Warning: file_get_contents(http://webbiscuits.net/images/blan.gif) [function.file-get-contents]: failed to open stream: HTTP request failed! HTTP/1.1 404 Not Found in /home/residenc/public_html/wp-content/themes/residencynotes/header.php on line 26

Archive for the ‘Medical Education’ Category

Sunday, March 9th 2014


Fourth year medical students are trying to get The Ellen Show to their Match Day in San Antonio. Help this go viral. To that end that have a pretty talented mock up of Pharrell William’s ‘Happy’.


Monday, December 9th 2013

More Medical Students, More Residency Spots?

I’ve been a critic of my home state for its rapid expansion of undergraduate medical education opportunities without concurrent expansion of graduate medical education opportunities. But to be fair, such isn’t unique to Texas.

We continue to enroll record number of medical students across the country.

There was…a 3 percent increase from 2012 in the number of students who enrolled in their first year of medical school. That number, 20,044, exceeded 20,000 for the first time.

Not in itself a bad thing. We just need the residency spots to go along with such.

[T]he Resident Physician Shortage Act was introduced in the U.S. Senate, and the bipartisan Training Tomorrow’s Doctors Today Act was introduced to the U.S. House of Representatives. The bills aim to help meet the nation’s increasing demand for new physicians by funding an additional 15,000 Medicare-supported graduate medical education (GME) positions over the next five years.

While broad bipartisan support the issue isn’t ‘urgent’ enough that these bills are likely to become law before this Congress is finished. Which is a sad state.

Nor are many states doing much to aid graduate medical education expansion.

We should be skeptical of the modeling of the coming physician shortage. But it makes no sense to increase medical school spots without making residency training available.

Thursday, October 31st 2013

A Medical Education Bubble

There’s a nice, brief editorial ahead of publication in the New England Journal of Medicine. Everyone needs to consider this when discussing American physician earnings; especially as compared to the rest of the world.

[I]f we aim to reduce the costs of health care, we need to reduce the costs of medical education. We don’t have to believe that the high cost of medical education is what causes increases in health care costs in order to develop this sense of urgency. We just have to recognize that the high costs of medical education are sustainable only if we keep paying doctors a lot of money, and there are strong signs that we can’t or won’t. Only about 20% of health care costs are attributable to physician payments, and many of the current efforts to reduce costs are aimed elsewhere, such as hospital payments, and have only indirect effects on physicians’ earnings. But physicians’ and dentists’ earnings have been sluggish since the early 2000s.3,4 Even if prospects for physicians’ income fall fast, a burst bubble can be averted if schools see it coming before their students do and lower their prices.

Monday, October 21st 2013

The Risks of Pseudoscience

Go read this on the New York Times Opinionator. Great piece about

confusing the possible effectiveness of folk remedies with the arbitrary theoretical-metaphysical baggage attached to it. There is no question that some folk remedies do work. The active ingredient of aspirin, for example, is derived from willow bark, which had been known to have beneficial effects since the time of Hippocrates.


What makes the use of aspirin “scientific,” however, is that we have validated its effectiveness through properly controlled trials, isolated the active ingredient, and understood the biochemical pathways through which it has its effects

Just because some folk remedies work doesn’t lend credibility to folk or naturopathic theories of healthcare.

Monday, October 21st 2013

The Fourth Year of Medical School Is Unnecessary

Several schools around the country are offering trails of doing medical school in three years, instead of four.

In general medical school consists of two years of true lectures (or increasingly didactics) focused on the rote learning of the science – anatomy and biochemistry and physiology and pathology and pharmacology and the like. This is followed by a year of core clinical rotations in hospitals and clinics. And then, finally, a fourth year of largely elective clinical rotations and considerable time off.

It is that fourth year that is the most questionably necessary. There’s some benefit to considerable elective time to be sure. It is difficult to get a feel for all the specialties of medicine in your short medical school career. And yet, based on a limited view you decide what you want to specialize in in residency. Might I have been more interested in internal medicine if I had gotten a feel for cardiology or heme/onc or have been more interested in radiation oncology or in opthalmology or radiology if I had more than the vaguest sense of those specialties?

The answer might be in continuing to allow some elective time by compressing the classroom time at the beginning of medical school. Several schools already do away with break time in the first two years of medical school and compress the basic sciences into 18 months without losing anything I think.

The fourth year of medical school has a limited contribution to training adequate physicians. It is considered an easy year, a break and reward for the past three. But it isn’t like you’re paying less to attend school in that year. Or that you’re getting any younger in your journey to being a physician. As said, there’s some benefit to the electives you get to do early in your fourth year. But those can probably be preserved somewhat by reducing your time in the classroom.

I think these trail programs of cutting medical school to three years are going to be largely successful and you’re going to see three year medical schools grow enormously over the next generation. It might even be the new norm in my lifetime.

