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Archive for the ‘Medical Education’ Category

Wednesday, January 9th 2013

Do Nothing

I’ve been reminded recently how much of medicine is watch and wait. I’ve been reminded of it in the context of being on call and cross cover. When I’m not on service but I’m taking overnight call I think I probably do less fiddling and tampering with patient’s care than when I’m on service and seeing the same patients day in and day out. Getting along in training also probably predisposes me to such inactivity.

And I’m not sure that’s a bad thing.

As every resident, I get a lot of phone calls from nurses when I’m on call in house. A lot of it is tedious and just things to be taken care of from afar, such as the day team didn’t reorder restraints, and a lot of it is just unnecessary, such as the patient doesn’t have an incentive spirometer at the bedside at 2am, and a little bit of it deserves undivided attention and action, such as the patient has had a legitimate neurological status change, but some of it is just stuff that just raises a shrug. Examples from my last call include the fact that a patient’s urine output was only 20cc for an hour but their pressures were fine, that a lumbar lumbar drain hadn’t drained anything for the last hour but was tidaling, that a patient threw up once but already had prn antiemetics available, that a patient with a monitored head injury and concurrent ARDS and maxed ventilator settings on his current mode had a stable but less than ideal pCO2 of 44.

Thanks for the update, I guess, let’s just watch and see what happens over the next hour or two or three.

Behold the issues turn out not to be issues at all. The patient puts out plenty of urine over the next hour, the lumbar drain starts draining over the next two hours, the patient doesn’t vomit again, the patient’s pCO2 stays stable and he has no intracranial hypertension issues.

Maybe it is just a matter of better triage, teaching patience to those at the bedside. Then again, even if the phone call was after the still tidaling lumbar drain hadn’t drained anything in three hours my solution might still be to just stare at it. It seems to work. I guess helping the triage process and separating the wheat from the chaff and knowing when to just shrug and watch is just part of being a resident; maybe a physician in general.

Monday, January 7th 2013

Foreign Medical Students In Texas

It is a medical education themed day as I return to blogging after a month off.

We’re potentially awaiting this month a ruling from the Texas Higher Education Coordinating Board on January 24th whether medical students at the for profit American University of the Caribbean can do clinical clerkships during their third and fourth years in Texas hospitals. This ruling following the Attorney’s General office giving an opinion that THECB does have the authority to grant or deny AUC’s request.

To be clear, this wouldn’t require hospitals to take these students but if the THECB rules in AUC’s favor it would allow the university to negotiate with hospitals in the state to allow their medical students to come through. Considering the money AUC is likely flash to secure spots for their students it is almost a forgone conclusion there will be a number of opportunities for their students in Texas.

I’ve written previously about growing opposition to foreign medical students rotating in the United States in states that already allow such. And there is much opposition amongst Texas medical schools and organized medicine and legislators.

Texas medical schools, charged with increasing enrollment to meet the state’s physician shortage, are already “starting to stumble over each other” finding their students the right clerkships, said Dr. Cynthia Jumper, who heads the Texas Medical Association’s medical education council and chairs the internal medicine department at Texas Tech University Health Sciences Center. While there may be a few extra positions available now, Jumper said, there won’t be for long. 
“What extra room there is now has already been spoken for,” she said.

Senate Higher Education Chairwoman Judith Zaffirini, D-Laredo, also voiced opposition. In a letter to Fred Heldenfels, the chairman of the coordinating board, she said approving AUC’s request would set a precedent opening the door to a slew of foreign schools, and she questioned the board’s authority to approve private professional programs. “May God bless you and inspire you to agree with my perspective,” she wrote.

It isn’t merely a matter of physical capacity, in the sense of how many medical students Texas hospitals can support. There is a limiting factor in that Texas medical students cannot, for all practical purposes, rotate on the same teams within hospital that AUC foreign medical students are on. Examples exist of citations from the Liaison Committee on Medical Education, the body that accredits all allopathic U.S. medical schools, for mixing of LCME and non-LCME medical students on clinical rotations. A summary of the accredidations standards of the LCME can be found here (PDF).

