Friday, September 28, 2012

How can an applicant really tell what a surgical program is like?

Dear Sir,

I am a 4th year medical student currently in the process of applying for residency training in general surgery. I am sure this is a perennially impossible question to address adequately; do you have any advice on how to begin to discern the true quality of various programs at which one interviews? As interview offers begin to come in, I've spoken with my own chairman and various faculty of differing age groups. I have spoken with our program's residents about other places they interviewed. I've read the reviews written on online forums like and SDN. I've looked at the ACS board pass rate data and the program's individual websites. I suppose I am asking if there are any generalizable factors that you would consider either positive or negative when considering a program. If it matters, my current long-term goals are to practice some type of general surgery or one of its specialties in a small-medium sized academic medical center...of course, that's open to change.

Name withheld by request

Great question. You have done an excellent job of investigating already.

It is very difficult for an applicant to gain insight into a program’s real nature in a half-day interview. Obviously programs try to spin things in the best light possible. Unless they have a death wish of their own, even the residents who show you around may not tell you the unvarnished truth. The down side would be that they will hurt themselves by denigrating their program because fewer good candidates might rank it highly.

Ask more than one resident some of these questions when the faculty is not present.

Are most of the residents happy?
Are residents or attendings doing the most of the cases?
Do PGY-1 and 2 residents get to do any cases as the operating surgeon or are the first two years spent covering floors and/or admitting patients?
Are any residents finishing the program not having performed enough complex procedures?
Are the busiest attending surgeons letting the residents do meaningful portions of their cases?
How much autonomy do the residents have regarding postop care?
Every year, the RRC for Surgery sends an on line confidential questionnaire to all the residents in every program. What were the issues raised on the last RRC questionnaire? Have they been addressed?
How good are the important support services like anesthesia, radiology, laboratory, pathology, ED and nursing?
Is the main hospital in good financial shape? Are they laying off personnel or cutting back services?
If you were sick, would you want to be treated at this hospital?
Are there any scut-heavy rotations and how many are there?
Are the outside rotations good? Are there problems with their locations? How’s the teaching?
Are the program director and the chairman of surgery supportive of the residents?
If you had to do it over, would you still choose this program?

If you are still interested in a program after your interview day, I suggest you call a couple of random residents who are on call at night or on a weekend. You are more likely to find candid responses to the above questions in that setting.

You need to have some questions ready for the faculty who interview you and the PD and chairman too. You need to review the program’s website and be careful not to ask a question that you could have learned the answer to on line. I used to hate that. Clarifications are OK, but don’t ask about factual information that is available on line. Below are some questions for the faculty. You can use some of the ones you asked the residents but exercise good judgment. Some of these questions can be a little edgy. You don’t want to provoke the interviewers.

When was the last RRC site visit? Were there any concerns or citations? If yes, what were they and have they been corrected?
Is the main hospital in good financial shape? Are they laying off personnel or cutting back services?
Are any residents finishing the program not having performed enough complex procedures?

Take notes. Compare resident and faculty answers. Good luck.

Thursday, September 13, 2012

A college student has second thoughts about med school

[The content of this email was edited for length and clarity.]

I'm a junior in college. I was on the path to medical school since sixth-grade. The problem is now I'm not so sure.

Lately, I've been going to sleep at night and waking up with an uneasy feeling in the pit of my stomach. For the first time since grade-school I'm having second thoughts on this career path. Before I studied abroad, I was hard-wired for medical school. But after experiencing so much life after studying abroad, I'm not handling the pre-stress of a medical school education that well anymore. I know there are realities, such as finishing at a relatively late age in life, the large amounts of accumulated debt, and the inability to set time aside for relationships (family, friends, significant other, etc). My alternate goal from here is to finish up my bachelor's in chemistry with a minor in computer science, then pursuing a master's in computer science.

So with this new plan in mind, I decided to call my parents. My mother took it exactly as I expected her to—delighted that I had found a new goal. "We're behind you all the way," said my father, "but remember that the choices you make now affect how happy you are in the future." Then he brought up the income issue and that I wouldn't want to have second thoughts later about sticking with medical school.

