tag:blogger.com,1999:blog-24391716643900246942023-11-16T08:54:12.309-05:00Ask Skeptical ScalpelSkeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.comBlogger30125tag:blogger.com,1999:blog-2439171664390024694.post-43193176140413491952015-01-17T10:31:00.000-05:002015-01-17T10:31:44.976-05:00Going to med school and becoming a surgeon when you're olderA 34-year-old attorney writes <i>I have a good salary, am married, and have two children. My whole life I've been drawn to medicine (I'm an EMT, have experience on the job with trauma related injuries, etc.) and have always enjoyed it. However, I have a Bachelor's in English literature, so I've always put it as unattainable to become a doctor. Now, once again, I'm considering doing one of the post bac premed programs out there and going for it. <br /><br /> Am I insane? At my age, I'll likely be 41-42 by the time I'd complete medical school, then residency. I'd love your opinion. </i><br />
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Let's do some math. You are 34. Most post bac premed programs take at least a year if you go to school full-time. Assuming you can get into a program this summer, you will be applying to medical school for a class starting in the fall of 2017. You will be 36 years old when you start. <br />
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Four years of medical school plus five years of general surgery residency and you will be 45 years old. If you want to take a fellowship in something for a year or two, add those years on. <br />
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What are you going to do for income while you are pursuing your medical degree? And let's not forget the tuition cost of the post bac program and medical school, living expenses, and your paltry salary for the 5 years of your residency. <br />
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I wrote a <a href="http://skepticalscalpel.blogspot.com/2010/12/is-medical-school-tuition-debt.html">post</a> about this four years ago. It was about a then 30-year-old man did not get into medical school until 2014 which means he is now in the middle of his first year at the age of 34. <br />
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My discussion of the "cons" of doing this is much more expansive in that post. Just remember that tuition costs have risen much faster than inflation and will continue to do so in the foreseeable future. <br />
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I can't tell you not to do it and it certainly has been done by others, but I strongly advise you to give it a lot of thought. <br />
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He replies<i> Thanks for the response. Unfortunately, you paint the bleak reality I was afraid of. As I likely won't make cutoffs for the good post bac programs this year, you'd have to add another year to the equation. <br /><br />What if I went for a less rigorous residency like emergency medicine? Or what if I consider having the military pay for medical school? <br /><br />Does this change anything? Your post is so bleak, it definitely gives pause. <br /><br />The family issue is a tough one. I'm fortunate to have about $200k in liquid assets, but it's still a big financial hardship. </i><br />
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$200K might just about cover your tuition for the post bac year and 4 years of med school. <br />
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Yes, emergency medicine will save you a couple of years, but it is very competitive. <br />
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Remember one thing about the military. Once you are in, they own you. They can send you to remote bases in the states, Afghanistan, or wherever they want. You cannot believe anything they tell about your ability to choose an assignment. <br />
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Readers, please comment if you agree or disagree. Skeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.com28tag:blogger.com,1999:blog-2439171664390024694.post-23361161036237460972015-01-13T07:04:00.002-05:002015-01-13T07:04:56.452-05:00Academic vs. community hospital for surgery residencyHere's question from a senior med student at a state school. She has excellent grades, USMLE Step 1 and 2 scores > 245, has co-authored 4 published papers, and was elected to AOA. She writes <br /><br /><i>I am looking to re-locate to a large city for residency as a number of my family members live there. I have interviewed at the large academic centers in the city as well as their community affiliates. I have also been involved in research and always assumed I would enjoy the biggest "named" institution possible. As I have interviewed, I truly feel that I would get better training (and be happier) and the academic-affiliated community programs in that city. However I have been told my several advisors at my home school that this would be "career suicide" and it would be "idiotic" not to take the best name that I have a chance at matching at. As far as fellowship, I have literally no idea what I want to do. Maybe surgical oncology, maybe transplant? Maybe vascular, maybe nothing?!</i><br /> <br /> <i>What is your insight into this? Should I seek what I perceive to be the best training/fit or should I rank the higher name academic programs for the sake of my career? </i><br /><br />Here's my opinion. Be advised that it is strictly my opinion and may be neither popular or correct.<br /> <br /> You should have no problem matching at any affiliated community hospital program and probably have a very good chance to match at every academic program in the city you want to be in.<br /> <br /> I hope you have properly researched your top choices and are confident that the residents are happy and doing a lot of cases. Also you should be sure that the leadership of the program is stable. I suppose your mentors your school want you to take the academic track because that's what they did. It also enhances the reputation of the school when its students match in big name programs. <br /><br /> You remind me of me except I didn't have the publications you do. I took the "comfortable" choice for residency and never regretted it. I trained in the same city you are looking at. It's a great place to live. <br /> <br /> I see it this way. Suppose after a couple of years in a community program, you decide you want to be an academic surgeon. After you residency, you can always take a fellowship in something at an academic medical center. <br /><br />But if you go with a university program and are miserable, then what do you do? Five years (plus a year or two of research) is a long time to be miserable. <br /><br />I went into more detail about this in a <a href="http://skepticalscalpel.blogspot.com/2012/01/which-type-of-surgery-residency-should.html">post</a> three years ago. <br /><br /> Listen to your heart. Go for the place that you feel most comfortable with. <br /> <br /> I strongly suggest ranking all of the programs you feel you can live with—just in case. <br /><br />Good luck and let us know how it turns out.<br />
