Pauline Chen had a post in the Times last week about surgical informed consent. Informed consent is an important part of the surgeon/patient communication transaction. Surgeon reviews the proposed operation, the rationale behind it, and the possible complications. For example--- a patient comes in with biliary colic. We describe the anatomy and pathology. We aver that surgical resection will lead to cure. The operation (laparoscopic cholecystectomy) is described in detail. Potential complications are addressed (bile leak, CBD injury, bleeding, infections, cardiopulmonary morbidity, etc.) Patient is informed that although complication rates are low, there is still a statistical probability that her procedure will encounter such problems. Given all this information, patient then decides what she ultimately wants to do. Informed consent.
Dr. Chen talks about this concept called "surgical buy-in" where the patient is prepared for worst case scenarios prior to the operation. When a case goes bad, we surgeons have a tendency to implement the full court press, whereby we try anything and everything to get our patients back on course, even when the situation begins to look futile. It's our ingrained sense of responsibility and duty to try to reverse the deterioration. But sometimes these last gasp maneuvers are not what the patient would have wanted.
There's an article in Critical Care Medicine from March that talks about this buy in. For complex elective operations (Whipples, liver resections, transplants, rectal surgery) surgeons would negotiate with patients prior to the surgery the extent to which both the surgeon and the patient were willing to labor if things took a turn for the worse. In other words, the surgeon would say something along the lines of: "If you leak from your pancreaticojejunostomy and get septic would you be willing to be reintubated? Taken back for revision? If you were unable to be weaned, would you consider a tracheostomy? What about CPR? Is there a time limit you would restrict aggressive intervention to, i.e. if you weren't improving by 6-8 weeks of intensive therapy, then palliative measures would be undertaken?"
It's a great idea. As long as we restrict the protocol to those complex operations. I'd hate to put my patients through such a terrifying question and answer session prior to a lipoma excision or a breast biopsy.
Sunday, October 17, 2010
Get Rid of the 4th Year of Med School
A poorly kept secret amongst recent med school grads is the fact that the last year of medical school is a complete joke and waste of time. Most 4th years will do rotations in July and August in the specialty they hope to match in, for the purpose of cozying up to attendings for recommendation letters. But after that, it's a 6 month vacation until match day. I did a surgical ICU rotation in July and then followed that up with a stint on cardiothoracic surgery. I spent the rest of the year half assing my way through rotations like radiology, anesthesiology, and pathology case studies. Most days I got to the gym around noon for a 4 hour session of pick up hoops. And oh yeah, I borrowed about $35,000 to finance that lifestyle.
There are two main reasons to reorganize medical school education along the lines of a three year program. One, it's a waste of loan money and squanders a year of earning potential. Two, it just may be a contributing factor in driving more students out of internal medicine, primary care, and general surgery.
Let me explain. If you eliminated the fourth year, students wouldn't have the oportunity to rotate through subspecialties like dermatology and radiology and cardiology and orthopedics. Hence, less chance to be brainwashed into thinking that general medicine and surgery were beneath them. The third year curriculum would expand the exposure to internal medicine and general surgery and family practice. Someone who really really wanted to do a cardiology rotation could do so, but would have to eliminate either OB/gyn or psychiatry. As it is now, the entire fourth year is built around the idea of winning praise from subspecialist academic physicians. Is it any wonder that medical students look down upon the "mere generalist" professions?
There are two main reasons to reorganize medical school education along the lines of a three year program. One, it's a waste of loan money and squanders a year of earning potential. Two, it just may be a contributing factor in driving more students out of internal medicine, primary care, and general surgery.
Let me explain. If you eliminated the fourth year, students wouldn't have the oportunity to rotate through subspecialties like dermatology and radiology and cardiology and orthopedics. Hence, less chance to be brainwashed into thinking that general medicine and surgery were beneath them. The third year curriculum would expand the exposure to internal medicine and general surgery and family practice. Someone who really really wanted to do a cardiology rotation could do so, but would have to eliminate either OB/gyn or psychiatry. As it is now, the entire fourth year is built around the idea of winning praise from subspecialist academic physicians. Is it any wonder that medical students look down upon the "mere generalist" professions?