Leaving this path after seven or eight years of planning is a huge deal. Maybe this would be different if I were already in a committed relationship that could endure during medical school. But I'm not at the moment, and suddenly the idea starting a family in my 30s with ~300k debt looming over my head is almost unreasonable to me now. Not to mention the social distance I'd put between myself and my family and friends throughout the process of studying and clinical rotations.

I feel guilty. I feel like a disappointment. Not in my parent's eyes, but my own. I'm not sure whether I'll regret this decision or not, and I know that's not something you can answer for me either. I guess I'm just seeking some advice about all of this. What were your feelings before entering medical school? Do you think I'm insane for jumping ship?

Consider yourself lucky that your epiphany occurred now and not after you were in med school or even worse, in a residency. Your email says to me, no, shouts to me, that your heart isn't in it.

I went to med school because I relished the challenge. I had no doubts. I thought I wanted to be a psychiatrist and explore people’s minds. Obviously, that notion didn’t last. I opted for surgery because of the reward of seeing patients get better immediately.

Regarding income, I can't remember where I read it, but last year someone did the math. The loss of earning potential during med school and residency can’t be recouped. You will likely never be debt free if you owe $300K after med school. Don't forget, you will need to do 3 or 4 years of residency during which time you will earn $50-60K per year. The interest on your loans will pile up. I fully expect doctors' incomes to fall over the next few years too. Most of all, money is a terrible reason to choose a career. You should do what makes you happy. I know many MDs who have lots of money and are miserable.

My tuition at a private medical school was $1200 per year to start. Even in late 1960s dollars, my father paid for it with a check. I graduated with no debt.

And of course, medicine has changed dramatically over the years. I'm not sure that I would do it again if I had the chance.

By the way, I wouldn’t assume that being in a relationship before going to medical school would be a lasting solution either. The stress of med school and residency can be difficult for even the best of relationships.

I applaud your parents for supporting you. The second worst reason to choose a career after money is because you don't want to disappoint your parents.

I hope this helps. Good luck.

Tuesday, August 14, 2012

Why I left academic medicine

A medical student who thinks he wants a career in academic surgery asks, “You were deep into academic medicine and walked away from chairman, program director, etc. Why?"

[Background: For over 23 years, I was a full time surgical chairman and residency program director in three different community hospitals affiliated with medical schools.]

Good question. For many years I had always said something like, “No matter what crisis happens with the residents or the chairman’s job, it pales in comparison to having a patient with a complication.” In other words, non-clinical problems were annoying but manageable.

Then one day I realized that was no longer so. Patients with complications still caused me many sleepless nights and that hadn’t changed. What had changed was that resident issues and administrative hassles finally became intolerable.

The rules set by the accrediting bodies, the ACGME and the Residency Review Committee [RRC] for Surgery, had always been difficult to comply with, especially for a small program. They became more onerous every year or two until it reached the point where I can’t imagine how anyone can stand it. Residents can complain to the RRC anonymously and no matter how factually you refute the complaint, the RRC always believes the disgruntled resident. Add in the work hours rules and the lack of motivation of some of today’s med school graduates and I had had enough.

The position of surgical chairman in a community teaching hospital is like that of a football referee. At any given time, half your constituency is not happy with you. The administration pays your salary and expects you to spout the party line. But you need your attending surgeons to treat the residents well and support the program. Many times you have to make decisions that are guaranteed to alienate many people.

A lot of energy was spent investigating complaints. Families were unhappy with the residents; attending surgeons were unhappy with the residents and conversely; nurses were unhappy with the residents and/or the attendings; someone was rude to someone else; someone shouted; someone cried and on and on.

And the site visits. Drop everything; the state is here to investigate a case or the state is here to interview the residents about their work hours. The Joint Commission is coming in six months. We need to meet twice a week to make up for all the unnecessary but JC-mandated stuff we haven’t been doing for the last two-and-a half years. Countless hours were spent buffing up the paperwork for an RRC site visit. I think that’s where I learned creative writing.

