Chronic shortage of training sites worries medical schools

The Association of American Medical Colleges (AAMC) says many of its members are worried about a shortage of training sites for students and residents.

The AAMC’s 2016 Medical School Enrollment Survey found that 80% of schools were concerned about the number of available clinical training sites. There were also issues with the numbers of primary care and specialty preceptors.

The graphic below shows that these problems are not new, but in general seem to be worsening. [Click on the figure to enlarge it.]

The situation is exacerbated by increasing competition for clinical sites from osteopathic schools, offshore medical schools, and nurse practitioner and physician assistant schools.

Can surgical residents please have some autonomy?

A comparison of appendectomy outcomes for senior general surgeons and general surgery residents revealed no significant differences in early and late complication rates, use of diagnostic imaging, time from emergency department to operating room, incidence of complicated appendicitis, postop length of stay, and duration of postop antibiotic treatment.

The only parameter in which a significant difference was seen was that attending surgeons completed the procedure significantly faster by 9 minutes—39.9 vs. 48.6 minutes, but this may have been influenced by the fact that attending surgeons used laparoscopic staplers 13.5% of the time as opposed to use by the residents in only 2% of cases, also a significant difference.

This before-and-after study of more than 1600 appendectomy patients was published in JAMA Surgery. Between 2008 and 2012, residents were permitted to perform appendectomies without direct supervision by an attending surgeon. The pre-2012 group included 548 operations performed by general surgery residents alone. Because of a policy change, all of the appendectomies from 2012 to 2015 were performed by attending surgeons alone or directly supervising a resident.

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. 

Can a US IMG with a marginal USMLE Step 1 score still match in surgery?

A US IMG with a USMLE Step 1 score between 200 and 210 wrote me with several questions.

Disclaimer: This is my opinion which may not be shared by the majority of surgical program directors. The questions are italicized.

Is there a way to find programs that don't have Step 1 cut offs? No.

Should I email them my 230 on the USMLE practice test? That would be of no use.

Should I explain my situation or will that seem like a sob story? I've had bad luck but just a string of it and I feel like it would sound like I was making too many excuses. As I read your story, it did sound like too many excuses. The problem for you is that there are numerous other candidates out there who don’t have these issues and have better scores.

Should I strategically book rotations during interview season and hope they decide they want me (does that happen and do you have any tips on this)? The value of so-called “audition electives” is controversial. I never put much stock in them, but I think many program directors do. If you decide to do some audition electives, you should focus on smaller community hospital programs. Many programs list where their residents went to medical school on their websites. You should pick places that have taken US IMGs recently.

Changing pre-med requirements and med school curricula

Ezekiel Emanuel, the University of Pennsylvania physician and ethicist, has written an opinion piece suggesting many changes in both pre-medical education and the medical school curriculum.

He would do away with many of our hallowed medical school prerequisites such as calculus, physics, and organic chemistry, feeling that those subjects are simply used to "weed out" certain students. I confess I once believed that such subjects were worthwhile. However, Emanuel makes a convincing argument that rigorous college courses in more relevant disciplines such as statistics, genetics, ethics, and psychology with a special focus on human behavior would suffice.

Regarding medical school, Emanuel points out he was taught the Krebs cycle on four different occasions in college and medical school and never used it once in practice or research. I have made a similar observation in a previous blog post.

He considers pathology, cytology, and pharmacology to be largely irrelevant to medical practice but concedes that some may disagree.

Surgical training is different in Japan

Quite different than what we are used to in the United States as a paper published online in the American Journal of Surgery explains.

In the US, all residency programs are vetted by the Accreditation Council for Graduate Medical Education (ACGME). Japan has no central accrediting organization. Each hospital establishes its own training program without any national standardization.

Medical school graduates in Japan take a national practitioner examination and then complete a two-year rotating internship. Specialization in general surgery residency takes three more years after which the residents may obtain board certification.

The authors surveyed 76 teaching hospitals in Hokkaido, a prefecture in the north of Japan, and 49 (64.5%) responded.

Program directors were in place in 81% of the residency programs. Of that number, 79.3% devoted less than 5 hours per week to education [compared to an ACGME mandate that 30% of a program director’s time must be devoted to education], and 72.4% had dialogues with residents only when necessary.

Of those responding to the question, 31/36 (86%) "had teaching activities outside of clinical settings," but no program had protected time dedicated to teaching.

Fewer than half of the programs had skills or simulation laboratories, with 12.5% having formal simulation training as part of their educational agenda.

Only 55.6% of the programs evaluated the competency of their trainees in knowledge, skills, or scholarly activities.