Personally, I hope to keep foreign medical students out of Texas hospitals. That may be a little bit of a surprising stance from me. I think, however, that the primary concern here should be in protecting the education of Texas’ own medical students, which the state already has significant investment in. I think foreign medical students taking up clinical clerkships in Texas hospitals may put that at risk.

Monday, January 7th 2013

Osteopathic and Allopathic Education in Texas

Osteopathy has an interesting history in the United States. Unlike other ‘opathies’ and rejections or alterations of allopathic medicine which arose in the eighteenth and nineteenth centuries, the history of Dr. Andrew Still’s treatment philosophy, is remarkable in the turn it took back towards biomedical principles and how leaders of osteopathic medicine in the twentieth century fought allopaths and the entrenched medical community to broaden their scope of practice until today when a D.O. degree is an equivalent of an M.D. degree anywhere in the United States.

I’ll ignore whatever debate remains over the benefits of osteopathy and manipulative medicine. Largely because the founding principles of osteopathy are largely nowhere to be found in the everday practices of doctors of osteopathic medicine. Very few D.O.s use manipulative medicine in their practices. And while there are some other distinctions between allopathic and osteopathic medical education in the United States, such continue to shrink. There has been a gradual infolding of osteopathy back into allopathic medicine; an irony of the fact osteopathic leaders at the beginning of this century worked so hard to be accepted by their counterparts in medicine. Nearly 70% of graduates, or perhaps more nowadays, of osteopathic medical schools do residencies sponsored by institutions focused on allopathic education.

No wonder there are irregular questions about the continued necessity of osteopathic medical education. From a 1993 article in the Journal of the American Osteopathic Association,

[T]hese changes…raise a number of disturbing questions for the profession. Foremost is the continued existence of or a need for osteopathic medicine in our society. Why should the United States support parallel medical systems on the assumption that osteopathic medicine is different when, after graduation, most DOs choose to train in the allopathic medical profession?

It’s a legitimate question, still being played out even twenty years after that article. On the one hand the number of osteopathic graduates, as all medical schools, continues to grow and new osteopathic medical schools continue to open. I’m not sure that hints at some unfilled need for osteopathy as it remains most of those graduates will largely shun such in their real world practice. And, on the other hand, slowly schools of osteopathic medicine are looking to award doctors of medicine in addition to, or as replacements of, their current doctor of osteopathic medicine degrees.

Such is the case at the school of osteopathic medicine in Texas. Several years in the works, and somewhat of a political nightmare to this point, the University of North Texas’ Health Science Center Texas College of Medicine is likely to have a bill introduced in the next legislative session to allow the school to offer an M.D. degree. So focused were some at the school on approval for an allopathic track that it created discord over a parallel move to merge the health science center with the University of North Texas at large.

Merger talk became a distraction, with questions raised about whether one effort hinged on the other or one would take precedence over the other.

When the merger issue came before the regents again in November, it was taken off the agenda. Jackson said it’s been tabled indefinitely.

Any change to the governing structure of the Fort Worth and Denton campuses would require approval from the Legislature, governor and Texas Higher Education Coordinating Board.

With the 2013 session starting Jan. 8, [UNT Chancellor] Jackson said

The president of the health science center seems to have voiced such a belief – that asking the legislature for the merger at the same time as asking them to approve the M.D. degree would be a distraction and reduce the chances of approval for the M.D. degree – in his contentious opposition to the merger. Such opposition eventually cost him his job last month.

Seeking permission for the M.D. degree I think heightens the question of purpose that continues to surround osteopathic medicine.

The D.O.s I know are largely excellent physicians. There is nothing in their education that distinguishes them. I also don’t personally know a single D.O. who has ever let it be known to me they routinely use something unique to osteopathy in their everyday practice. I’m not sure why then we continue to pay lip service to osteopathy and to distinguish ostoepaths and allopaths by the letters after their names. Maybe its time we were just all the same. Maybe if UNTHSC wants an M.D. degree for TCOM, then that should also be the end of its D.O. degree.

