not represent the majority of graduates.

I'll bet I can name most of the top 5 programs right now. These are not necessarily the programs that produce the best clinically trained residents.

Here are my guesses: Massachusetts General, Johns Hopkins, Mayo Clinic-Rochester MN, New York Presbyterian-Columbia, Cleveland Clinic.

In the past, some institutions on my list were rumored to be terrible places to learn to perform surgery because the residents did a lot of watching and retracting but not much operating. Whether that is true today or was so in the past, I could not tell you.

I guarantee you that no community hospital will rank in the top 20 [maybe top 50] despite the fact that such hospitals produce many fine clinical surgeons.

I have no idea which programs produce the best clinically trained surgeons. After the Doximity-U.S. News survey results are published, you won't know either.

Wednesday, July 23, 2014

Should you wear a hazmat suit when you operate an elevator?

In their quest to culture every object on planet Earth, researchers have found that hospital elevator buttons are more contaminated with bacteria than restroom surfaces.

Of 120 randomly cultured elevator buttons, 73 (61%) grew bacteria. Washroom surfaces were cultured 96 times with 41 (43%) showing microbial growth.

As is customary with papers like this, the media sensationalized the findings with headlines like "Why you should never ever touch that hospital elevator button."

Most stories eventually mentioned the fact that the authors said the majority of bacteria found ”had low pathogenicity," but some, including,,, and, did not. In fact, the MRSAID blog also confused the benign streptococcus found in this paper with the pathogen that causes strep throat.

I've written several posts about the culturing of various inanimate objects and pointed out that disease transmission has not been documented for almost all surfaces on which bacteria are found. If you click on the "Infection" label to your right, you can read as many as you wish.

Like most papers in this genre, this one has some flaws. You can read the full text here.

It was published in an open-access journal called "Open Medicine." It is not among the top 40 internal medicine journals listed by impact factor. It has no discernible impact factor at all and is not listed PubMed.

The title of the paper "Elevator buttons as unrecognized sources of bacterial colonization in hospitals" overstates the case a bit.

This table shows the types of bacteria found on both the elevator buttons and surfaces in the restrooms.
You can see that pathogens were few. Multiple organisms were found in several instances accounting for some of the numerical discrepancies. I could not figure out how the percentages were calculated. In neither column did the percentages add up to 100%.

Samples of restrooms surfaces were taken "a few months" after the elevator buttons were cultured. The authors conceded that this may have confounded the results.

Washroom sample swabs were taken from the exterior and interior entry-door handles, the privacy latch, and the toilet flusher. They did not swab toilet seats, which previous studies have shown are the gold standard to which all inanimate surfaces should be compared.

It may surprise you to learn that most of the bacteria found on elevator buttons and restroom surfaces can also normally be found ON YOUR HANDS!

Tuesday, July 22, 2014

New post on "The Medical Bag" website

I am now writing for a website called "The Medical Bag."

No it's not about a female doctor.

The site is a medical news and social area for physicians, but others are welcome to read what's there.

This week's new post (link) is about a recent paper claiming that cardiac surgeons' skills deteriorate after even one day of not operating. You won't be surprised, but I disagree.

Tuesday, July 15, 2014

More bizarre tales from "The Night Shift" ED

Much to my surprise, a medical TV show called "The Night Shift" is still on the air. It's about an emergency department the likes of which you or I have never seen. When it debuted back in May, I wrote a scathing review.

An emergency medicine physician, Nick Genes, has been blogging about the show, and his post about last week's episode caught my eye. So many outlandish things happened that I had to see it for myself. [link here]

Nick's review was so comprehensive and on the money that I won't try to top it. I'll leave out the flashbacks to one ED doc's time in Afghanistan, the chemical plant explosion, and the stripper who gave an intern a lap dance in an ED storage room and focus on the surgical cases.

A 16-year-old girl was brought in because of shortness of breath which turned out to be due to a fork lodged in her larynx. It was removed by the emergency physician who also made the diagnosis of bulimia. The parents refused to let the girl be admitted, so she swallowed a scalpel and vomited a large amount of blood.

At this point, most ED docs would ask for a surgery consult, but not those who work on television. Here the head ED doc and the intern performed a laparotomy in the ED, opened the stomach, and retrieved the scalpel.

As you can see, the rules are a bit more relaxed in the ED. No one is wearing a cap or mask, but at least they've all donned gloves and protective eyewear.

Another crisis arose, and the ED chief had to leave. On her way out she said, "Close her up. Run in another two units. And move her up to the OR." We are left to wonder whether the injury that caused the massive bleeding was dealt with and why she was being taken to the OR after the procedure was over? The ED docs on the show never seem to do any charting or paperwork so maybe they needed a surgeon to write the postoperative orders.

