tag:blogger.com,1999:blog-4968787219619380438.post4554242497923145374..comments2023-09-21T04:02:29.457-04:00Comments on Skeptical Scalpel: Residents, duty hours, and respectSkeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.comBlogger36125tag:blogger.com,1999:blog-4968787219619380438.post-70600911174031504372018-01-02T08:15:26.659-05:002018-01-02T08:15:26.659-05:00I don't have a problem with getting a second o...I don't have a problem with getting a second opinion, but your anecdote suggests all surgeons are knife happy, which is not true.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-17676658107040576262018-01-01T16:54:49.636-05:002018-01-01T16:54:49.636-05:00I read with interest some of the stories regarding...I read with interest some of the stories regarding surgical internship and residency and unfortunately it doesn't seem that this topic has touched upon the issue of surgical intervention by surgeons when non surgical intervention may be just as viable I practiced medicine in San Francisco for years as an endocrinologist and one day I fell walking my dog down a steep hill. I immediately consulted with the chief of orthopedic surgery at a major teaching hospital regarding an isolated fibular fracture(bimalleolar). Immediately she said she would get me in for screws and a plate the next morning since she recognized me. After looking at the film and the extent of the fracture, I went for a second opinion where we decided to proceed with ultrasound and after 9 weeks of intensive treatment and a boot, the imaging showed correct alignment and proper healing of the bone. Twenty years later and the ankle still remains strong, with no arthritis My point being, hospitals welcome surgical intervention as a revenue stream,especially in cases like mine which are quick same day procedures without batting an eye and little consideration of long term complications from a plate and screws in a 45 year old (at the time). Credentials or not, after that experience, I always encourage patients to get a second opinion on these type of quick surgical interventions. Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-76223538831982193572017-12-29T09:31:49.294-05:002017-12-29T09:31:49.294-05:00wasn't mentioned because, other than caffeine,...wasn't mentioned because, other than caffeine, it is not possible to obtain stimulants in a hospital. You can't write a prescription for yourself and no one would risk writing such a prescription for others. If you were caught, you could lose your license and career.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-51359055028281569862017-12-28T20:16:10.220-05:002017-12-28T20:16:10.220-05:00Just a layperson here, but interesting reading.
Am...Just a layperson here, but interesting reading.<br />Am shocked the above discussion on extremely long hours could occur without some mention of "chemical support" especially when y'all have such easy access to anything you need.......Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-51746383145508443662017-12-15T14:06:10.814-05:002017-12-15T14:06:10.814-05:00Anonymous Europe: Medicine should not be about scr...Anonymous Europe: Medicine should not be about screwing up our lives to save other's.....Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-33028762991355913532017-12-05T13:30:38.875-05:002017-12-05T13:30:38.875-05:00That story casts a lot of doubt about the credibil...That story casts a lot of doubt about the credibility of board certification, doesn't it?artigerhttps://www.blogger.com/profile/13361655152970244221noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-88545980672747680012017-12-05T10:07:10.730-05:002017-12-05T10:07:10.730-05:00Frank, sickening story. Thanks for the link.Frank, sickening story. Thanks for the link.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-87161749816057138782017-12-05T09:47:39.384-05:002017-12-05T09:47:39.384-05:00Looks like this surgeon missed something during hi...Looks like this surgeon missed something during his training. the sad part is bad surgeons still get hired. https://www.msn.com/en-us/news/us/va-knowingly-hires-clinicians-with-problem-pasts/ar-BBG77wE?li=BBnb7Kz&ocid=spartandhpfrankbillhttps://www.blogger.com/profile/05592389641852861124noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-65278321148606435852017-12-05T09:20:26.617-05:002017-12-05T09:20:26.617-05:00I've been saying that for years.I've been saying that for years.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-53190961418682163962017-12-02T16:14:57.290-05:002017-12-02T16:14:57.290-05:00Sounds like the whole surgical training idea needs...Sounds like the whole surgical training idea needs to be re-worked. I completely agree that we are no longer training surgical residents to be capable of general surgery on day 1 after graduation. That's a shame.Ruggerhttps://www.blogger.com/profile/06098113624490857426noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-78808484891533474752017-11-27T01:08:14.774-05:002017-11-27T01:08:14.774-05:00The interesting thing I am noting in the comments ...The interesting thing I am noting in the comments is this; we are glossing over the bigger picture. Maybe older docs did have it worse, it doesn't matter. That still doesn't make it right. It wasn't right then, and it isn't now. Docs who work 120 hours a week are not good for pt's, or themselves. How can attending help residents NOW, so things get better? How do we improve our culture form within?Isaac Gnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-42779844582077048092017-11-22T11:10:25.436-05:002017-11-22T11:10:25.436-05:00Your comment reminded me of something. When someon...Your comment reminded me of something. When someone starts, "With all due respect..." someone else is going to get disrespected.