Study: 31% of general surgery residents need remediation. Why?

A recent paper in Annals of Surgery depicts the rate of resident remediation over a decade or so at six general surgery programs in California. The authors reviewed the records of 348 categorical general surgery residents and found that 107 (31%) required mediation with knowledge deficits the primary reason in 74%. Other issues, such as interpersonal and communication skills, patient care and professionalism, were cited far less often.

Need for remediation did not correlate with attrition. Remediated residents left programs at a rate of 20% compared to 15% of non-remediated residents, p = 0.40.

On multivariate analysis, only two factors were associated with the need for remediation. One was USMLE Step 1 scores which were lower in the remediated group. But the median difference in scores between remediated and non-remediated residents was only 7 points with wide and overlapping interquartile ranges, and both median scores were above the average for all medical students over the years of the study.

The other factor was quite remarkable. Remediated residents were significantly more likely to have received a grade of "honors" for their medical school clerkship and surgery. How can this be?

The authors speculated, "One thought is that medical students start residency under-prepared for the rigors of surgical residency." Now where I heard that before? I have previously blogged (here) about the unrealistic third-year experiences of medical students on surgical rotations. While I agree that they likely are not ready for the workload, I'm not sure what it has to do with the primary reason for their poor performance—a perceived knowledge deficit. Does hard work cause them to forget everything they’ve learned or are they taught the wrong stuff in med school?

I think not. The real reason may be found in the way medical students are graded. A group from Harvard looked at medical school grading systems and found that honors grades in third-year surgery clerkships are given to an average of about 30% of students ranging from a low of 7% to an mind-boggling high of 67%. I understand that those accepted to med school are smart, but how is it that two-thirds of the class can achieve honors in surgery? Could it be that some of the honors grades given to residents who eventually needed remediation were not warranted?

If you would like to read more about this, you may read the full text of the paper on medical school grades here or a summary on my blog.

We order too many preop tests

As predictable as the leaves falling this time of year, another paper on the subject of unnecessary preoperative laboratory testing has appeared.

A group from the University of Texas Medical Branch looked at more than 73,000 elective hernia repairs in the National Surgical Quality Improvement Project (NSQIP) database. Almost 2/3 of the patients had preoperative laboratory tests. Of that group, 58.6% had a CBC, 53.5% had electrolytes, 23.7% had liver function studies, 18.7% had coagulation studies and 9.9% had all of the above. Even 54% of patients with no co-morbidities had at least one test.

An abnormal test was found in more than 60% of those tested, of the 7200 patients who had lab tests done on the day of surgery, 61.6% had at least one abnormal test including 23% with a coagulation abnormality, 41% with a chemical abnormality and 33% with an LFT abnormality. Despite these results, the scheduled surgery was done.

Tests did not predict complications in patients without co-morbidities. Obtaining a test (not necessarily an abnormal result) was associated with a higher risk of major complications (0.4% versus 0.2% p < 0.0001) but not wound complications. However, abnormal results did not predict complications.

The authors of the paper recommended that surgical societies establish guidelines for preop testing.

Hernia patients, particularly those without comorbidities, are similar to normal people. Obtaining lab studies on these patients is analogous to obtaining labs on the next 100 people who walk past the hospital. Few abnormal results will be found, and most of them will be false positives.

This fact has been known for at least 30 years, yet surgeons, who as shown by previous studies order 80% of preop tests, still continue to order them. Some question whether anesthesiologists insist on having the tests done. Is it defensive medicine? Force of habit?

When I was a department chairman and this subject came up for discussion, at least one person always said, "But if you miss one patient with (you fill in the blank), you will get sued." That type of comment is very difficult to refute because there is a grain of truth to it.

As far as I can tell, "I was following evidence-based guidelines" is not a foolproof defense against a malpractice suit. While there have been some attempts to legislate that following evidence-based guidelines should "immunize" doctors against malpractice suits, to my knowledge, no such laws exist. In 2004, an article in the AMA’s Virtual Mentor journal discusses this point very well as does a paper from the Journal of Law, Medicine & Ethics.

What then is a practicing physician to do? That unnecessary pre-op testing occurs has been understood for many years. The paper points out that the estimated cost of preoperative testing is anywhere from $3 billion to $18 billion. Several esteemed associations and societies have established guidelines which are not followed.

Meanwhile, extensive preoperative testing of ambulatory patients continues at the discretion of the surgeon, anesthesiologist and probably the patient’s primary care doctor too. And the tab mounts.

Can you guess the diagnosis using this radiology report?

Here are some excerpts from a radiology report I received. I left out some portions that were not pertinent and I highlighted in bold some of the better parts. My comments are in brackets.

This was in reference to a CT scan of the abdomen for abdominal pain.

Free peritoneal air is present. Proximal small bowel loops are dilated to about 4 cm in diameter. In the lower abdomen and upper pelvis there is a region of edema and a change in caliber of the diameter of the bowel consistent with bowel obstruction. This edema also surrounds the sigmoid colon. There are diverticula and diverticulitis is a consideration. Perforated diverticulitis is also another consideration for the free air. There are some collections of air along the right side of the sigmoid colon which may be extraluminal or perhaps some prominent diverticula. A small abscess in this region is a consideration. There is diffuse edema in the lower omentum.