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Readers, feel free to disagree or agree as you see fit. <br />Skeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.com5tag:blogger.com,1999:blog-2439171664390024694.post-51530319282962464312014-08-13T13:06:00.000-04:002014-08-13T13:06:04.320-04:00Applicant worries about the future of surgeryA medical student writes: <br /><br /><i>I am a few weeks away from applying for residency training in general surgery. Lately I've been lamenting that I was not born in the 1950s. I worry that the physician that I became enamored with so early in life is looking more and more like the surgeon I may never become. <br /><br />Increasing enthusiasm for innovation in surgical technology is subtly paving a road toward a time in which a surgeon may be rendered obsolete. The rise of the two M's—machines and mid-levels—may herald a very different future from that which I ever imagined. <br /><br />I love to solve problems and stand (not sit!) above an anesthetized patient making use of my hands and tools directly. There has never been a higher challenge than surgery which involves clinical skills in diagnosis, peri- and intraoperative disease management, and a sense of duty, service, and sacrifice. And now, robotics calls into question why hands might ever need to be laid on patients, and time-honored sutures are replaced with Silicon Valley-prescribed tinker toys. <br /><br />Many articles call into question the relevance of physicians, particularly surgeons, in the not-too-distant future. <br /><br />Will mid-level providers take away many general surgery cases? Will opportunities to function as a surgeon be threatened by the relentless emergence of technological or perhaps financial pressures? Are surgical societies actively confronting these issues? </i><br /><br />I see you have thought about this in depth. <br /><br />The PAs I have worked with did a lot of rounding, H&Ps, clinic work, and discharge summaries. In the OR, they assisted and closed skin. In some specialties, they do more such as harvesting vein grafts and closing fascia. <br /> <br /> Here's an interesting <a href="https://www.blogger.com/courthousenews.com/2014/07/31/69982.htm">anecdote</a> about a PA who excised a neck mass by himself. He smelled it, said it was a benign sebaceous cyst, and threw it away. When the mass recurred, a surgeon biopsied it and found squamous cell carcinoma. <br /><br /> I don't see robots <a href="http://skepticalscalpel.blogspot.com/2014/07/surgery-in-space-i-foresee-problems.html">operating</a> independently for quite a while, if ever, although NASA apparently has a robot that can be inserted into the abdomen and perform an appendectomy while being controlled remotely. <br /> <br /> There is much variability in the location of the appendix, the inflammatory response, and the location of surrounding structures. How can a robot can ever be programmed to do this supposedly simple operation without human guidance? <br /> <br /> If NASA has a miniature robot, it may be possible to control it while standing next to the patient. Having never seen it, I just don't know.<br /> <br /> Surgery will undoubtedly change a lot in the next 40 or 50 years. As I wrote <a href="http://skepticalscalpel.blogspot.com/2013/06/what-was-surgery-like-in-1970s.html">here</a>, it certainly has since the 1970s. It might change at a faster rate too. But surgeons have adapted well, and they will continue to do so. <br /> <br /> Surgical societies have not exactly shined during all of these changes. When laparoscopic general surgery was introduced in about 1990, mainstream surgical leaders called it heresy and were slow to catch up. Conversely, few said anything about the introduction and widespread acceptance of the da Vinci robot, which has not been shown to improve outcomes despite all the fanfare and expense.<br /> <br /> Someone (the feds?) will have to put the brakes on unproven technologies or the country will go broke.<br /> <br /> So if you want to be a surgeon, go for it, but be prepared for change.<br /> <br /> <br /> <br />Skeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.com3tag:blogger.com,1999:blog-2439171664390024694.post-67399960460511611002014-08-05T10:09:00.001-04:002014-08-05T10:09:35.327-04:00Board passage rates and residency program quality<i>I am 3rd year med student thinking of surgery programs to apply to next year. I came across this <a href="http://www.absurgery.org/xfer/5yr_summary.pdf">document</a> on the American Board of Surgery website. It shows the qualifying exam and certifying exam first-time pass rates for general surgery residents between 2008-2013. <br /><br />Is this a worthwhile marker for evaluating surgery programs and identifying top programs? Also, is first-time pass/fail on the QE/CE a measure of preparation to practice as a general surgeon upon graduation or is it poorly correlated with a graduate's ability to function independently? <br /><br />I have a moderately competitive Step 1 score and I want to choose a program that would make me a general surgeon without needing to take a fellowship upon graduation. <br /><br />[Note: The email was edited for length.] </i><br />