This story about orthpedic surgeons not disclosing financial ties to the medical device manufacturers in their scientific papers is nothing new. Lack of transparency plagues the medical literature, especially in lucrative, product-driven fields like ortho and cardiology. What struck me were two points.
One, over half of orthopods who accepted over a million dollars from device companies in 2007 did not disclose this information in articles they published in the subsequent year. That's astounding. And illegal according to anti-kickback laws.
The medical device industry's practices were so flagrant that they prompted an investigation by the Justice Department. Indeed, the payments reported in the new study appear in Internet listings set up by five big orthopedic device makers — Zimmer, DePuy Orthopaedics, Biomet, Stryker and Smith & Nephew — as part of a September 2007 settlement that capped a federal inquiry of company kickbacks to doctors. Zimmer, DePuy Orthopaedics, Biomet and Smith & Nephew also paid the government $311 million in penalties.
Secondly, the amount of money is just staggering. The study from Archives of Internal Medicine indicates that 41 orthopods were paid a total of $114 million, with pay outs varying between $1-$8 million to each surgeon. My God, I chose the wrong specialty.
The good news is that there is some law that will go into effect in 2013 whereby a government database will keep track of doctor gifts/payments of more than $10 bucks. So we have that going for us. Which is nice.
One, over half of orthopods who accepted over a million dollars from device companies in 2007 did not disclose this information in articles they published in the subsequent year. That's astounding. And illegal according to anti-kickback laws.
The medical device industry's practices were so flagrant that they prompted an investigation by the Justice Department. Indeed, the payments reported in the new study appear in Internet listings set up by five big orthopedic device makers — Zimmer, DePuy Orthopaedics, Biomet, Stryker and Smith & Nephew — as part of a September 2007 settlement that capped a federal inquiry of company kickbacks to doctors. Zimmer, DePuy Orthopaedics, Biomet and Smith & Nephew also paid the government $311 million in penalties.
Secondly, the amount of money is just staggering. The study from Archives of Internal Medicine indicates that 41 orthopods were paid a total of $114 million, with pay outs varying between $1-$8 million to each surgeon. My God, I chose the wrong specialty.
The good news is that there is some law that will go into effect in 2013 whereby a government database will keep track of doctor gifts/payments of more than $10 bucks. So we have that going for us. Which is nice.
Long hours? Or a long time training?
I’m not a fan of too much work. Over the years, I’ve done my fair share of long shifts, nights, weekends, public holidays, and combinations of all the above.
I don’t function well when I’m tired and hungry and thirsty. And most patients don’t want to be seen by an overworked, sluggish, grumpy doc whose priority is a bed and some food. Certainly, I wouldn’t have wanted any member of my family to have depended on care from me after working 27 hours straight.
I always thought my colleagues agreed with me. Enough miserable faces on the corridors of the various hospitals I’ve worked in made me feel a collective yearning for better conditions.
I thought, therefore, that there would be widespread endorsement of the European Working Time Directive (EWTD) when it came into force in Ireland and the UK. The EWTD is designed to limit the working hours of doctors within the European Union. Depending on the stage of implementation, it can mean working a maximum of 48-56 hours per week.
Of course, here in Australia, they’ve managed to do that without relying on international law. Down under, the rules for doctors’ hours seem to be enforced on a regional basis. In fact, from what I can gather, the rules seem to be MADE locally too. But, by and large, it works. Sure, I’ve been miserable and tired and hungry working in Oz, but I’ve never had to work 72 hours on the trot, let alone do it on a regular basis, as happens in Ireland.
Forgetting for a moment that the Irish government has decided to simply ignore the EWTD, and continue to make their juniors work ridiculously long hours, I was amazed to learn that there are significant groups of doctors in the UK and Ireland who oppose the implementation of the EWTD.
These doctors argue that registrars, like me, and other junior staff, need to be exposed to lots of cases in order to become proficient consultants. They argue that patients come to harm at the hands of tired doctors, but also from inexperienced seniors.
I can see their point. However, I don’t buy it. I can’t accept that dangerously long hours are the only way, especially when urban Australia manages fine without total burnout of their medical staff. There has to be a middle ground.