No abnormal masses are seen in the pelvis. No significant amount of free pelvic fluid is present. {Is there an insignificant amount of fluid?]

No appendicitis. No diverticulitis. No free air.[!]

IMPRESSION: Proximal small bowel obstruction. Questionable diverticulitis with questionable small abscess adjacent to the sigmoid colon. Pneumoperitoneum [“Pneumoperitoneum” means free air in the abdominal cavity.]

Is there diverticulitis? Is there free air? What the hell is going on?

So if you were the surgeon, what would you do?

At least the radiologist used the correct plural form of the word “diverticulum.” See my previous post on this topic.

The Apocalypse Is Near: Part IV

A report from Egypt says that a medical center there is treating various maladies by having patients drink camel urine. It apparently is good for “the treatment of skin diseases such as ringworm, tinea and abscesses, sores that may appear on the body and hair, dry and wet ulcers, swelling of the liver, toothache, and for washing eyes.” Ah … no, thanks.

In Britain, 26% of the population has received a diagnosis of depression at some point in their lives. That is depressing. However, it doesn’t mean that they were all clinically depressed. I don’t know what goes on over there, but here in the US, it seems all you have to do is tell a doctor you feel depressed and you will likely receive a prescription for an anti-depressant.

How’s this for chutzpah? Francesco Schettino, the former captain of the ill-fated liner Costa Concordia, has sued the company that owned the ship for wrongful termination after he was fired. You may recall that he is facing charges of manslaughter and abandoning the ship. [LINK]

Here are five stories that make me pessimistic about the future of our country.

1. A boy removed the brakes from his bicycle, promptly ran through a stop sign and crashed into a car. [LINK]

2. An adult couple who were babysitting tied a 2-year-old girl to a coffee table because she wouldn’t stay away from the refrigerator. Yes, that’s bad, but it gets worse. They “began to wonder if it was a bad idea to tie up the girl, and discussed the situation with an upstairs neighbor” who then called the police. [LINK]

3. Two law students were arrested for killing a rare exotic bird at a hotel in Las Vegas. They were tossing it around and then decapitated it. Did I mention they were law students? The article describing this heinous crime says they attended “Berkeley University in northern California.” I think the reporter meant to say University of California, Berkeley, but how would he have any way to know this since Berkeley is at least 500 miles from Las Vegas? [LINK]

4. Another northern California story details a new diversion created by boys at a high school. They started a “fantasy slut league” in which “Male students earn points for documented engagement in sexual activities with female students." This is so bizarre that even I can’t think of anything to say about it. [LINK]

5. The University of North Carolina has banned the use of the word “freshman” to denote a student in the first year of college because the term is “non-gender inclusive.” From now on, they are to be called “first year students.” The story is amusing as it points out the problems with the words sophomore, junior and senior. [LINK]

Law school revamps final year curriculum. Will med schools ever do the same?

The New York Times reports that NYU Law School is planning to change its third-year curriculum to better prepare its graduates for the realities of legal practice today. In case you don’t know, law school graduates are having a tough time finding work and many require on-the-job training to make up for what they didn’t learn in school.

From the article: “There is a growing disconnect between what law schools are offering and what the marketplace is demanding in the 21st century,” said … the chairman of the panel of alumni recommending the changes.

A revelation from the article is that the third year of law school has been considered a waste of time by many observers.

“One of the well-known facts about law school is it never took three years to do what we are doing; it took maybe two years at most, maybe a year-and-a-half,” Larry Kramer, the former dean of Stanford Law School, said in a 2010 speech.

There has been much debate in the legal academy over the necessity of a third year. Many students take advantage of clinical course work, but the traditional third year of study is largely filled by elective courses. While classes like “Nietzsche and the Law” and “Voting, Game Theory and the Law” might be intellectually broadening, law schools and their students are beginning to question whether, at $51,150 a year, a hodgepodge of electives provides sufficient value.

Although I wasn’t aware of this issue in law schools, it sounds familiar in a way. Copy the above paragraphs, take your word processing program and replace “law school” with “medical school” and “third year’ with “fourth year” and you will have an accurate story about medical education.

The fourth year of medical school has been known to be a waste of time for at least 40 years. Most schools allow some or all of it to be electives of the students’ choosing. This results in anesthesia rotations in Paris and dermatology rotations in New York City. In a previous blog, I have pointed out some of the problems of both the third and fourth years of med school.

A 2011 piece in the New York Times Magazine pointed out that some law firms are providing new associates with intensive training in the nuts and bolts of lawyering that they apparently don’t get in school. For example, although they had studied mergers in law school, graduates had no idea how to make a merger happen.

As an interesting parallel, some surgical residency programs have begun to offer “boot camps” (See links here and here.) as a way to teach incoming first-year trainees some of the material they should have learned in medical school. Apparently, this is necessary in Scotland too, where the boot camp lists such topics as communication skills for surgeons, polytrauma, how to lead a ward round and handling and writing the evidence. These all seem like subjects appropriate for a med school curriculum, but lacking.

I hope that someday medical schools will recognize the problem as NYU Law School has done. Meanwhile, I will keep cranking out the blogs.