<br />Thanks for asking a couple of really good questions. The answers are not black and white. On page 23 of its requirements, the Residency Review Committee (<a href="https://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/440_general_surgery_07012014.pdf">RRC</a>) for Surgery states that board passage rate is one measure for evaluating program effectiveness, and "At minimum, for the most recent five-year period, 65% of the graduates must pass each of the qualifying and certifying examinations on the first attempt." <br /><br />A quick look at the board passage rates in the ABS document shows that 31% of programs, most of which are community hospital-based, did not reach the magic 65% quota. <br /><br />Two years ago, I blogged about the two major reasons why the 65% board passage threshold on the first try discriminates against community hospital programs. You can read the full piece <a href="http://skepticalscalpel.blogspot.com/2012/06/does-size-matter-surgery-residency.html">here</a>, but briefly one issue is that university hospitals attract smarter residents who are better test takers, and the other is that smaller programs are statistically more likely to have test result outliers. <br /><br />I am unaware of any correlation between passing the boards on the first try (or the second or third tries) and a surgeon's ability to practice independently. In fact, another <a href="http://skepticalscalpel.blogspot.com/2012/01/which-type-of-surgery-residency-should.html">post</a> I wrote discussed a paper that surveyed 4882 surgical residents. It found that community hospital trainees were more satisfied with their operative experience and more confident that they could work independently than those who trained in university programs. <br /><br />But there is another consideration. Fair or not, programs with first-time board passage rates chronically below 65% are at some risk for both RRC probation, which is detrimental to recruiting, and possible discontinuation. It is difficult to quickly turn around a low board passage rate because the number of graduates is small in most community programs and the stain left by a failed first-time taker lasts five years. <br /><br />So what should you do? <br /><br />Perhaps you should play it safe and apply to community hospital programs with adequate first-time board passage rates. <br /><br />Comments from surgical educators, current residents or recent graduates of surgical training are welcome. <br /><br /><br /> <br />Skeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.com6tag:blogger.com,1999:blog-2439171664390024694.post-1187831753477983642014-06-17T09:17:00.002-04:002014-06-17T09:17:28.509-04:00A non-US citizen international student's chances of matching in surgery"Brian," a medical student in Egypt, wrote me about obtaining a surgical residency in the US. Due to space limitations, I have edited the email. He will take USMLE Step 1 soon. He has no green card. <br /><br />He read a previous <a href="http://askskepticalscalpel.blogspot.com/2014/05/us-citizen-img-surgery-prelim-resident.html">post</a> of mine about a US citizen international medical graduate (IMG), but still had several questions. <br /><br />He asked what qualities separate an applicant matching in a categorical position from one matching in a preliminary position? <br /><br />"Categorical" means, barring any performance or behavior issues, the resident will complete a full 5-year general surgery residency program. <br /><br /><a name='more'></a>There are two types of preliminary positions. Designated general surgery preliminary positions are 1- or 2-year commitments to residents who have already matched in another surgical subspecialty such as urology or orthopedics. People who match as designated preliminary residents are usually automatically accepted into the one or two year general surgery positions. <br /><br />Non-designated preliminary positions are 1-year general surgery slots with no guarantee of progression to either a categorical general surgery or subspecialty surgery position. These positions are almost always filled after the match with those who failed to match in a surgical subspecialty or general surgery. <br /><br />He brought up the results of a 2012 NRMP survey of general surgery program directors that indicated what factors influence them to grant interviews and rank applicants. Link <a href="http://www.siumed.edu/oec/Year4/References/NRMP%20PDSurvey%202012.pdf">here</a>. See pages 54-60. <br /><br />Factors used in selecting applicants to interview are numerous and not completely consistent with other surveys, but the two highest responses were letters of recommendation-89% and USMLE Step 1 scores-84%. Other notable parameters were personal statement-74%, grades-78%, dean's letter-63%, visa status-56%, and involvement in research-56%. <br /><br />Many of the other factors listed scores higher than 50% as well. Since so many were considered important and the response rate was only 30.9%, the value of the survey is questionable. I am highly skeptical that three-quarters of program directors really think a personal statement is important. In my time as a PD, I found most of them to be worthless. <br /><br />Of respondents, 99% interview US seniors, 73% interview US grads (i.e., those who are already doing a first year somewhere), osteopathic 53%, Canadian 50%, fifth pathway 35%, US citizen IMG 56%, and non-US citizen IMG 41%. <br /><br />The average numbers of applications received is 623, number interviewed-68, number ranked-42, number of yearly positions available in the match-5. <br /><br />All programs require Step 1 scores with 83% having a threshold averaging at least 210. One's chances of getting an interview increase with a score above about 225. <br /><br />An application from a non-US citizen IMG with a USMLE Step 1 score of less than about 220 would be very likely to be discarded. <br /><br />I recently blogged about a <a href="http://skepticalscalpel.blogspot.com/2014/03/how-to-select-surgical-residents.html">paper</a> reporting the results of a different survey of surgery program directors with a 65% response rate which ranked USMLE Step 1 scores as number one. That paper placed a little value on research or publications. Some other data from this survey are interesting and