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-84917381968513788652017-11-21T15:33:55.207-05:002017-11-21T15:33:55.207-05:00Anonymous Europe: You just can’t compare two total...Anonymous Europe: You just can’t compare two totally different eras. The old fossils usually can’t even turn a computer on (experience..). They do not even know where to log the operations or how to do the documentation properly, because it is all shuffled onto us... depriving us from gaining experience by performing operations. We are running their wards, running miles every day, while all they do is sit in their rooms and “do academic work” (=nothing). Besides, the world was different back in their days. Their wives did not want to divorce them if they did not nurture their marriage (also experience)., and maybe it was not that important to them to know their children before they turned 30..... <br />I still recall stories about what they used to do while being on call (and that was definitely NOT surgery, unless you consider bbqing on the roof surgery...). <br />Sorry, I do NOT mean any disrespect to anyone. There are fossils out there also, who can turn on a computer and help us out, even teach us.Maybe the picture I painted is somewhat tainted and I do not see every aspect of it,maybe it is just the bitterness speaking. Still I completely have to agree with the email. <br />I gave up science completely, because you just can’t do two things well at a time. Either you are a good surgeon or a good scientist these days, or you live alone.... Besides, I have a Ph.D. and that is the greatest regret of my life. Had I started with the surgical training earlier, I would be a way better surgeon by now. The old fossils fooled me back in the day, that I needed that Ph.D, and I will learn the procedures afterwards. Yeah... count on it. I will never get fooled again.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-83790375239956027762017-11-21T14:16:03.655-05:002017-11-21T14:16:03.655-05:00Jonathon, thanks for the comment. I agree the regu...Jonathon, thanks for the comment. I agree the regulations and compliance issues are a huge part of the problem. I just saw a tweet from Harvard cardiologist Michael Gibson. It said ordering and documenting a flu shot takes 32 mouse clicks. And a doctor has to enter all the data. That's part regulation and part poor EHR design. Here's a link to an article about it. Scroll way down to find the mouse click part of the story. https://in.reuters.com/article/us-usa-healthcare-burnout/counting-the-costs-u-s-hospitals-feeling-the-pain-of-physician-burnout-idINKBN1DL0EXSkeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-32960537371040843262017-11-21T13:53:11.927-05:002017-11-21T13:53:11.927-05:00I am an RN currently working as a senior EHR softw...I am an RN currently working as a senior EHR software analyst. I get a front row seat into the lives of the residents/fellows/attendings within the enterprise where I work and I can tell you that the regulatory and compliance burden is OUT OF CONTROL. As a software analyst I could create a program that would allow you as a physician to complete your documentation in a timely and efficient manner, thus freeing up your time to spend it with patients. In fact, this is what I would love to do...I have a deep sense of respect and solidarity with my physician colleagues. Unfortunately I am prevented from creating streamlined workflows because of the useless bureaucrats working within the regulatory-compliance industries. Instead I spend the majority of my time designing software schemes that allow the organization to capture documentation that will keep the hospital in compliance. THIS is why physicians are spending so much time in front of the computer. The EHR is not the enemy. The compliance and regulatory State is the enemy. Anonymoushttps://www.blogger.com/profile/16230600657736845895noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-52583264277289941522017-11-21T13:12:51.682-05:002017-11-21T13:12:51.682-05:00I know we have a record of every issue. And that r...I know we have a record of every issue. And that record is copied and pasted into every progress note in the chart. If residents are doing that (and I know they are), they are just creating more work for themselves. PS: Except for the assessment and plan, no one reads the notes anyway.<br /><br />Why should the fact that a patient has a few more positives in her past medical history result in more work for a resident? I'm not buying it.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-23858327119953752502017-11-21T12:27:46.899-05:002017-11-21T12:27:46.899-05:00On the topic of patients being "sicker" ...On the topic of patients being "sicker" nowadays...<br /><br />I don't think that the general public is any sicker today than it was 20, 30 years ago. <br />However, I think that we've seen a wave of medicalization that has brought disease more to the front of the mind for the general public. People may have had the same problems in the past, but I don't think they were conscious of them to the level that we are today (And especially with all the WebMD self diagnoses...).