My take on the long hours culture is as follows:
1) If we juniors want to reduce our hours then we have to expect it to take longer to become consultants. Everything in medicine is being streamlined these days, and that needs to stop. We need to return to 5/6 year medical degrees, and long apprenticeships as house officers and registrars.
2) A lot of doctors' time is taken up doing admin work that anybody could do (chasing xrays, filling out blood forms, chasing blood results on the computer etc). These tasks should become the work of someone else, so that doctors actually spend their time doctoring. I remember as an intern working out that about 60% of my tasks could be done by a competent member of admin staff.
3) Our training is important. But so are our lives outside medicine. I sympathise with the wannabe surgeon who wants to work all hours, learning how to do craniozygomatic surgery. But, there are those of us who have wives, girlfriends, kids, and a family life. I want to be a good consultant. But I doubt I’ll look back from my deathbed and say “I’m glad I worked so much”.
4) Patients need to do more. Relatives, friends, patients and strangers are almost always sympathetic towards me, regarding the plight of junior doctors. But how many have ever raised the issue with a canvassing politician? I don't expect the public to have our interests forefront in their mind at election time. But this is about patient safety, as much as it is about modern day slavery. As things stand, the politicos and the media often betray us as greedy and as a vested interest group, and very little of that gets refuted.
5) We have to be wiling to take industrial action. End of. I would be very reluctant to do so in oz, as my job is busy, but tolerable. But if a pregnant junior doc in Ireland who is working 48 hours solid, with no scheduled breaks, isn't entitled to strike, then who is. the media would love it. They would betray us as lecherous public servants trying to bleed the state dry. The media and politicians would distort the facts to make us look greedy. But screw them. I bet we could hold out longer being abused by tabloid readers then they could hold out with no doctors. Obviously, I would never advocate withdrawing acute services. But a work-to-rule or skeleton staffing would cause some browning of pants in the corridors of power.
The Australians do a good job of it (well, in the cities they do, their rural healthcare provision can be pretty piss poor). Ireland and the UK should learn from them. Mostly we’re rostered on for a 38 hour week. We do on-call and out of hours, of course. But those shifts tend to be interspersed with good weeks, where we can catch up with friends and family This is not the case in Ireland and the UK.
I know from experience that some Ozzies will post comments here telling me that they work terrible hours too. And of course that can be true. I once did a paeds emergency medicine job here where my partner was getting seriously worried about my health. I was literally exhausted all the time. I was grumpy, and never seemed to have any joy in my life. That’s not the way to live. And it’s not the frame of mind I want the doctor in when I bring my sick kid to see them.
I know everyone is an expert when it comes to public sector reform. Just look at the comments section of any newspaper article or blog on the issue. So I’ll keep my ideas about system change to myself. But Ireland, the UK and Australia need to wake up to this issue. More complex issues have been dealt with in the history of mankind.
All three countries have started the process of saturating us with medical school graduates. In Ireland and Australia especially, every man and his dog can become a doctor. Of course, there hasn’t been a sufficient expansion in the number of hospital training posts to cope with all these new graduates.
That will have the desired effect of making our young doctors accept crappy conditions, as it’s likely to be the only route to a scarce training post.
Perfect solution, if you’re an administrator or politician. Tough luck if you’re a doctor or patient.
Sadly, doing anything about it is a catch 22 situation. There are those who have tried. But what’s the most common response when you ask local juniors to engage on this issue, and stand up for their rights? Yep, you guessed it....”S
I don’t function well when I’m tired and hungry and thirsty. And most patients don’t want to be seen by an overworked, sluggish, grumpy doc whose priority is a bed and some food. Certainly, I wouldn’t have wanted any member of my family to have depended on care from me after working 27 hours straight.
I always thought my colleagues agreed with me. Enough miserable faces on the corridors of the various hospitals I’ve worked in made me feel a collective yearning for better conditions.
I thought, therefore, that there would be widespread endorsement of the European Working Time Directive (EWTD) when it came into force in Ireland and the UK. The EWTD is designed to limit the working hours of doctors within the European Union. Depending on the stage of implementation, it can mean working a maximum of 48-56 hours per week.