illustrate the difficulty that a non-US citizen international graduate will have finding a program. <br /><br />Another question was about letters of recommendation. Generally, a letter stating that the applicant has waived his right to review it is far more useful than one that the applicant has reviewed. <br /><br />He asked about grades and class rankings. As I discussed in a previous <a href="http://skepticalscalpel.blogspot.com/2012/10/medical-school-grading-and-t-ball.html">post</a>, grades and class rankings from US medical schools are fairly useless due to inflated grades and the lack of uniform grading standards. The same applies to international schools. <br /><br />Regarding the chances of getting a categorical position after doing a non-designated preliminary year. I don't believe there are any data on this. This <a href="http://askskepticalscalpel.blogspot.com/2014/05/us-citizen-img-surgery-prelim-resident.html">post</a> of mine attempted to sort out the possibilities. <br /><br />He asked, "What is the profile of a competitive IMG for categorical general surgery?" I can only give some data and my opinion. To get an interview in a lower tier program, I would say he needs at least a 250 on USMLE Step 1, at least one clinical rotation on surgery in a US hospital, a letter of recommendation or two from US surgeons (preferably one who is known regionally or nationally), a publication wouldn't hurt but I'm not sure it helps, and obviously a very favorable dean's letter or the equivalent from his school. <br /> <br /> To be honest, his chances are slim. I could be wrong and hope some readers will comment.<br /> <br /> <br />Skeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.com10tag:blogger.com,1999:blog-2439171664390024694.post-80482318356787865922014-05-16T13:37:00.000-04:002014-05-16T13:53:16.021-04:00What do students do on third-year surgery rotations?<!--[if gte mso 9]><xml>
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A woman who has been accepted by a few medical schools and
is trying to decide which one to choose asks
</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">What
extent of involvement should be expected for medical school surgery rotations?
I have enjoyed shadowing general surgery and feel that a field involving some
procedure may end up being my fit, or at the very least something to enjoy in
medical school. I am curious as to the type of participation in procedures
(suturing/closing for example) that is typically allowed as a student versus
that allowed and expected as a resident. </span></i></div>
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<br /></div>
<div class="MsoNormal">
In most third-year surgery rotations, students can do some
suturing of skin and maybe lacerations in the ED provided the student has
practiced knot-tying and using instruments outside of the OR. Opportunities to suture
in the OR are fewer these days because of skin stapling and the use of glue,
which are both faster than suturing. Hardworking and interested students are
far more likely to be rewarded with things to do by residents.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Otherwise, there's a lot of camera holding for laparoscopic
cases and retracting for open cases. Students used to do H&Ps and write
postop orders but the electronic medical record has curtailed those activities
greatly.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Medical school has changed a lot over the years. As a
fourth-year student in the early 1970s, I placed many subclavian central venous
catheters—some of which were unsupervised. Six years ago, I was about to let an
intern place a subcutaneous chemotherapy port in the OR. It was halfway through
the academic year. I asked her how many subclavian catheterizations she had
done. She said she hadn't done any but had seen one.</div>
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<br /></div>
<div class="MsoNormal">
I can't say whether that lack of experience is common to
most current med students, but I think it may be.<br />
<br />
Of course, residents get to do much more as they progress through the years. Residents
in community hospital programs tend to do more cases during their first 2 years
and often will have performed more cases over the 5-year course of residency
training than those in pure university based programs. Of course, there are
exceptions.<br />
<br />
If this is really a major factor in your decision-making process, I suggest you
try to talk to some students at the schools that you have been accepted by and
see what they have been able to do during their third-year surgery rotations.</div>
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<br /></div>
<div class="MsoNormal">
You will probably find that students who do third-year
clerkships at community hospitals affiliated with med schools get to do more
hands-on work too.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The same goes for those applying to residency. If you really
want to know what goes on, talk to some of the residents who <i style="mso-bidi-font-style: normal;">weren't</i> chosen to meet the applicants on
interview day.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I hope some of our readers will comment.</div>
<div class="MsoNormal">
<br /></div>
Skeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.com20tag:blogger.com,1999:blog-2439171664390024694.post-86741983688932854072014-05-08T08:45:00.000-04:002014-05-08T08:45:05.637-04:00US citizen IMG surgery prelim resident needs advice<!--[if gte mso 9]><xml>