Not surprisingly, only 8.6% of program directors were satisfied with the way their programs functioned.

To become board-certified in Japan, residency graduates must take a written exam for which the pass rate is 82.1% and an oral examination which has a pass rate of 100%. The pass rate for the oral exam has been an issue. A medical specialty board was established in 2014 and is preparing to oversee the quality of resident education and certification.

Lead author Dr. Yo Kurashima, Director of Surgical Education Research at Hokkaido University Graduate School of Medicine, answered a few questions via email. He said some of the hospitals limit resident work hours and allow residents to go home after call. However, "most do not define work hour limitations, so residents usually work from early in the morning to midnight every day."

No universal surgical residency curriculum exists in Japan, but a national surgical society recently listed criteria that must be achieved prior to board certification.

Dr. Kurashima did some training in Canada where he became familiar with North American residency methods.

For his next project, he said, "We are just starting a national survey which will investigate resident satisfaction regarding their residency.”

I suspect the residents might raise some concerns. I wonder if they will have time to respond.

A high school student has questions about a medical career and pathology vs. surgery

A female high school student asks about pathology, surgery, and medicine in general. [Email edited for length.] See if you agree with my answers.

The field I am most interested in is pathology. I have a very logical mind and would enjoy being able to solve the complex puzzle of disease. I would also like the somewhat flexible hours compared to other more intensive specialties. However, I do have some qualms.

I'm also interested in general surgery. I would love to learn how to perform all the different types of surgeries that surgeons perform. If I were to be a pathologist, would it be "knife-free"? Pathology really intrigues me, but participating in the occasional surgery sounds like it would be extremely interesting and full of learning opportunities.

There is some knife wielding in pathology. Specimens must be properly cut, and there is the occasional autopsy. However, it's definitely not surgery.

What does a pathologist really do? I've looked at various descriptions online, and none of them seem to be very specific. What would a typical day look like for a pathology resident? I was also wondering what types of skills pathologists are taught?

So you want to be a Radiologist

A student writes, I've been following some of your posts and noticed some of the comments by others mentioning that radiology residencies/jobs are drying up and even face the possibility of disappearing completely. Could you explain why? I am currently a senior pre-medical student who's taken a recent liking to radiology after following a few radiologists in a hospital, so I would just like to get some input.”

A colleague, Dr. Saurabh Jha, an Assistant Professor of Radiology at the Hospital of the University of Pennsylvania, has graciously agreed to respond. He can be followed on Twitter @RogueRad.

Should I go into radiology?

I used to be a surgical resident in the UK. One day, I was a little dispirited during a brutal call, and my senior resident asked “do you love surgery?”

“I like surgery,” I replied.

“If you don’t love surgery, love it unconditionally I mean – like loving your child – you will be unhappy.” He warned.

I really liked surgery. I like radiology. I’m happy as a radiologist. Radiology fits my temperament. You don’t have to love radiology like one has to love surgery, but you have to like it. It helps if you like it a lot.

The worst reasons to go in to radiology are to make lots of money and to avoid patients. The days of radiologists making $500 K + 12 weeks of vacation after reading 20,000 studies a year are over. Radiologists doing interventional, ultrasound, mammography and fluoroscopy (such as barium enemas) must speak to patients, and speak well.

Radiology is a tech-heavy field. If you’re excited by technology, you will like it. Radiologists are leading healthcare in IT. If you have an interest in health IT, then some programs will integrate informatics with your training.

Residency involves substantial reading. You have to master anatomy, radiological pathology, and physics, as well as have a decent knowledge of clinical medicine. Prepare for 20-30 hours of reading a week. Radiology is now 24/7. Calls are intense – 12 hour shifts are non-stop. But when you are off, you are off.

Believe it or not, international health – if you are into that – increasingly asks for radiologists. Although you won’t be parachuting in to Sierra Leone or quarantined in Fort Hood.

Will there be jobs when I graduate?

It's that time of year again

Hopes are high; everyone is prepared; all the talk is over. The big day is finally here.

No, it's not about the Super Bowl. It's about the American Board of Surgery In-Training Examination (ABSITE).

Every year at the end of January, all surgical residents take a five-hour, 250 question multiple-choice test. For many, it can be a watershed moment because their careers may be on the line.

I have written about the use of the ABSITE as a criterion for resident promotion. Whether you think it should be or not, it is used that way—sometimes as the only criterion. You can bet that in a few weeks, some residency programs will post notices saying they are looking for a categorical PGY-2 or 3 due to an "unexpected" vacancy for July 2015.

