Monday, January 30, 2017

Caribbean medical schools: A look inside

Did you know that several Caribbean medical schools provide postgraduate premed courses so students can complete their science requirements? At least one school’s nearly year-long premed curriculum includes 8 hours per day of classroom work, rudimentary general chemistry and organic labs, and a physics lab with 40-year-old equipment. The fee is more than $30,000 cash, no loans. That's a lot to pay for courses that are not accredited and credits transferable only to other Caribbean schools.

The goal of these premed programs is to prepare students to take the Medical College Admission Test (MCAT). However, some schools require only that applicants take the MCAT but do not reject anyone on the basis of their scores. 

A former student said, “Little did I know that a [Caribbean school] acceptance was the equivalent of a lottery ticket. They actually attempted to weed us out of the small (and unaccredited) pre-med class! It took me a month to figure it out.” One of his professors told him the administration said not to pass everyone in the premed course into the first year of medical school.

He struggled through the premed requirements and wound up at a different school. The dean at that school spoke to the students about USMLE testing and what to expect in the clinical years. Many times during the talk, that dean referred to the school’s “top students” in a way which implied that only the best students were likely to match to a residency position.

Another school administrator told him that some residency programs would not even look at his application if there was an F on his transcript. While most program directors would probably verify that statement, it was not widely known among the students at his medical school. Some had even failed a course but were still planning to become surgeons.

Regarding his struggles in the second year of medical school, the student said the volume of material was overwhelming, everyone in his class was stressed, and approximately one-third had dropped out. He observed that students who were doing well were “type A personalities who had some measure of prior academic success…and could make it through any US or Canadian program with ease.”

He barely made it through the first year with mostly C grades. During his second year he dropped two courses and had to repeat them.

After eventually withdrawing from that school, he applied to another and was turned down.

He warned that those who are thinking about going to school in the Caribbean don’t understand how many don’t make it through.

Dropouts and accurate figures on what percentage of each graduating class passes all USMLE steps and matches to a residency program are unknown.

Meanwhile tuition debt keeps accruing and doesn't go away. The student has over $200,000 to pay off and will be doing so without the benefit of a physician's income. He is now trying to get a job related to his undergraduate major—business.

Regarding the offshore medical school experience, the student had the following observations:

The schools accept many students who they know will not make it through to fill up the class and make a lot of money in the process.

I didn’t find the material in medical school to be all that difficult; it’s the volume of the material and the time constraints that are the problem.

I could not figure out why my studying was only yielding C's when some people were getting the A's and B's. I'm starting to believe people are born smart.

I am not a good test-taker. I make the process harder than it is. The right answer might stare me in the face but I'll always second guess it.

I was informed that residency programs look at more than STEP scores. I was actually under the impression that no matter what red flags I had on my transcript, my STEP scores would decide my future, but I was told by other students that residency programs will look at pre-clinical grades and I even heard from one student that an IM program asked for college transcripts! If that is the case, I would never stand a chance.

I wanted to be a primary care physician. Was all this stress worth it to go into primary care?

I keep reading that the match will continue to get harder and harder.

I have blogged about the decreasing number of residency positions available for international medical graduates.

Despite the recent ban on immigrants from certain countries, I do not expect the situation to change much for US citizen IMGs.

If it comes to a decision about whether to attend an offshore school or not, do your homework. Talk to people who have been there. It's not all palm tress and sunsets. 

Tuesday, January 17, 2017

More about adhesions and postoperative pain

In November 2016, I wrote about adhesions and whether they are the cause of chronic abdominal pain. I and several surgeons who commented felt they weren't.

Some new information from the February 2017 issue of the journal Surgery is just in. A randomized, double blind, placebo-controlled trial from The Netherlands was originally published in 2003 after one year of follow-up. At that time, there was no apparent benefit from an operation to lyse [divide] all adhesions laparoscopically in 52 patients compared to a placebo operation that involved performing only laparoscopy to assess the extent of adhesions in 48.

The current paper looked at outcomes 12 years after the original surgery was done. Follow-up was available for 73% of the patients—42 in the group who had adhesiolysis and 31 who had laparoscopy only.

The authors concluded, “Laparoscopic adhesiolysis was less beneficial than laparoscopy alone in the long term. Secondly, there appeared to be a powerful, long-lasting placebo effect of laparoscopy. Because adhesiolysis is associated with an increased risk of operative complications, avoiding this treatment may result in less morbidity and health care costs.”

Unfortunately the paper has a few flaws.

Friday, January 13, 2017

"Malpractice" from the viewpoint of a plaintiffs' attorney

Lawrence Schlachter is a neurosurgeon who after 23 years in practice, was forced to stop operating because of a hand injury. He went to law school, became a plaintiffs’ attorney, and wrote a book called “Malpractice.” Although it is intended for patients, physicians might want to read it to learn something about how a plaintiffs’ lawyer thinks.

I’m not surprised that Schlachter cites the heavily extrapolation-based Journal of Patient Safety study claiming 400,000 medical error-related deaths per year and the thoroughly debunked Makary study claiming 251,000 deaths per year due to medical error. He does a little extrapolating of his own and comes up with 562,000 patients per year.

I agree with Schlachter about many issues. He says the best way to avoid becoming a victim of negligence is to take good care of yourself. If you need to be hospitalized, aggressively be your own advocate or have a relative or friend do it. You cannot assume that mistakes will not happen.

Monday, January 9, 2017

How can we instill more confidence in our graduating chief residents?

For over six years, I have been writing about problems in surgical education. My seventh blog post ever was about the negative impact of changes in surgical residency training.

In that post, I cited a residency program director who felt that rules imposed by the Accreditation Council for Graduate Medical Education (ACGME) resulted in excessive supervision of residents who never had a chance to operate independently. Many feel that this is a major factor resulting in 80% of graduating chiefs opting to do one or more years of post residency fellowship.

Excessive supervision continues in 2016. In his presidential address to the Southwestern Surgical Congress, John R. Potts, III, M.D., a former surgical program director and now Senior Vice President of Surgical Accreditation for the ACGME, had a similar observation. He said, “I have personally encountered individuals finishing general surgery residency programs who have never completed any operation—regardless how simple and basic—without an attending surgeon being with them throughout that operation.” [Emphasis by Dr. Potts]

Wednesday, January 4, 2017

The occasional surgeon

On the Forbes website, Dr. Robert Pearl writes

"When I was selected to become CEO of The Permanente Medical Group, the Permanente half of Kaiser Permanente, the time required for my responsibilities forced me to give up doing surgery on a regular basis. But every year since then, during the week between Christmas and New Year’s Day, I have returned to the operating room. The timing works, as the leadership demands become minimal and it’s unlikely I’ll suddenly be needed to fly to another part of the country. It’s a magical time for me, contrasting dramatically with my world as CEO. For several hours each day, my focus is not on millions of Kaiser Permanente members—or, for that matter, on all the complexities of healthcare policy, politics and strategy—but, rather, on a single patient at a time."

Dr. Pearl is a Yale medical school graduate who trained at Stanford and has been board-certified in plastic surgery since 1979. The American Board of Plastic Surgery did not start requiring maintenance of certification every 10 years until 1995.

We do not know what specific surgical procedures he does during his magical time. Is he removing moles, performing reconstructive surgery, or doing facelifts and nose jobs? Do his patients know that he only operates a few days per year? What happens if a wound complication requiring revision surgery arises? Who follows up his patients?