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<![endif]-->Maicon, a non-designated preliminary general surgery resident, writes <br /><br /><i>I read with interest your post on matching rates for international medical graduates. I am a US citizen IMG, born here, but grew up (since 2 years of age) in another country and completed my medical school there a few years ago.<br /><br />My USMLE scores are step 1 - 235, step 2 - 251, Step 2CS and Step 3 passed on first attempt. Knowing that general surgery was hard to get, I worked (unpaid) in the surgery department at a large Northeastern academic center.<br /><br />I got a prelim spot at a decent program with a program director I respect. I worked my ass off, studied hard, and got in on research projects early.<br /><br />ABSITE: 1st year - 90th percentile (highest in our class), it got me a 2nd year at the same program, 2nd year - 79th percentile.<br /><br />Did a ton of research with a couple of publications and presentation, and won a teacher award by med students. My evals were good, and I got great recommendation letters. I thought I covered my bases.<br /><br />My program doesn't have a spot for a 3rd year and am unable to find one, despite the good intentions of my mentors. It is frustrating that, try as I might, I am still out of a residency on June 30th of this year.<br /><br />Should I continue to pursue the surgical field, do a research fellowship which I have seen from previous blogs/articles doesn't help much, do a subspecialty fellowship (Cardiothoracic ICU/critical care/Burns), or switch to medicine or FP? From, your previous posts, I feel you will probably suggest to switch. </i><br /><br />Thanks for reading my blog and for your email. I am sympathetic to your plight. I've seen it many times.<br /><br />I wish I was still running a program. It sounds like I could have used someone like you.<br /><br />If you have no financial or other pressure to get on with your life and are young enough, I suggest you take a fellowship in one of the clinical areas you mentioned such as critical care. An accredited one is preferred because you could take the board exam when you finally get through a 5-year GS program. Even a non-accredited fellowship in a clinical area is better than doing research. Your chances of obtaining a categorical spot are enhanced by taking care of patients instead of test tubes.<br /><br /> If you do a good job with the fellowship, you might be able to sneak into a categorical slot somewhere. Make sure you take the ABSITE again too. The scores are really important.<br /><br />Have your program director keep an eye on the program directors' list serve. Categorical slots open up frequently—even into June.<br /><br />Good luck.Skeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.com9tag:blogger.com,1999:blog-2439171664390024694.post-60281356391475782282014-03-28T08:48:00.001-04:002014-03-28T08:48:08.430-04:00A college junior wonders if she will get into med school<!--[if gte mso 9]><xml>
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[Email abridged and edited.] <i style="mso-bidi-font-style: normal;">A 21-year-old married woman, who is a junior at a large public
university, has always wanted to be a doctor. She had some family and mental
health problems (panic attacks, depression) which have affected her grades. She
has a current GPA of 2.8, but when recalculated by including grades in repeated
courses and deleting the poorer grades as her college allows, her GPA is 3.3.
She and her husband have a combined $24K of student loan debt.</i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;">She feels very
strongly that her family and mental health are no longer issues and is getting
A's in science courses that she previously did poorly in. She says, "I seriously
feel like a completely different person. I feel capable of getting good grades.
However, people keep telling me that I might not even make it into med school
because of my low GPA. The thing is though I don't care what I have to do. I am
so passionate about learning and helping people. My dream has been to work and
eventually have a free clinic on the side to help people who can't afford
healthcare. That's why I'm in this. But is there a chance I can even get in? I
know that's what I want, but people (peers, degree advisors, and my anatomy
professor) keep bringing me down." </i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
This is a very difficult question to answer definitively. I
really can't speculate on your chances of being accepted to medical school.
Your level of commitment is outstanding. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
There is one missing variable—your MCAT scores. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
You may want to take the <a href="http://www.princetonreview.com/medical/mcat-information.aspx">MCAT</a> at the next available
opportunity. Great scores would be encouraging. Poor scores would seal the
deal. You would have to move on to something else.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Your combined debt is low and you are young, both of which
will allow you to spend a little extra time beefing up your GPA.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
If you are thinking about applying to offshore medical
schools, please do some research. As US medical schools expand their classes
and new schools open, there will be fewer residency positions for offshore
graduates. If you look at Table 1 on page 2 of the 2013 <a href="http://b83c73bcf0e7ca356c80-e8560f466940e4ec38ed51af32994bc6.r6.cf1.rackcdn.com/wp-content/uploads/2014/01/NRMP-and-ECFMG-Publish-Charting-Outcomes-in-the-Match-for-International-Medical-Graduates-Revised.PDF-File.pdf">match data</a> for
International Medical Graduates (IMGs), you will see that 2420 US citizen IMGs
failed to match to a residency position. It's only going to get worse as I noted <a href="http://skepticalscalpel.blogspot.com/2013/02/law-school-applications-are-way-down.html">here</a>.</div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi-edVYUmN_gPIMW1l3GPKfUA08NgNepiBhN5upmkDptRdPIJK-KIeuRbGEVJLALAXqRKNj4Y0VxOQu_331pDPuYG5uCu_AOVNregJELpGdMcy6zrUrdXNSKlg87Q_vXLi9jxR-R8nqJjZL/s1600/IMG+Match.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi-edVYUmN_gPIMW1l3GPKfUA08NgNepiBhN5upmkDptRdPIJK-KIeuRbGEVJLALAXqRKNj4Y0VxOQu_331pDPuYG5uCu_AOVNregJELpGdMcy6zrUrdXNSKlg87Q_vXLi9jxR-R8nqJjZL/s1600/IMG+Match.jpg" height="296" width="640" /></a></div>
<div class="MsoNormal">
Have you considered another option such as becoming a
physician assistant? The path is shorter, and PAs are becoming more and more
autonomous. It might help you to look at a post of mine from a couple of months
ago on "Ask Skepticalscalpel" called "<a href="http://askskepticalscalpel.blogspot.com/2013/12/a-woman-asks-should-i-be-nurse.html">Should I be a nurse practitioneror a doctor</a>?"