Friday, October 19th 2012

Game Theory Got Residents To Where They Are Today

The National Residency Matching Program is a process almost all medical residents go through. Since 1952 the program has strived to match graduating medical students to residency training programs. Medical students are offered interviews at a number of residency programs. The medical students then rank all the residency programs they interviewed at in terms of preference, while the residency programs do the same for all the medical students they interviewed.

The algorithm the NRMP then uses to match medical students with residency programs isn’t terribly complicated to understand, but I’m sure the math behind it and proving its efficiency were.

Now two American economists whose work centered on such matching algorithms and game theory have won the 2012 Noble Prize for Economics. As the NRMP website itself describes the contributions of Lloyd Shapley and Alvin Roth,

Shapley and his colleague, David Gale, developed the “stable marriage” algorithm in which men and women rank each other as potential mates and a series of offer rounds produces a best match. The Gale-Shapley algorithm is the basis of the matching algorithm used by the NRMP, and Roth worked with NRMP to adapt it so that it proposes matches on the basis of the applicant rather than the program rank order lists.

While others built off Dr. Shapley’s work for the debut in 1952, Dr. Roth worked directly with the NRMP in the 1990s to tweak the match, especially as it related to match married couples.

For the fourth year medical students going through interviews for residency right now and the match, just remember however frustrating the process is it was complicated enough to warrant a Noble Prize. So, some respect.

Wednesday, October 3rd 2012

Why The Stigmata of Social Media Will Be Brief

To be honest I can’t even recall everything I’ve ever posted about on this blog but it would not surprise me if there is something amongst the archives that I someday regret. Maybe this blog and my Twitter account and some Facebook photo will keep me from becoming President. We’ve heard the refrain before that indiscriminate social media use will come back to bite my generation and the ones behind me. There’s some truth to it for sure, but only a touch the bombardement and the focus on such overplays it and shows a level of naivete amongst the “experts.” A laughable title considering the youth and evolving technology of this field.

Well, here is geneticist Juan Enriquez making the familiar argument,

“What if you’re at a bar and people can pull up you Facebook, Twitter, Google searches, your academic citations and all of your other electronic tattoos,” he said.

“You’re no longer just that good looking guy or girl.

“All the tattoos on this person are a lot more explicit than the ones hidden under your underwear.”

Dr Enriquez said that humanity is being challenged – and potentially threatened – with digital immortality.

But my argument is that, the fact such information is readily available will vastly change how our children judge each other based on it. It is going to change social norms. In fact, let me propose that these changes will be relatively dramatic and quick; we’ll see it before out children come of age actually.

Don’t get me wrong, you can get in trouble with social media use. But the apocalypse is not coming and the ways social medial changes our behavior and judgements and prospects will be largely positive, not negative. Dr. Enriquez and others need to calm down.

Saturday, September 29th 2012

How Many Medical Schools Does Texas Need?

The state of Texas is very close to opening two new free standing medical schools. One in the Rio Grande Valley and one in Austin. While still hurdles to jump through for these two new schools they look to be part of Texas’ relatively rapid expansion in undergraduate medical education capacity. In the past two decades Texas has seen both new schools and an aggressive expansion of the capacity of its current schools. But such is of questionable necessity. Below is data from 2006 U.S. Census Bureau estimates of state populations and 2006 AAMC medical school enrollment numbers for public medical schools.