Another attending surgeon and I used to take in-house call the night before the examination so that all of the residents could take the test after a decent night's sleep.

Now the test may be given on different days so that the entire group does not have to take it at once.

One difficult situation I faced as a program director was when I had a good clinical resident who just could not do well on a multiple-choice examination. I had to decide whether keeping a resident who scored at the 10th percentile was worth the gamble. Scoring in the 10th percentile or less on a regular basis means that the resident has a good chance of failing the written board examination.

Of course, the very nature of percentiles is that 10% of those who take the test will finish in the 10th percentile or below. Also, the failure rate of the written board examination has hovered around 25% for many years.

The problem for programs is that the Residency Review Committee for Surgery mandates that 65% of a program's graduating residents must pass both parts of the board examination on the first attempt.

Of the many things I do not miss about practicing medicine during this turbulent era, the palpable level of anxiety surrounding the buildup to the exam and waiting for the dreaded results to come back rank high on the list.

I wish all residents who are taking the test the best of luck. I hope you were reading all along and not trying to cram a year's worth of studying into the week before the test.

May you all score above the 50th percentile.

Now I'm really worried about surgical education

Here's why.

A friend told me that a new attending on his staff was having some problems. Although the young surgeon was a graduate of five years of general surgery training plus two years of fellowship, he was unable to do an inguinal hernia or a laparoscopic cholecystectomy by himself.

This is just an anecdote, but the issue has been identified by others. Remember the paper from Annals of Surgery in September of 2013 that described a survey of fellowship directors? It stated that 66% of graduates of five-year general surgery training programs could not conduct a major case unsupervised for 30 minutes, and 30% could not independently perform a laparoscopic cholecystectomy

A study published online in JAMA Surgery last month looked at 20 years of ACGME surgical resident case logs and found that although minimally invasive surgery is being done much more frequently, it is currently performed in more than 50% of cases for only five procedures—cholecystectomy, appendectomy, adult anti-reflex surgery, partial gastric resection, and thoracic wedge resection.

In 2007, the Residency Review Committee for Surgery increased the required number of basic laparoscopic surgery cases from a minimum of 34 to 60 and from 0 to 25 for advanced . The authors expressed concern that there might not be enough minimally invasive cases for all of the residents to do. They also pointed out that there was still in need for residents to learn open surgery since all but five operation procedures are still predominantly performed that way. However, as laparoscopic cases increase, the number of open cases will decrease because the total number of cases done by graduating chief residents has not changed significantly in 20 years.

A year ago, I blogged about some potential problems that might occur when surgical residencies are expanded and new programs are begun. Specifically, I wondered if there would be enough teaching cases to go around. It is interesting to see my speculation bolstered by data.

A program director recently told me that there may be a movement afoot to start a Fundamentals of Open Surgery course.

What is going on here? There is already a Fundamentals of Laparoscopic Surgery course. Do we really need to have a separate course to teach residents open surgery? Isn't that what a "residency" is supposed to do?

How did surgeons of my generation ever learn how to operate without courses in the fundamentals of laparoscopic and open surgery?

The visionary surgeon Leo Gordon saw it coming in 2002. He predicted the need for a "macrolaparotomy" course, and it can be run by the newly created American Board of Open Surgery.

Recognition

The following is based on an actual case that occurred a long time ago in a galaxy far, far away.

A 65-year-old man arrived in the emergency department by ambulance after being found unresponsive. His respiratory rate was 40/minute, heart rate was 170/minute, and temperature was 102.2°. He did not respond to Narcan or an ampule of 50% dextrose. Blood sugar was 600 mg/dL. The diagnosis of diabetic ketoacidosis was made. IV fluids and an insulin drip were given. After some hydration he became more alert and complained of abdominal pain. On examination, his abdomen was tender to palpation. Four hours after arrival, a surgical consultant was called and diagnosed an incarcerated inguinal hernia. Before the patient could be taken to surgery, he suffered a cardiac arrest and could not be resuscitated. Review of the case revealed that although blood cultures were drawn and were eventually positive, antibiotics had not been ordered.

What happened? The possibility that this patient was septic never occurred to the doctors managing the case. I am sure that if a scenario like this appeared on a test, those doctors would have immediately chosen the right antibiotics. Some doctors are "book smart" but can't deal with a real live patient.

Can you define "professionalism"?

A while ago, I wrote about a medical student whose school tried to dismiss him just prior to graduation for unprofessional behavior.

A judge ruled that the school could not do so because it had tolerated some similar behavior earlier in his medical school career and had not considered it important enough to mention in his letters of recommendation.