And the meetings. Risk management meetings could last three hours during which time you would have the opportunity to try to explain why a surgical complication occurred to a room full of non-surgeon MDs and non-physician administrators. We used to deal with this sort of thing quite effectively at morbidity and mortality conference.

Then there were the committees. At one of my former hospitals I was either chairman or a member of the following committees: Pharmacy, Critical Care, Infection, Medical Executive, Operating Room, Surgical Performance Improvement, Strategic Planning Work Group, Product Evaluation, Library, Clinical Leadership Group, Cancer, Trauma, Budget, Graduate Medical Education, and Risk Management. I’ll save you the trouble. That’s 15 committees.

For a long time, I enjoyed being a residency program director. I am proud of the more than 50 chief residents I helped train. I view them as my legacy. I regret that running a program and teaching residents stopped being fun a few years ago. I also liked being a chairman until medicine took a turn toward the dark side.

I could go on but this post would reach 20,000 words.

So my young friend, think long and hard about that decision to become an academic chair.

Wednesday, August 1, 2012

Who should place a Foley catheter?

A nurse who understandably asks to remain anonymous writes, “In our hospital, we have an increased catheter-associated urinary tract infection (CAUTI) rate related to poor skills by medical residents. The surgical nurses want to insert the caths, but the residents jump in and do not perform the skill correctly. Feedback please.”

Thanks for the interesting query. Several thoughts come to mind. I can understand a new resident wanting to learn how to perform this procedure. But after doing a few, I think that the novelty would wear off, especially at 3:00 in the morning. Also, it is likely that the nurses would be able to do it in a much more timely way.

In my current hospital, which is non-teaching, nurses place Foley catheters without incident or opposition. I don’t know our rate of CAUTI, but I doubt it is high.

You might try the direct approach and speak to the residents when they don't do it right, but unless they've read my "Hints for new residents" blog where I mention that you can learn a lot from nurses, they may become indignant.

I assume you have some data to back up your assertions that your CAUTI rate is high and can document that the residents are not doing it correctly. Having dealt with teaching hospital politics for many years, I suggest the following to you.

Speak with your nurse manager and the nurse who does clinical education and tell them what the specific problems are. For example, are the residents not adhering to sterile technique? Are they not following the steps properly?

The nurse manager and clinical specialist should talk to your infection control nurses and their supervising physician, who should then discuss the matter with the residency program director. This will keep you out of the line of fire and not jeopardize your relationship with the residents.

This process is good way to handle any sort of conflict. In the military, it is known as following the chain of command.

Wednesday, July 11, 2012

Management of small bowel obstruction

Pascal Frey (@alpascal) asks, While reading your posts on Twitter I stumbled upon "Ask SkepticalScalpel," and I really like your idea. As a medically and technically interested resident I always like to ask many questions and have only little time (and experience) to find (or get) good answers. So here's my first question for you: is there any good data on the outcome comparing conservative vs. surgical treatment of small intestine ileus (of any form or origin, e.g. due to adhesions)?

Good question. It's a topic that I've always been interested in and it's about the third most common illness I see. The short answer is "No." I am not aware of any quality study comparing the results of surgery vs. observation for small bowel obstruction.

Management depends on the cause of the small bowel obstruction. Obstruction due to hernia or tumor almost always requires surgery. Obstruction secondary to adhesions responds to observation, bowel rest, NG suction and IV hydration in about 75% of cases. Early postop bowel obstruction or ileus is a big problem and nearly always gets better without re-operation.

The hardest decisions are who needs an operation and when to operate. If one waits for fever, tachycardia, localized pain, elevated WBC or metabolic acidosis to operate, it’s often too late and a resection of part of the intestine will be necessary. There are numerous papers on this subject, but it always comes down to each case being handled by almost instinct.

Outcomes are hard to compare because a randomized trial would be difficult to do because of the diverse nature of the patients and the types of obstruction.

I’m sorry I couldn’t be more definitive. Thanks for your interest.