State 2006 Public Medical School Enrollment 2006 Estimated Population Public Medical School Seats Per 10000 Population
Alabama 971 4599030 2.11
Arkansas 605 2810872 2.15
Arizona 492 6166318 0.79
California 2899 35457549 0.79
Colorado 611 4753377 1.28
Connecticut 346 3504809 0.98
Florida 1283 18089888 0.71
Georgia 749 9363941 0.8
Hawaii 255 1285498 1.98
Iowa 630 2982085 2.11
Illinois 1722 12831970 1.34
Indiana 1164 6313520 1.84
Kansas 703 2764075 2.54
Kentucky 1026 4206074 2.44
Louisiana 1122 4287768 2.61
Massachusetts 450 6437193 0.7
Maryland 650 5615727 1.15
Michigan 2363 10095643 2.34
Minnesota 924 5167101 1.79
Missouri 767 5842713 1.31
Mississippi 427 2910540 1.47
North Carolina 1024 8856505 1.15
North Dakota 246 635867 3.87
Nebraska 491 1768331 2.78
New Jersey 1402 8724560 1.6
New Mexico 329 1954599 1.68
Nevada 218 2495529 0.87
New York 2480 19306183 1.28
Ohio 3908 11478006 3.4
Oklahoma 617 3579212 1.72
Oregon 516 3700758 1.39
Pennsylvania 1236 12440621 0.99
South Carolina 931 4321429 2.15
South Dakota 207 781919 2.64
Tennessee 861 6038803 1.42
Texas 5243 23507783 2.23
Utah 429 2550063 1.68
Virginia 1803 7642884 2.35
Vermont 426 1945482 2.2
Washington 805 9047320 0.89
Wisconsin 664 5556506 1.19
West Virginia 663 1818470 3.64

Texas public medical school numbers include Baylor College of Medicine which recieves some public funding in return for giving preference to Texas residents.
Washington’s population includes Alaska, Idaho, Montana and Wyoming. Residents of those states receive preferential admission to the University of Washington School of Medicine.
Vermont’s population includes Maine. Residents of that state receive preferential admission to the University of Vermont.

While Texas does not top the list in per capita public medical school seats it isn’t far behind.

    States With Most Per Capita Medical School Seats
    1. North Dakota
    2. West Virginia
    3. Ohio
    4. Nebraska
    5. South Dakota
    6. Louisiana
    7. Kentucky
    8. Virginia
    9. Michigan
    10. Texas

It is slightly disingenuous to compare a state like Texas with smaller states on the list above including Nebraska, South Dakota, North Dakota and West Virginia. There are considerable relatively flat infrastructure costs to running an institution like a medical school. If those states with small populations are going to make a commitment to public undergraduate medical education it is nothing to say they’re going to enroll 200 students instead of 30, and so of course their per capita rates will be higher. In light of that Texas’ per capita numbers are even more favorable.

Texas has the most public medical school students in the country and, perhaps more importantly, the most public medical school campuses in the country. While I don’t have the data, with so many freestanding health science campuses and so many medical students it would not surprise me if Texas already spent more on public undergraduate medical education than any state in the union. And while Texas population continues to grow so has the number of medical students enrolling in the state with every medical school increasing its class size since 2006 and a new medical campus opening in El Paso since the data above.

In 2011 the growth in medical school enrollment in Texas had more than kept up with Texas’ impressive population growth and left the state with 2.36 medical school seats per 10000 population. The new slots in the Rio Grande Valley and Austin promise to continue that trend and boost Texas’ per capita numbers higher. I would argue that while we need to prepare our undergraduate medical education capacity to keep pace with our growing population, that the number of current graduates, even for the foreseeable future, is completely adequate for the health care needs of Texas.

The more substantial problem may be in training these medical students after they graduate. The 2010 medical school graduating class in Texas had 1404 medical students competing for 1390 first year resident positions. Nearly half of Texas medical school graduates, their education subsidized considerably with Texas tax payer dollars, leave the state for residency and are unlikely to return. Texas’ contribution to graduate medical education is abysmal as compared to many other states. From the Houston Chronicle article linked to above,

[T]he state’s coffers are a relatively small part of funding — $79 million was allotted last session. The lion’s share comes from Medicare, which is, if anything, in potentially worse shape than Texas.

Unlike many states the medicaid program provides no direct graduate medical education funding in Texas.