Read the many comments because they are pertinent.
</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I hope this is helpful to you. Check back here for comments
as they are often more useful than what I write.</div>
Skeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.com32tag:blogger.com,1999:blog-2439171664390024694.post-14850779864724579912014-03-18T12:06:00.000-04:002014-04-03T19:12:04.301-04:00Help! My friend didn't match in orthopedics ... again<!--[if gte mso 9]><xml>
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<br />
<div class="MsoNormal">
Maicon [not his real name] writes</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">My
friend wanted to be an orthopedist, but his grades and USMLE scores were just
average for medical school—Step 1 was 215. He applied last year, got some
interviews but didn't match. He started a research fellowship in ortho at an
academic center and re-applied. I tried to tell him to defer applying until he
finished the fellowship so he could have something to show for it other than,
"I started a fellowship and working on blah blah blah." This year, he
got fewer interviews and failed to match again. During all this, I had advised him
to also apply to general surgery, but he always resisted. He now has decided to
try for an unfilled general surgery preliminary position.</span></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">I
realize this is an elaborate discussion however you would be doing a major service
for many applicants of this kind who have nothing to go on other than delusions
or conspiratory paranoia.</span></i><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;"></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">Sad to say, but this happens every year.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">The advice to do a year of orthopedic research was
misguided. He has just wasted a year of his life.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">I'm not sure what goes on in orthopedics. However,
in a recent <a href="http://skepticalscalpel.blogspot.com/2014/03/how-to-select-surgical-residents.html">post</a> on how general surgery program directors select residents, I
noted that previous research experience was extremely low on the list of
criteria as was having done a preliminary general surgery year. </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">I wonder how many who do a research year succeed in
getting an orthopedic residency position. My guess would be less than 5%, if at
all.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">He should be honest in his application for the
general surgery non-designated preliminary position. The program directors will
know the truth anyway. The good news is that there are over 450 unfilled positions
this year and not enough bodies to fill them. </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">The bad news is that these positions can be dead
ends in many cases. That is, your friend could do a year or two of preliminary
surgery and then have no access to a third-year categorical spot. Another issue is that in some programs,
non-designated prelims are treated like second class citizens by being given all the
scut rotations.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">There is some hope though. Here's a <a href="http://www.ncbi.nlm.nih.gov/pubmed/24209641">paper</a> that found an amazing rate of success for non-designated prelim surgery residents obtaining categorical positions, but it's from Mass General. Abington Memorial Hospital <a href="http://www.ncbi.nlm.nih.gov/pubmed/21810503">reported</a> surprisingly good outcomes. Yale's <a href="http://www.ncbi.nlm.nih.gov/pubmed/19887183">results</a> weren't quite as good. UC-Denver also had some mixed <a href="http://www.ncbi.nlm.nih.gov/pubmed/23111047">results</a>. There could be some publication bias here. Programs with dismal records of placing prelim trainees may not have chosen to report their experiences.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">If he does obtain a preliminary spot, he must work
very hard and do very well on the general surgery in-training examination in the hope that someone drops out or is
cut from a categorical position and that he will be selected to replace that
individual. If not, he will chalk up one or two more wasted years.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">A backup plan for a different specialty career should
be in mind in case he is unable to eventually secure a categorical general surgery position. </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
My feeling is that if an applicant doesn't match in a dream specialty, he should forget about a year of research, scrap that dream,
and move on. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
As always, comments are welcome.</div>
<div class="MsoNormal">
<br /></div>
<br />Skeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.com11tag:blogger.com,1999:blog-2439171664390024694.post-2774469206748064772014-03-17T08:51:00.001-04:002014-03-17T08:51:08.736-04:00A med student asks about rural surgery training<!--[if gte mso 9]><xml>
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<span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">Lionel, a first-year med student at a US school,
writes</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">I'm
really passionate about rural surgery and the idea of having a wide variety of
procedures that you have to be able to take care of—ortho, c-sections, urology,
ENT, abdomen, etc. But the thing is, everyone I talk to says this is an
unreasonable expectation to have going forward as current training isn't
conducive to learning all those things in 5 years, given the number of fellows
present and the general trend towards super-specialization these days. Yet, I
read about massive needs for rural general surgery. It doesn't quite add
up. </span></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">What