Of course, here in Australia, they’ve managed to do that without relying on international law. Down under, the rules for doctors’ hours seem to be enforced on a regional basis. In fact, from what I can gather, the rules seem to be MADE locally too. But, by and large, it works. Sure, I’ve been miserable and tired and hungry working in Oz, but I’ve never had to work 72 hours on the trot, let alone do it on a regular basis, as happens in Ireland.
Forgetting for a moment that the Irish government has decided to simply ignore the EWTD, and continue to make their juniors work ridiculously long hours, I was amazed to learn that there are significant groups of doctors in the UK and Ireland who oppose the implementation of the EWTD.
These doctors argue that registrars, like me, and other junior staff, need to be exposed to lots of cases in order to become proficient consultants. They argue that patients come to harm at the hands of tired doctors, but also from inexperienced seniors.
I can see their point. However, I don’t buy it. I can’t accept that dangerously long hours are the only way, especially when urban Australia manages fine without total burnout of their medical staff. There has to be a middle ground.
My take on the long hours culture is as follows:
1) If we juniors want to reduce our hours then we have to expect it to take longer to become consultants. Everything in medicine is being streamlined these days, and that needs to stop. We need to return to 5/6 year medical degrees, and long apprenticeships as house officers and registrars.
2) A lot of doctors' time is taken up doing admin work that anybody could do (chasing xrays, filling out blood forms, chasing blood results on the computer etc). These tasks should become the work of someone else, so that doctors actually spend their time doctoring. I remember as an intern working out that about 60% of my tasks could be done by a competent member of admin staff.
3) Our training is important. But so are our lives outside medicine. I sympathise with the wannabe surgeon who wants to work all hours, learning how to do craniozygomatic surgery. But, there are those of us who have wives, girlfriends, kids, and a family life. I want to be a good consultant. But I doubt I’ll look back from my deathbed and say “I’m glad I worked so much”.
4) Patients need to do more. Relatives, friends, patients and strangers are almost always sympathetic towards me, regarding the plight of junior doctors. But how many have ever raised the issue with a canvassing politician? I don't expect the public to have our interests forefront in their mind at election time. But this is about patient safety, as much as it is about modern day slavery. As things stand, the politicos and the media often betray us as greedy and as a vested interest group, and very little of that gets refuted.
5) We have to be wiling to take industrial action. End of. I would be very reluctant to do so in oz, as my job is busy, but tolerable. But if a pregnant junior doc in Ireland who is working 48 hours solid, with no scheduled breaks, isn't entitled to strike, then who is. the media would love it. They would betray us as lecherous public servants trying to bleed the state dry. The media and politicians would distort the facts to make us look greedy. But screw them. I bet we could hold out longer being abused by tabloid readers then they could hold out with no doctors. Obviously, I would never advocate withdrawing acute services. But a work-to-rule or skeleton staffing would cause some browning of pants in the corridors of power.
The Australians do a good job of it (well, in the cities they do, their rural healthcare provision can be pretty piss poor). Ireland and the UK should learn from them. Mostly we’re rostered on for a 38 hour week. We do on-call and out of hours, of course. But those shifts tend to be interspersed with good weeks, where we can catch up with friends and family This is not the case in Ireland and the UK.
I know from experience that some Ozzies will post comments here telling me that they work terrible hours too. And of course that can be true. I once did a paeds emergency medicine job here where my partner was getting seriously worried about my health. I was literally exhausted all the time. I was grumpy, and never seemed to have any joy in my life. That’s not the way to live. And it’s not the frame of mind I want the doctor in when I bring my sick kid to see them.
I know everyone is an expert when it comes to public sector reform. Just look at the comments section of any newspaper article or blog on the issue. So I’ll keep my ideas about system change to myself. But Ireland, the UK and Australia need to wake up to this issue. More complex issues have been dealt with in the history of mankind.
All three countries have started the process of saturating us with medical school graduates. In Ireland and Australia especially, every man and his dog can become a doctor. Of course, there hasn’t been a sufficient expansion in the number of hospital training posts to cope with all these new graduates.