There are many arguable benefits of medical campuses. They bring a likely economic benefit to the local economy and they promote prestige and contribute to the local academic community. They also likely help promote community health. But their primary mission, indisputably, is education and undergraduate medical education is not something we need more of in Texas. The press for these medical schools represents local politics and activity within the university system they are poised to be a part of; egos from Austin and the Rio Grande Valley looking at these campuses as a matter of benefit for their local communities.

[T]o hear [state Senator Kirk Watson] speak these days, nothing is more important — and, perhaps, more career-defining — than establishing a medical school at the University of Texas, as well as a new teaching hospital, comprehensive cancer-care center and other elements of what supporters call “Watson’s 10 in 10” — 10 health care goals to achieve in 10 years.

“We have so many good people ready to do it that success is immensely possible, and to not do it and not get started on the path would be extraordinarily regrettable,” Watson said last fall. “This is big. It’s going to be hard. But it needs to be done.”

Some of the costs of these academic healthcare endeavors will be borne by these communities – Travis county’s health district is asking voters in November for a property tax increase – but plenty 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.

Wednesday, September 26th 2012

Lost In The Monotony

Residency is a period of survival, even in the age of duty hour restrictions. It is a period of sometimes putting your head down and going one day to the next which, can often, run together. And depending on how the call schedule comes together it can be difficult to recall fully your responsibilities. Am I on call today or tomorrow? This weekend? So I know I’m not alone in showing up to one of the hospitals we cover yesterday promptly at 4 pm to take overnight call and realizing to my embarrassment that I was 24 hours early.

Once when I was a medical student doing a general surgery rotation I stayed overnight for “call” and then went home in the morning at about 10am. I quickly fell asleep. I woke up to the sun on the horizon from my bedroom window and a bedside clock that read “7.” I jumped up, forwent a shower and raced to the hospital. Out of breath, at the end of the stairs I found the team’s work room empty. Frantically I dialed my fellow medical student on the service to ask her if the team was already on the floors rounding only to learn she was at home making dinner and I was twelve hours early. I had mistaken 7 pm for 7 am. That truly would’ve been a feat to sleep 20 hours straight instead of the actual 8 hour nap I had pulled.

Shift work does this to you I suppose.

Wednesday, September 5th 2012

Not Even All Physicians Understand Acuity Apparently

I’ve written about trying to communicate acuity to families. Maybe that needs to be expanded to encompass the same to other physicians.

To be fair I’m sure some of this, perhaps much of it, rests solely on my shoulders. Recognizing that I’m still going to make an accusation that talking life and death with families and patients is a skill not fostered in many providers. More accurately for this anecdote, and importantly for the care of patients, some physicians flat out fail to recognize the necessity of such discussions and decisions by families.

A while back I saw in consult a young man with a subdural hematoma who had been found down at home after days unseen. He was young but it was a serious injury that had, presumably, persisted unmitigated for some time, likely on the order of > 24 hours. It was not an unreasonable question about how the parents would want to proceed. And while I can’t offer quotation marks this is near verbatim from the consulting physician:

- I don’t think you can blame a parent for not wanting to make a life or death decision about their child on the spur of the moment
- I don’t think a family’s decision has any bearing on triage

These comments came as they got more and more frustrated with my lack of transfer orders while I had lengthy conversations with the family and awaited their decision on whether to proceed with surgery or not. The argument was that I should transfer the patient to the neurosurgical service and the family could then take their time deciding on whether to proceed with surgery or not. My argument was that if the family elected for end of life care there was no need for transfer.

To be fair I’ve changed the story considerably, for obvious reasons, but attest fully that those consulting physician comments are essentially synonymous with the actual quotes. I don’t feel comfortable adding the quotation marks lest I transcribed a word here or there. I’ve left out my own parts of the conversation that prompted those remarks, and thus considerable context. But I would argue there is no context you can give those comments where they are not incredibly naive. Everyday physicians throughout the hospital ask families to make spur of the moment life and death decisions. Everyday a family makes a decision for or against a laparotomy in an unstable trauma patient or a craniectomy in a patient with a head injury. And the decision is, often, to go now or not at all. This story doesn’t completely reflect that urgency but the principle remains. It was at that moment that the surgery offered maximal benefit. There’s no decision to wait until tomorrow or the next day, it is now or we discuss other options such as maximal medical care or end of life care.