is your take on this? Also, how do I go about pursuing a career as a rural
surgeon in this academic/training environment? Community program? Academic
program? I know Cooperstown, Oregon and Gunderson have rural surgery
fellowships but I haven't heard anything about them or how to determine if you
need to pursue this extra training.</span></i><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;"> </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Good questions.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
An email exchange yielded more background information. He went
to college in a rural area, has worked in an orphanage on a farm, and spent
some time with physicians in rural Africa.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
He has thought things through very well and seems quite
committed to becoming a rural surgeon.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
In medical school, he plans to do one elective in rural
surgery and another at a hospital that serves as the primary clinic/surgical
center for 160,000 people in a poor African country.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
He is also going to spend a summer doing research at an
academic center just to get an idea of what that is like.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I sent him some links to papers on the subject of rural
surgery most of which he had already seen.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Here is what I think.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
If you choose the right program, you would not have to take
an extra year of fellowship to become a competent rural surgeon. For example,
the Oregon program includes a year of rural surgery in their five-year curriculum
for those who wish to do it.<br />
<br />
There are some other programs besides the ones you named, and there may be more
by the time you are ready to choose a residency. You might also think about
programs with international rotations.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
If you are truly committed to becoming a rural surgeon, a
pure academic program is probably not for you. You are not likely to get enough
diversified subspecialty experience in such a place. A community hospital
program that offers a chance to rotate on some of the subspecialties and OB would
be better, and there will be few or no fellows competing for cases.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I hope that some readers will contribute other perspectives
to the discussion.</div>
<div class="MsoNormal">
<br /></div>
<br />Skeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.com6tag:blogger.com,1999:blog-2439171664390024694.post-75403576787943891472014-02-05T11:43:00.000-05:002014-02-05T11:43:59.407-05:00A med student loves open surgery, asks about the future of pediatric surgery<!--[if gte mso 9]><xml>
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<span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">Dimitar [not his real name] writes [edited for length]:<i style="mso-bidi-font-style: normal;"> I am a medical student who has already
applied to the field of general surgery and finished the interview process. I
hope to become a pediatric surgeon because it is one of the last fields that
allows for one to operate all over the human body and to be a true general
surgeon.</i></span>
<br />
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<br /></div>
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<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">However
I have been struggling with something that I hope you can help me with. I love
the technical aspect of surgery. I enjoy becoming better at tying knots, suturing,
and various surgical skills, and above all I love traditional open procedures. I
like to feel with my hands and not with those laparoscopic instruments, I like
to see with my own eyes and not through a tiny little camera all through a tiny
little port. My biggest fear is that everything will become robotic, and that
an open procedure will be a rarity in the future. And pediatric surgery most of
all is basically an advanced laparoscopic fellowship. I want to make clear that
I do not hate laparoscopy, I just enjoy the open procedures much more. I
understand that this is probably a very selfish thought as laparoscopy has
better recovery times, less pain, shorter hospital stay etc., but I guess that
is why we have websites like this where I can ask anonymously what I am to
ashamed to asked in public with hopes of getting a non-judgmental response.</span></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">To
sum it up, I feel like I was born to do surgery back in 1950 or something when
everything was open. I would like to find a field that would allow me to
operate all over the body and do it the traditional way. Other than trauma, and
transplant, what are my options? Would general surgery ever get back to what is
was before? If I don't learn to love this laparoscopic and robotic thing am I
screwed?</span></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Those are very good questions. Let's start with your worry
that pediatric surgery "is basically an advanced laparoscopic
fellowship." I'm not so sure about that. If you look at the statistics for
residents who finished pediatric surgery fellowships in 2013, you will find
that many open cases are being done. This <a href="http://www.acgme.org/acgmeweb/Portals/0/PedSNatData1213.pdf%2045%20residents%20in%2042%20programs">link</a> gives you all the information
you need. By my estimation, more than half of all pediatric surgery cases done
by fellows were open. That's the good news.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
For some bad news, you need to get the full text of this
American Journal of Surgery <a href="http://www.americanjournalofsurgery.com/article/S0002-9610%2813%2900508-4/abstract">paper</a> that appeared online in November 2013.