<br /><br />Also, as Just a Thought said, the documentation used to be a lot simpler, so we didn't have a record of every exact issue that was talked about in visits, whereas now we would know that the pt had problems A, B, and C, but was treated for bronchitis.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-54866830066496348132017-11-21T10:25:06.201-05:002017-11-21T10:25:06.201-05:00Anon from 11/20, I have blogged about some of the ...Anon from 11/20, I have blogged about some of the studies that show retention of info is better when notes are taken by hand. I wonder how well it is retained when a scribe writes it down. I'm guessing "not very well."<br /><br />Chris, your comments are spot on.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-56062497849079462772017-11-20T14:13:51.436-05:002017-11-20T14:13:51.436-05:00Anonymous 6:20
I agree that today's residency...Anonymous 6:20<br /><br />I agree that today's residency is harder, and unbearable for a surgeon trained in the 90's.<br /><br />I work nights in two different settings. In job #1 I was hired to replace residents no longer supplied to the VAMC starting in 2011 due to hours restrictions. Residents sign out the services to me at night. At job #2, I'm a locum in a small private non teaching hospital where I can give verbal orders and roll back over to sleep. <br /><br />Over just six years, the documentation/training module/order entry burden has exploded at job #1 and remained stable at the other. I now find it unbearable to work nights in the teaching setting. While my job description in the two settings is identical, job #2 is far easier - and feels more like my 90's residency, even if I spend the night operating. The other is non-stop non-clinical nonsense. The end of verbal orders is an under-recognized paradigm shift which hugely impacted how one spends time in a hospital. <br /><br />Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-2374086042996181352017-11-20T14:06:04.307-05:002017-11-20T14:06:04.307-05:00Fossil here, var nonsurgeon.
It's a little s...Fossil here, var nonsurgeon. <br /><br />It's a little strange to be told by today's trainees that we don't understand the systems they work in now while also being "schooled" on what we went through back in the day.<br /><br />With few exceptions, EHRs have been a burden on anyone who has to deal with them. I pushed the admins to include students and house staff in testing the systems, in good part because they tend not to balk at digital solutions as much as we dinosaurs do. They are often in the best position to offer the most useful feedback. <br /><br />It's telling when admin is willing to consider this--create electives in order to utilize the tech experience some of our students and trainees had in their pre-medical school lives. And even more telling when they don't. That's when all of us should pull together to push for systems that improve patient care, rather than the bonuses admins receive, on the backs of students, trainees, nurses, attendings, and everyone else attempting to provide actual patient care.<br /><br />It's worth pointing out that at least for some of us, time not spent at the computer as trainees was spent writing notes by hand, drawing blood cultures, and transporting patients to radiology. Personally, I think all of that was better for patient care. There's an emerging literature that students attending a lecture retain more information taking notes by hand than on a computer. And however annoying drawing sepsis labs and blood cultures myself was, I rarely if ever had false positive cultures and the time spent doing all of that meant I was actually with my patients. That sharpened my sense of who was ok and who was about to crash.<br /><br />If faculty need scribes, it's hard not to imagine that residents and fellows need them, too. All of us should be at the bedside (or OR or clinic or procedure room) more, not less, and should work together to make that happen.<br />Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-33396390494547782902017-11-20T13:53:39.481-05:002017-11-20T13:53:39.481-05:00I think population sickness is tied to the economi...I think population sickness is tied to the economic health of the population. Clearly, there are some pockets of America which have been economically decimated over the past few decades. There, health quality is surely lower. I don't need a study, but there are studies I'm sure (https://www.npr.org/sections/health-shots/2016/12/08/504667607/life-expectancy-in-u-s-drops-for-first-time-in-decades-report-finds). (Worldwide, as poorer nations get richer, their health quality, life expectancy, etc., have been dramatically increasing...)<br /><br />I'm a rad onc. I did a surgical internship though. I've hung out with and been friends with many inspiring, thoughtful surgeons. Twenty years ago, I think pretty much all the surgeons and surgical residents I knew were very pro-surgery. Also, most of us in general were pro-medicine back then whether we were surgeons or not. Now it seems many surgeons are burnt out and the surgeons-to-be are kind of trepidatious. As are many of us in medicine in general. <br /><br />What I think we are saying is that old docs and new docs and docs-to-be see things getting worse and not better, that the overall trend for this is out of our control, that doctors don't run the system and the people who do are going to keep trying to make things better (and it will only continue to make things worse). Todd J. Scarbrough, M.D.https://www.blogger.com/profile/09254631173069503684noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-58567684909842464412017-11-20T10:29:25.721-05:002017-11-20T10:29:25.721-05:00Just, I don’t know how we could determine whether ...Just, I don’t know how we could determine whether patients today are sicker than they were in the past. Research on the topic would generate a lot of clicks though.