That will have the desired effect of making our young doctors accept crappy conditions, as it’s likely to be the only route to a scarce training post.
Perfect solution, if you’re an administrator or politician. Tough luck if you’re a doctor or patient.
Sadly, doing anything about it is a catch 22 situation. There are those who have tried. But what’s the most common response when you ask local juniors to engage on this issue, and stand up for their rights? Yep, you guessed it....”S
Kaplan Medical School Admissions Panel Discussion
By now, the metaphors for entering the health care profession are common and clichéd: the journey, the mountaintop, the door. But one metaphor is less common, and in fact it is actually quite literal: the conversation. To enter into the medical profession is to enter into conversation – many conversations – with colleagues and patients about the most fundamental questions of being and human existence. To be trained in the art and science of medicine is to be trained to ask – and seek answers to – questions about life and death, disease, pathology, illness, sadness, and also wellness, completeness, satisfaction, and peace. “Every journey starts with one small step” in medicine is translated to “Every journey starts with one small question: What brings you in to see me today?”
Premedical students – you – have many questions: about your goals, your dreams, the challenges and opportunities before you, near and far, as you enter into your chosen profession. Sometimes you know what questions to ask, and sometimes you don’t. Sometimes you know whom to ask; and sometimes, you don’t. The important thing here is this: you have to talk through this. You have to talk and ask questions, and listen and think. You have to be in conversation with your mentors and your peers. To that end, we invite you to join us in a special evening of dialogue on the issues that impact your entry into the healthcare profession.
Kaplan Test Prep, in partnership with the American Medical Student Association, Phi Delta Epsilon International Medical Fraternity, and the Student Doctor Network, will present a live online medical school admissions panel discussion called the Medical School Insider on Tuesday, May 11, at 7:30 pm ET. This two hour event will feature a panel of leading experts in medical school admissions, premed and medical education, and life in medicine. Following the panelist presentations, attendees will have the opportunity to engage with the panelists in an hour-long moderated Q and A session.
Confirmed panelists include:
Dr. Carlyle Miller
Associate Dean for Student Affairs
Weill Cornell Medical College
Dr. Karen Hamilton
Assistant Dean for the Office for Diversity and Community Outreach
University of Pennsylvania School of Medicine
Dr. Adam Aponte
Associate Director for Recruitment and Retention
Mount Sinai School of Medicine
Mr. John Brockman
MS4, Case Western Reserve University School of Medicine
President
AMSA
Dr. Emil Chuck
Health Professions Advisor
George Mason University
Mr. Budge Mabry
Director, Texas Medical and Dental Schools Application Service
Director, Joint Admission Medical Program
Doctors Miller, Hamilton, and Aponte have long individual histories of student advocacy and, in particular, addressing the challenges of under-represented minorities in medicine. John Brockman is the newly elected National President of AMSA, the largest medical and premedical student organization in the country. Dr. Chuck is a pre-health advisor and a popular professor of biology. He is well-regarded by national medical and educational organizations, such as AAAS and AACOM, who invite him to speak and present at annual conferences. Budge Mabry is the director of the TMDSAS, the centralized application service for all eight of the Texas medical schools. He is also the director of the Joint Admission Medical Program (JAMP), an academic pipeline program in Texas for under-represented minorities and economically-disadvantaged students in medicine.
Click here to enroll in this exciting event. This is a great opportunity to converse with medical education experts to learn from their perspectives about all the factors – your curricular and extracurricular activities, the MCAT, your personal statement, the primary and secondary applications, and the interview – that contribute to your success in gaining admission to the medical school that’s right for you.
Premedical students – you – have many questions: about your goals, your dreams, the challenges and opportunities before you, near and far, as you enter into your chosen profession. Sometimes you know what questions to ask, and sometimes you don’t. Sometimes you know whom to ask; and sometimes, you don’t. The important thing here is this: you have to talk through this. You have to talk and ask questions, and listen and think. You have to be in conversation with your mentors and your peers. To that end, we invite you to join us in a special evening of dialogue on the issues that impact your entry into the healthcare profession.
