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Archive for the ‘Residency’ Category

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.

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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.

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.

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.

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.