Saturday, October 19th 2013

Missing Patients

I’ve never heard of anything like what happened at San Francisco General Hospital. Very tragic and very strange.

Family and friends of a patient who disappeared from her room only to be found dead in a hospital stairwell more than two weeks later demanded answers from authorities and medical officials, who said they, too, were horrified at what happened to Lynne Spalding.

“We need to know what Lynne’s condition was. We need to know what she was being treated for and frankly we need to know what medications she was on and what state of mind she was in,” Spalding’s friend and family spokesman David Perry said


Spalding had been missing for 17 days before she was found on Tuesday in a fourth-floor stairwell during a routine check. San Francisco General Hospital Chief Operating Officer Roland Pickens told the San Francisco Chronicle the stairwell was several hundred feet from the unit where Spalding was being treated.


Spalding was taken to the hospital because she had lost weight and appeared disoriented and weak, and her family and friends were concerned about her physical state. She was admitted for a bladder or urinary tract infection on Sept. 19 and was reported missing from her room two days later.

Spalding’s relatives and friends spent days “scouring the streets of San Francisco with fliers because we were under the assumption that San Francisco General had been searched and Lynne was not here,” Perry said at a news conference at the hospital.

Sunday, October 13th 2013

The Time We Spend With Patient’s Isn’t A Disaster

A month ago an article in the Annals of Internal Medicine looked at the work day of medicine doctors in training. In the study medical interns were spending just 12% of their time with patients. The rest of the time was spent charting or entering orders or talking to other doctors or in didactics or in other non-direct patient care activities. Back in 1989 interns spent 20% of their time with patients.

The finding drew commentary from, amongst other online sources, Medrants and Dr. Pullen republished at Kevin, MD.

Decreased time with patients isn’t a good thing, but it is hardly a disaster. The smaller time with patients represents increased non-direct patient care requirements, such as documentation, as well as decreased reliance on the physical exam and patient history.

I’m going to argue that the history and physical exam have long been overvalued and the loss of focus on such, which is both a cause and consequence of the fact physicians spend less time with patients, cost nothing in terms of quality of care. Many aspects of the history and physical exam have remarkably poor reliability and reproducibility.

From Evidence Based Physical Diagnosis,

We can debate what represents good, rather than a poor, reproducibility on the margins but can probably all agree when interexaminer agreement on whether a pleural rub is present, when listening to a patient’s chest, is worse than chance that taking the time to auscultate for such a finding may hold little value. Similarly when the neurological examination of diabetics’ distal lower extremities shows that,

The interobserver reproducibility of the physical signs was moderate to poor

Or when clinicians can’t identify an S3 or S4 heart sound,

The overall interobserver agreement for the detection of either S4 or S3 was little better than chance alone

It is easy to imagine how nuanced physical exam findings (or lack thereof) could differ from one physician to another. Perhaps more surprisingly is of how little value the patient history has in some studies. In one study of a patient presenting with a stroke, neurologists asked to assess whether the patient had had a previously undiagnosed transient ischemic attack based on history alone achieved a kappa value of only 0.19.

Not to be dismissive completely of the physical exam and history. I’m not advocating a physician sitting as a computer and deciding the plan of care solely off what they read there. But in a world with ever improving diagnostic studies we shouldn’t bemoan the fact that the threshold has lowered for obtaining and relying on such. You still order such based on an initial exam and history but chide an order for a chest x-ray based on a history of suspicious sounding chest pain with only a limited physical exam. What does doing “A-to-E” or percussing add to the plan of care when the reliability of such results may be very low?

Nor is this a new phenomena. Many of the critical studies date to when the oldest commenting now would’ve been in training. The anecdote of the great clinician making reliable, consistent diagnoses off physical exam and history alone even in the most complex of cases is just that. The truth is, even if at greater cost, with the tools available today the current average clinician is a much better diagnostician than the average clinician of whatever yesteryear you want to cite.

Not that tests are perfect. Look at the interobserver kappa values for the various methods of diagnosing an intraarticular calcaneal fracture on x-ray. There are two things we can say about studies however. First, as the disease gets more “severe,” the reliability gets much better. That’s not something you can say in the studies, about something like a pleural rub.

For worst fracture grade we found good intraobserver (76–88%) and interobserver (74–88%) agreement, and excellent reliability with square-weighted kappa’s of 0.84–0.90 (intraobserver) and 0.84–0.94 (interobserver).

And, perhaps more importantly, as technology and computers get better, the reliability is improving.

Here’s what Dr. Watcher has to say on the time we spend with patients and the physical exam and history,

Even if we could create a new generation of expert physical examiners, would it be worth the time and trouble? I doubt it. When I was a medical student, I spent a couple of months at London’s Brompton Hospital, the UK’s premier lung disease specialty hospital. Brompton physicians lavished attention on the chest exam – elegantly listening for whispered pectoriloquy and egophany, percussing for dullness, and palpating for asymmetric chest excursions. Such exams often took 10 minutes. Ever the spoil-sport, around Minute 8, I found myself wondering why we just didn’t get a chest radiograph. Not because the ritual wasn’t engrossing – and yes, even “magical” at times – but because at some point, all of this elegance has to be weighed against cold-hearted considerations of accuracy, reliability, inter-observer consistency, and the cost of time.