In that post, I said, "'Professionalism' is difficult to define, especially when trying to do so in a courtroom."

In the comments section, a medical student wrote that he had been given a two-week suspension for unprofessional behavior for silencing his phone during an exam.

Another commenter told of several students who were caught colluding on a take-home final exam in statistics. Their punishment was that they had to agree to do their residencies at the medical school. [Digression: What does that say about the school?]

The Accreditation Council for Graduate Medical Education defines professionalism, one of its six core competencies, as follows:

"Professionalism—Demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles."

I'm always a bit confused when the definition of a term contains the term itself, and this is no exception.

Three internal medicine foundations combined to publish a somewhat clearer definition that is two pages long, but does not mention specific behaviors like cheating on a test, falsifying a medical record, or being arrested for driving under the influence of alcohol.

The American Board of Internal Medicine Foundation produced this "Word Cloud," which is supposed to help one better understand what professionalism is. But all it did was remind me why I hate word clouds.



It is said to depict "words physicians most associate with medical professionalism."

If you are having trouble reading some of them, I can help. Here are a few: "empathize, compassion, respect, responsibility, ethics, integrity, caring, honor."

Those sound pretty good, but here are some more: "tougher, smoker, diet, sick, job, prevent, financial, good insurance, disease, death." What do those words have to do with medical professionalism?

Since we have trouble defining professionalism, we can hardly blame the judge in the case I wrote about before for ruling in the student's favor.

He said, "Although courts should give almost complete deference to university judgments regarding academic issues, the same deference does not follow university character judgments, especially on character judgments only distantly related to medical education."

I disagree with the last part of his statement. I think character judgments are strongly related to medical education, but how are medical schools and residency programs supposed to teach professionalism and assess whether their trainees possess it, if it is so ill-defined?

Should resident promotion decisions be based on a written exam?

A few days ago, some surgeons on Twitter discussed the role of the American Board of Surgery In-Training Examination, a test which is given every year in January.

The test was designed to assess residents' knowledge and give them an idea of where their studying should be focused. However, many general surgery program directors (PDs) use the test results in other ways. Some impose remediation programs on residents with low scores and even base resident promotion or retention on them. Some even demand that all residents in their programs maintain scores above the 50th percentile.

The Residency Review Committee (RRC) for Surgery frowns upon these practices and states in its program requirements (Section V.A.2.e) that residents' knowledge should be monitored "by use of a formal exam such as the American Board of Surgery In Training Examination (ABSITE) or other cognitive exams. Test results should not be the sole criterion of resident knowledge, and should not be used as the sole criterion for promotion to a subsequent PG [postgraduate year] level."

The problem for program directors is that the RRC also mandates (Section V.C.2.c) that "as one measure of evaluating program effectiveness" 65% of a residency program's graduates must pass both the American Board of Surgery's Qualifying Examination (written) and Certifying Examination (oral) on their first attempts. I have said before that the "65% on the first attempt rule" does not seem evidence-based.

Improving the M&M conference

"Surgical pathology works more than 80 hours per week, has no regard for your gender or your life situation, and can be devious and sneaky in its presentation."

The following is a guest post by Dr. Leo Gordon, a surgeon from Los Angeles.

A recent paper in Annals of Surgery found that 24% of graduating surgical residents "were unable to recognize early signs of complications." One possible solution is a redesign of the morbidity and mortality (M&M) conference .

I have spent a significant part of my professional life in an effort—at this point it is a crusade—to change the nature of the M&M conference. For 11 years, I moderated 495 conferences, 1485 presentations, and 30 written examinations based on the error and complication-reducing points raised during the discussions.

If properly implemented, a redesigned M&M conference can satisfy the ACGME core competencies, the suggestions of the Institute of Medicine, and the public's demand for a reduction in medical errors.

What I have dubbed the "M&M Matrix" converts the weekly conference into a vibrant educational effort and creates a constantly updated patient safety curriculum for the resident and attending staff.

If the M&M Matrix is such a valuable idea, why hasn’t it been widely adopted?

Here are the reasons:

What can be done about letters of recommendation?

Many surgical educators feel that letters of recommendation are not particularly helpful in evaluating applicants or predicting eventual resident performance.

Among the issues are lack of uniformity of content, excessive use of superlatives, reliability—if the writer is not known to the recipient—and more.

Even if the writers are well-known academic surgeons, the degree of their personal knowledge of the applicants is not always clear.