The discussion with families obviously lacks that crassness but, as I’ve discussed previously, frankness is not always a bad thing. In a very empathetic way the family needs to be aware that they need to make a quick decision. And so for a consulting physician to hold it against me that I was awaiting a family’s life or death decision before proceeding seemed surreal and disconnected. It still does. It is hard to imagine a physician so removed from the reality of acute care in a large county hospital. It is hard to imagine a physician who would hold in so low regard a family’s wishes in determining the next step in care.

I think that this particular conversation was the most remarkable I’ve ever had with another physician concerning patient care. Maybe my incredulousness is misplaced. With admittedly only half of essentially a made up story, my side, at your disposal let me know in the comments if you think I’m way off base.

Tuesday, September 4th 2012

Automating Healthcare

In 1982 Vinod Kholsa was one of the four founding fathers of Sun Microsystems. Since he’s been a major player in the Silicon Valley venture capital community. So, there was some noise made when a man of that stature, at the Health Innovation Summitt in San Francisco last week, said that “80% of doctors can be replaced by machines.”

Let me just say I’m an optimistic futurist and I think that no human endeavor is immune from automation. Whether we dismiss them I’m sure in my lifetime a computer written novel and song will, by any objective measure, be masterpieces. Economic and human capital issues and consumer comfort aside, cab drivers and airline pilots and even physicians are largely replaceable by machines. While his 80% figure might be high, or maybe not, I don’t think there is anything remarkable about Vinod Kholsa’s basic premise that in interpretation of tests, even radiographs, diagnosis and prescription of treatment computers will be better than man. I think surgeons and proceduralists are safer for a while.

But there’s more to health care than treatment. As Dr. David Liu points out over at The Health Care Blog,

Health and medical care is an incredible intersection of technology, science, emotions, and human imperfections in both providing care and comfort.


There are some things that may never be codified or driven into algorthims. Call it a doctor’s experience, intuition, and therapeutic touch and listening. If start-ups can clear the obstacles and restore the timeless doctor-patient relationship and human connection, then perhaps the future of health care is bright after all.

Consider the reversal of the trend of self checkouts at supermarkets.

“It’s just more interactive,” Wearne said during a recent shopping trip at Manchester’s Big Y Foods. “You get someone who says hello; you get a person to talk to if there’s a problem.”

It’s difficult to imagine a quick embrace, if ever, of a health care system devoid of the human touch. You might indeed someday soon have better care offered by a machine, but primarily the human element, the comfort of the patient, is going to prevent Vinod Kholsa’s dream from coming to fruition in any sort of timely fashion…even if the technology allows for it.

Thursday, July 19th 2012

I Love My Pager

As long as I’m a resident and I’m not serviced by a call center I will love my pager. I say this despite my love of all things tech.

And apparently I’m becoming slightly anachronistic.

Doctors don’t want to carry a pager anymore. They want to carry their iPhone or their Android device.

The quote above comes from Brian Edds, for Ancome Software, in an NPR story titled ‘Are Pagers Obsolete?’. So many I’m out in the minority, but I want my pager. I’ll be brutally honest about why but I don’t want people to be able to reach me on a whim. At least not while I’m a resident. I’ve written before about the abuse of communication with resident physicians. About how matters are triaged ineffectively at academic centers, partly I suspect, because it seems as less of a faux pas to call a resident, as say, a ‘real’ doctor out in the private world.

As such, I don’t want my phone ringing while on call. I return my pages timely but I want that barrier wherein I have to return the call. That barrier where I can triage the calls myself. A text page about a missing home medication can wait until I’m done with a procedure, a page from the ER may need more immediate scrutiny. A phone call takes away some of that discretion. And until the amount of frivolity goes down, until I’m out in the world practicing and deciding the systems in which I’ll practice, I want my pager.