In my zeal to bring physicians back into the patient’s room, I’d place 20% of the emphasis on performing and interpreting a good, thorough physical examination, and 80% on teaching and promoting superb communication skills…describing prognosis, discussing alternative treatments, determining the patient’s attitudes about end of life care, and apologizing for medical errors, to cite but a few examples. These are teachable skills that will never go out of style, skills whose value won’t be supplanted by PET scan results and graphs of trended ANCA levels. And, to me at least, they highlight the patient-as-person and physician-as-humanist more than sticking a tuning fork on a forehead ever could.

And I agree, if there’s a reason to bemoan a lack of patient contact it is such.

What’s odd however is that it’s my impression that such communication is not something physicians have ever been particularly good at. Even in a past where time with patients was more robust it seems, at least in tales, that paternalism hampered things like discussing treatment options or prognosis or end of life care. We continue, even in the era of patient empowerment, to perform such poorly in my experience. Communicating risks and complex treatment options is time consuming and a difficult skill and one that is poorly taught. But I’m not sure it was done better when the time spent with patients was more.

12% of your time with patients may be enough. It itself isn’t necessarily a disaster. Maybe we just need to focus on the important things more and stop beating the nuances of unreliable skills that are of ever decreasing importance into trainees.

Saturday, October 12th 2013

More Undergraduate Medical Education For Texas

I went on a rant a while ago about the University of Texas system promising two new medical schools. One for Austin and one for the Rio Grande Valley.

[P]lenty of money will come from state general revenue afforded to the university systems. That is money from tax payers across the state who are likely to see no to nominal benefit from these new schools.

New medical schools in Texas are unlikely to improve our statewide physician shortage and may even do little to correct disparities in the communities they’re joining. We’re already graduating enough medical students and in a strong position to continue to do so for our growing population without new medical campuses. The schools will bring new graduate medical education funding, in the form of new Medicare dollars, but such will not keep pace with the new medical school graduates they promise. The costs of these new medical schools would be much better put towards improving graduate medical education in the state. That is something that would truly improve Texas’ doctor shortage and potentially the public’s health.

IN 2011 Texas’ had 2.36 medical school seats per 10000 population. That was 10th in the nation. Since then the state has opened a new public medical school in El Paso, expanded the class size of every existing medical school in addition to the two new University of Texas schools currently in planning.

Now, my hometown, San Antonio, is looking to get a new school of osteopathic medicine.

The City Council voted unanimously Thursday to approve a $7.7 million funding agreement for infrastructure improvements and job incentives, some of which will literally help pave the way for the University of the Incarnate Word to build an osteopathic medical school in downtown San Antonio.

With too few GME spots this will do nothing to help the physician shortage in Texas or San Antonio and is likely to have little impact on health in the surrounding community. Of course it has some economic and prestige effects but there should be more skepticism about the long term goals of such a school. Even more so in terms of the choice of an osteopathic focus.

Tuesday, April 30th 2013

Do “Better” Residencies Mean Better Physicians?

I’m not sure I believe that safety data from primary teaching sites for residencies can play large in informing medical students on the residencies they should choose.

[T]he most prestigious hospitals are not necessarily the ones teaching the most compassionate or even the safest care. Looking at how patients are treated in the last six months of life might seem like an odd way to compare hospitals, much less residency programs, but its actually a good measure of the kind of doctors residents will learn to be, and it speaks to broader aspects of the training program. Looking at these patterns of care can help medical students find the best residency programs for them — even if they’re not necessarily the “best” programs.

Wednesday, April 24th 2013

Work Restrictions Mean Overworking

Dr. Pauline Chen (always worth a read in the New York Times) has a take on why the most recent ACGME work hour restrictions for residents have been largely a failure.

“Fatigue is bad, but overwork is worse,” said Dr. Lara Goitein, lead author of a recently published editorial in JAMA Internal Medicine and a pulmonary and critical care physician at Christus St. Vincent Regional Medical Center in Santa Fe, N.M.


Health care trends over the last two decades have only exacerbated young doctors’ workload. Admissions to teaching hospitals increased nearly 50 percent from 1990 to 2010; in that same period, the number of doctors in training available to do the work increased by only 10 percent. And because insurers are pushing for shorter hospital stays, only the sickest patients, many of whom require complex care, remain hospitalized.

Are residents nowadays really expected to do more than those decades ago even if they’re technically working less? Maybe the stories of those before me trekking up hill both ways in the snow to save lives are something else. Then again, I am finding time to write this blog post.