During an extensive Twitter discussion over the weekend, someone mentioned that in an attempt to deal with this problem, emergency medicine had developed a standardized letter of recommendation.

A recent paper from the EM Standardized Letter of Recommendation Task Force shows that there is still work to be done. From the abstract:

For the question on "global assessment," students were scored in the top 10% in 234 of 583 of applications (40.1%), and 485 of 583 (83.2%) of the applicants were ranked above the level of their peers. Similarly, >95% of all applicants were ranked in the top third compared to peers, for all but one section under "qualifications for emergency medicine."

I've written before that dean's letters are more like public relations press releases than accurate assessments of a student's performance. You will rarely find negative comments in them. But another recent paper by a group of psychiatrists found that The presence of any negative comments in the dean's letter yielded significant correlations with future problems. Further, those applicants with future major problems had significantly more negative comments in the dean's letter than did those with future minor problems. Other factors such as USMLE scores, failed courses, letters of recommendation, and interviewer ratings and comments did not predict future problems.

These problems are not new. A 1983 New England Journal opinion piece about recommendation letters entitled "Fantasy Land" is remarkable for its validity even today. Here are a few choice quotes.

It's a land where everyone is "a pleasure to work with," has "excellent initiative," is "enthusiastic and conscientious," and possesses and "above-average fund of knowledge."

No one is ever poor, fair, or average; they are all "very good" or "excellent."

The author, Dr. Richard B. Friedman, said letters of recommendation were useless and advocated doing away with them.

A brief JAMA essay by Dr. Henry Schneiderman in 1988 called for more openness in describing students but acknowledged that negative comments were often "the kiss of death."

He proposed a new system of categorizing medical student performance. Here are just a few examples.



@AmirGharferi suggested this:

"Dr.G, do you feel comfortable writing me a strong letter?"
"No."
"Ok, I'll find someone who is."

That works if the student is aware enough to ask, and the faculty member is honest enough to say no. In my experience, even the most marginal of students can find someone—in addition to the dean, of course—to write a good letter.

I am no longer involved in the process of selecting residents. I have no suggestions.

What is your solution to this problem?

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.

Google Glass in the OR: Not ready for prime time

The Royal London Hospital and the Barts and The London School of Medicine and Dentistry presented the first live-streamed surgical procedure in the UK. The operation was an extended right hemicolectomy with resection of a metastatic liver lesion.

I was able to view the entire broadcast portion of the surgery live, and you can see it if you click  [2/27/15 Addendum: The link to the video has been taken down. Sorry.]

Here is what I thought about the event.

How should residents spend their time?

As everyone knows, residents are now restricted to working 80 hours per week. One of the lesser known side effects of this work hours limitation is the drastic loss of educational conference time.

Since at least one third of the residents must now go home after morning rounds, afternoon conferences are no longer possible. Most residency programs now devote part of at least one morning per week to dedicated educational time.

A new paper from JAMA Surgery describes how one program chose to comply with the mandate to teach some of the more fuzzy resident core competencies. Their weekly didactic schedule of 1 hour of grand rounds and 1 hour of small group learning now includes 10 hours per year [representing 10% of the 100 hours allotted to formal teaching] on practice-based learning and improvement, interpersonal and communication skills, systems-based practice, and professionalism.

From the paper's Table 3, the specific topics are structure and policy of US health care, advocacy, medical economics and finance, history and consequences of major legislation, innovation in health care, health information technology, comparative effectiveness, health care disparities, basic management principles, quality, performance improvement, patient safety, coding and billing compliance, legal issues, litigation, risk management, clinical practice models, contracts, relative value units (RVUs), personal leadership styles, power and influence: organization psychology, negotiation and conflict resolution, communication, ethics, and last but certainly not least, one of my favorites—Six Sigma. [What, no mention of "Lean"?]

I don't mean to disparage the authors of this paper. They're only trying to follow the rules. I'm just glad I'm no longer a residency program director having to commit 10% of my program's precious educational time to things like organization psychology, history and consequences of major legislation, and Six freakin' Sigma.

But I guess it could be worse. At this year's meeting of the Association of Program Directors in Internal Medicine, the following slide suggesting books that should be read by every chief resident was shown.

I would love to meet the chief resident who had not only the time, but also the inclination to read all 17 of these books.

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.

How to select surgical residents: The evidence

On Twitter a while ago, a medical student asked me how surgical program directors select new residents. Then a discussion arose among some academic surgeons on the same topic. Someone suggested that medical school grades were the best way to tell whether an applicant would be a successful resident.

The fact is that we aren't really sure what the best way to choose residents is.

First, here's what we really do.