Kaplan Test Prep, in partnership with the American Medical Student Association, Phi Delta Epsilon International Medical Fraternity, and the Student Doctor Network, will present a live online medical school admissions panel discussion called the Medical School Insider on Tuesday, May 11, at 7:30 pm ET. This two hour event will feature a panel of leading experts in medical school admissions, premed and medical education, and life in medicine. Following the panelist presentations, attendees will have the opportunity to engage with the panelists in an hour-long moderated Q and A session.
Confirmed panelists include:
Dr. Carlyle Miller
Associate Dean for Student Affairs
Weill Cornell Medical College
Dr. Karen Hamilton
Assistant Dean for the Office for Diversity and Community Outreach
University of Pennsylvania School of Medicine
Dr. Adam Aponte
Associate Director for Recruitment and Retention
Mount Sinai School of Medicine
Mr. John Brockman
MS4, Case Western Reserve University School of Medicine
President
AMSA
Dr. Emil Chuck
Health Professions Advisor
George Mason University
Mr. Budge Mabry
Director, Texas Medical and Dental Schools Application Service
Director, Joint Admission Medical Program
Doctors Miller, Hamilton, and Aponte have long individual histories of student advocacy and, in particular, addressing the challenges of under-represented minorities in medicine. John Brockman is the newly elected National President of AMSA, the largest medical and premedical student organization in the country. Dr. Chuck is a pre-health advisor and a popular professor of biology. He is well-regarded by national medical and educational organizations, such as AAAS and AACOM, who invite him to speak and present at annual conferences. Budge Mabry is the director of the TMDSAS, the centralized application service for all eight of the Texas medical schools. He is also the director of the Joint Admission Medical Program (JAMP), an academic pipeline program in Texas for under-represented minorities and economically-disadvantaged students in medicine.
Click here to enroll in this exciting event. This is a great opportunity to converse with medical education experts to learn from their perspectives about all the factors – your curricular and extracurricular activities, the MCAT, your personal statement, the primary and secondary applications, and the interview – that contribute to your success in gaining admission to the medical school that’s right for you.
Erectile Dysfunction can be countered by adopting a healthy lifestyle
I am an aspiring urologist. I find that there are countless people suffering from erectile dysfunction and impotency and are ashamed to talk about it.
ED is curable, so please consult a doctor. ED is often a result of some underlying root cause.
Diabetes, high cholesterol etc contribute heavily to ED.
Patients should also
1. Drink lots of water.
2. Work out 20-30min a day, basically running skipping, aerobic etc.
Splut it into 10min sessions if you must.
3. You could even try penis rings.
Improving life style can help a lot and at the very least you will find that the PDE5 inhibitors like Cialis and Viagra work better.
These days one can even buy Viagra without prescription, but people suffering from heart and kidney ailments must not try self medication.
Posted in Pharmacy Blogs
ED is curable, so please consult a doctor. ED is often a result of some underlying root cause.
Diabetes, high cholesterol etc contribute heavily to ED.
Patients should also
1. Drink lots of water.
2. Work out 20-30min a day, basically running skipping, aerobic etc.
Splut it into 10min sessions if you must.
3. You could even try penis rings.
Improving life style can help a lot and at the very least you will find that the PDE5 inhibitors like Cialis and Viagra work better.
These days one can even buy Viagra without prescription, but people suffering from heart and kidney ailments must not try self medication.
Posted in Pharmacy Blogs
Acceptance to medical school for non-science major
I am a junior at Univ of WA deciding on a major.
If I did well on the MCAT and maintained about a 3.7 GPA, would an East European Language, Lit and Culture major be considered seriously by medical school admissions?
I have A's and B's in Bio, Chem and Organic and plan on taking Physics this year.
My father is from Eastern Europe. I visit family there pretty regularly and I spent a year in high school as an exchange student in Europe. I speak German and with this major I would be learning Czech.
Thanks.
If I did well on the MCAT and maintained about a 3.7 GPA, would an East European Language, Lit and Culture major be considered seriously by medical school admissions?
I have A's and B's in Bio, Chem and Organic and plan on taking Physics this year.
My father is from Eastern Europe. I visit family there pretty regularly and I spent a year in high school as an exchange student in Europe. I speak German and with this major I would be learning Czech.
Thanks.
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