<br /><br />Robert, thanks for the reality check. My only disagreement with you is some people think doctors spend 50% of their time providing data for others to analyze.<br /><br />Unknown November 19 and Bob, thanks for the Australian point of view. Residents in the US have to keep logs as well. There is no way to tell whether the numbers and types of case entered are real or not. When a resident takes credit for having done a case, it is unclear what the criteria are for doing so. I have blogged about papers claiming that as many as 30% of US surgical residency graduates are unable to operate independently.<br /><br />Anonymous November 19, I would trust the states even less than I trust the hospitals to manage the Medicare GME money. In my state, physician licensing fees, which are substantial, go into the state’s general fund instead of being used to help police the profession or in any other way benefit physicians.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-84149096528643440012017-11-19T18:44:32.956-05:002017-11-19T18:44:32.956-05:00I think that we shouldn't lose the big picture...I think that we shouldn't lose the big picture. This is a symptom of a larger problem which is the lack of competition among hospitals in training residents. There is no incentive for a hospital to let a resident spend more time in the OR, the GME money is coming from Congress anyway without accountability. The ACGME? It's a creation of the same hospitals. It is true that the residents lost the battle of the anti-trust to the AAMC which got exemption in 2004 but that doesn't mean they should surrender instead, they should change the tactics and find allies in the states which can put political pressure on Congress in order to receive,the states, the medicare funding for the GME themselves and subsequently manage it according to the states' needs not the hospitals'. In addition, the states can coordinate that with their requirements for licensure. Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-75337758013067937432017-11-19T10:07:01.699-05:002017-11-19T10:07:01.699-05:00I should also add that in Australia to pass our te... I should also add that in Australia to pass our terms we have to keep a logbook. In this logbook we have to do a certain percentage of operations as "primary operator." The amount of an operation you need to do to be termed the "primary" as opposed to "assistant" is quite well defined by the College of Surgeons, however many of my supervisors encourage us to put ourselves as "primary" even when for 95% of the case we have assisted. I only mention this to say that whilst the official numbers of trainees operating is going down, this may not be the true scale of the issue as even these official numbers are very likely fudged.<br /><br /> This is an open secret. Bosses tell stories of new bosses who graduated having apparently done hundreds of cholecystectomies, but clearly have trouble doing simple cases. As a way of putting the issue aside, bosses say that we aren't really trained when we have our letters now, we really get trained during our fellowship. But this feels like a way of not addressing the problem at all, and in some ways justifying it.<br /><br /> There are many pressures in the health system these days, and cost and waiting lists weigh heavily on the senior consultants. It seems like too often though our training is not respected and pushed aside for more pressing issues. As a trainee, there is no more depressing a feeling than waiting all day to finally do a case, when a nurse manager walks in and tells your boss that the trainee can't do this case because there is no time and the list needs to be finished quickly.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-10034693644543766712017-11-19T08:16:09.742-05:002017-11-19T08:16:09.742-05:00As a training registrar in Australia, which is sim... As a training registrar in Australia, which is similar to a resident in the US, I can tell you the situation is very similar to what Anonymous 620 describes here. The truth is we still work long hours, we just don't get paid for it. Instead of being up all night operating for our bosses, our bosses do all the operating and we are up all night doing their research projects (and not getting paid for it). <br /><br /> This all sounds like whinging, but I should say on the whole we are still privileged to be surgical trainees. We love what we do and it is an honour to do even the little operating we can. However I don't know many people who wouldn't swap systems in a second.<br /><br /> That really is the proof of the pudding for me. No boss I know would have swapped their training for ours, yet most of us would love to go back to the old days. None of us are soft or lazy, we are just stuck in a training system that year after year puts out worse and worse skilled trainees and doesn't seem to care to change. I don't know of another industry where it could be confidently said that graduates 5 years ago were better, and 10 years ago were better than that ad infinitum.Anonymousnoreply@blogger.com