Not to be outdone, two other ED doctors diagnosed internal bleeding in a plane crash victim whom they had rescued after they were lowered from a helicopter. As they were taking him to the operating room [I'm not sure why since there are apparently no surgeons in this hospital and major surgery is done in the ED every day], they decided to stop for a CT scan. They were accosted by a man claiming to be a DEA agent, but who really was a drug dealer.

He wanted to talk to the patient who had been carrying a large amount of drugs. When he was rebuffed, he killed the CT tech and took the doctors hostage. In an effort to keep the patient alive, they intubated the patient without a laryngoscope by jury-rigging some IV tubing to a handy light source and performed a laparotomy without retractors and instruments in the CT suite. The patient died. The bad guy was subdued by a SWAT team, but not before he shot one of the docs in the abdomen.

Whether a surgeon will be consulted and how the wounded doc fares will be revealed during the exciting season finale tonight.

I can't wait.

Monday, July 14, 2014

Are sutures better than staples for closing skin for C-sections?

According to a recent randomized trial of 746 women having cesarean sections, closing skin incisions with staples resulted in a 10.6% incidence of wound complications, compared to 4.9% of the women closed with sutures. Put another way, suturing was associated with a 57% reduced risk of wound complications.

As usual, naive media, including The New York Times, accepted the study's findings without reservations. Also as usual, I did not.

Here's why.

Tuesday, July 8, 2014

Surgery in space: I foresee problems.

The astronauts are halfway to Mars when suddenly one of them develops abdominal pain and requires surgery. What will they do?

According to NASA, a miniature robot capable of assisting in surgery has been developed, tested in pigs, and is soon to be trialed in a weightless environment. The robot, which weighs less than 1 pound, can be inserted into the abdomen via the umbilicus and controlled remotely.

The press release from NASA said types of operations that the robot would be capable of performing were "emergency appendectomies, emergency cholecystectomies, emergency perforation of gastric ulcers [sic], and intra-abdominal bleeding due to trauma." NASA meant to say "repair of perforated gastric ulcers." Not surprisingly, many science reporters for media outlets, for example, SFGate and WiredUK, did not notice the error. New Scientist also missed it, but at least published a later correction.

However, even the famous da Vinci robot is incapable of performing surgery on its own.

The original idea was that a surgeon on the ground would direct the robot's movements, but that will not be possible for two reasons. In deep space, the time lag between the earthbound surgeon's actions and the robot's response would be too long, and a recent article about remote-controlled drone crashes highlighted the problems that can occur when links are lost or computers malfunction.

The plan is to train the astronauts to perform minimally invasive robotic surgery on each other. What could go wrong?

A lot.

Thursday, July 3, 2014

Wikipedia medical articles: Are they really inaccurate?

I have just started writing for a website called "The Medical Bag." I will be producing two blog posts per month for it.

My first post appeared yesterday. It's my analysis of a recent paper claiming that medical articles on Wikipedia  are unreliable.

The paper is methodologically unsound.

See for yourself. Here's the link.

Tuesday, July 1, 2014

My grandson survives a visit to the ED

Last weekend, my 16-month-old grandson was at a backyard barbecue with his parents. He had been eating some potato chips when he suddenly stopped breathing and turned blue.

Having had CPR training, my son started rescue breathing and suspecting aspiration, performed toddler airway clearance maneuvers. No obstruction was found. The child slowly awakened but was very drowsy.

Because of the concern for aspiration, an ambulance was called and the child was taken to the nearest hospital.

My son called and told me what happened. My wife and I drove to the hospital, which was 15 minutes from my home, but not one where I knew any staff.

By the time we arrived, child had been in the ED for about 10 minutes. Two nurses were trying to start an IV in his chubby arm, he was crying loudly. We took that to be a very good sign. He had already been examined by a doctor.

After successfully starting the IV, the nurses secured it and calmed down my daughter-in-law. She asked where she could buy a bottle of water. One of the nurses said not to bother and brought her a glass of ice water.

The nurses were gentle and professional, so much so that my wife, who is a former ED nurse, didn't mention that fact until nearly 5 minutes after we got there.

The initial vital signs taken were remarkable for a temperature of 104° F, prompting the emergency physician to suggest that the child probably had suffered a febrile seizure. He ordered a chest x-ray because of the history of possible aspiration.

The boy stopped crying and began to watch a cartoon on his father's iPhone. Soon he was smiling and laughing.

The x-ray was negative, and the fever came down with ibuprofen. I resisted the strong urge to point out that lowering a child's temperature has never been shown to prevent a febrile seizure.

We were all relieved that he was okay.

If you were expecting a tale of mistakes, sloppy nurses, and arrogant doctors, I am sorry to disappoint you.

Several essays, blog posts, and media articles about poor care received by doctors or their family members have recently appeared.

This is not one of them.

PS: The nurses complimented us for not trying to run the show.