Written by some senior pediatric surgeons, it gives some worrying information
about the specialty of pediatric surgery. The number of complex cases being
done by attending pediatric surgeons has remained static while the number of
pediatric surgeons has increased. It looks like many pediatric surgeons, even
in university hospitals, aren't doing enough complex surgery.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The other bit of bad news is that competition for pediatric
surgery fellowship positions remains intense. Here are some data from the last
five matches.</div>
<div class="MsoNormal">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiA_Vm3AjPOVkdrld3YpHMZj1nNak4Ueg9vrSmd3wotMEdJ_GRltNpMI388hScCoo9_tFFN1tMBPPdw02WHzHSW336TY10kM8JXbyiUo6WAjLoLQZfH7tpb26mmKGvX4P5ughGWl7ViyqeP/s1600/Peds+Surg+Applicants.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiA_Vm3AjPOVkdrld3YpHMZj1nNak4Ueg9vrSmd3wotMEdJ_GRltNpMI388hScCoo9_tFFN1tMBPPdw02WHzHSW336TY10kM8JXbyiUo6WAjLoLQZfH7tpb26mmKGvX4P5ughGWl7ViyqeP/s1600/Peds+Surg+Applicants.jpg" height="272" width="400" /></a></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
As you can see the number of applicants for each position
ranges from 1.5 to 2, and the number of unmatched applicants is rather high.
</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Trauma surgery is not the answer. There are so few open
trauma cases being done that in order for trauma surgeons to maintain their
skills, the specialty has morphed into "trauma, critical care, and acute
care surgery."</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I may be wrong, but I don't see general surgery ever
returning to the old days where open surgery ruled. Not only that, I think in
the future more and more cases will be done with minimally invasive techniques,
even if the robot turns out to be a bust.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
So in answer to your final question, I think you will have a
problem if you do not learn to love the laparoscopic approach.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I wish you the best of luck.</div>
<div class="MsoNormal">
<br /></div>
Skeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.com9tag:blogger.com,1999:blog-2439171664390024694.post-44690368110194672842013-12-20T12:25:00.002-05:002013-12-20T12:25:25.231-05:00A woman asks, "Should I be a nurse practitioner or a doctor?"<!--[if gte mso 9]><xml>
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<br />
<div class="MsoNormal" style="line-height: normal; tab-stops: 136.2pt;">
<span style="font-family: Arial,Helvetica,sans-serif;">She writes [email edited for length]:</span></div>
<div class="MsoNormal" style="line-height: normal; tab-stops: 136.2pt;">
<span style="font-family: Arial,Helvetica,sans-serif;">
</span></div>
<div class="ecxmsonormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><i style="mso-bidi-font-style: normal;">I don’t ever do
this sort of thing, but your blog seems to be pretty legit, so I guess I’ll go
ahead this once.</i>[Quite a testimonial for my blog, don't you think?]<i style="mso-bidi-font-style: normal;"> I’m a post-undergraduate student seeking to
become either a nurse (with likely continuation to a nurse practitioner </i><span style="mso-bidi-font-style: normal;">[NP]</span><i style="mso-bidi-font-style: normal;"> degree)
or a doctor. The problem is I don’t know which way I should go.</i></span></div>
<div class="ecxmsonormal">
<br /></div>
<div class="ecxmsonormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><i style="mso-bidi-font-style: normal;">I know I have the
ability to get through medical school, but I’m not sure if it is worth it as
far as cost and benefit is concerned. I do, however, like the idea of the
autonomy that comes with being a doctor rather than a nurse. I have a
very analytical mind, and would enjoy the diagnosing and problem-solving that
comes with being a doctor. In fact, I’m not sure I would be happy without
the authority to determine and pursue treatment I had researched myself.</i></span></div>
<div class="ecxmsonormal">
<br /></div>
<div class="ecxmsonormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><i style="mso-bidi-font-style: normal;">On the other hand,
I really like interacting with patients and getting to know them personally. Ideally,
I want a job where I help people solve their medical issues, diagnose, have
autonomy, and interact regularly with patients. My main question is, does
this happen more as a nurse practitioner or doctor?</i></span></div>
<div class="ecxmsonormal">
<br /></div>
<div class="ecxmsonormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><i style="mso-bidi-font-style: normal;">I’d also like to
know if you think medical school is worth it with the rising cost of education
and likely fall in salary (at least in the US with Obamacare). I’m practical
and even if medical school is really what I want, I cannot justify going after
a degree that won’t be worth the cost. On the same note, if there is a great
shortage of doctors, will NPs be stepping up into doctors’ roles more often? Is
such a role assumption legitimate? And what will this mean for the medical
community and individuals going into medicine?</i></span></div>
<div class="ecxmsonormal">
<br /></div>
<div class="MsoNormal" style="line-height: normal;">
<span style="font-family: Arial,Helvetica,sans-serif;">[Note:
She is in her early 20s with very little debt right now, will finance future
education with loans, is not married, but eventually wants to have a family.]</span></div>
<div class="MsoNormal" style="line-height: normal;">
<br /></div>
<div class="MsoNormal" style="line-height: normal;">
<span style="font-family: Arial,Helvetica,sans-serif;">Thanks
for the kind words about the blog. </span></div>
<div class="MsoNormal" style="line-height: normal;">
<br /></div>
<div class="MsoNormal" style="line-height: normal;">
<span style="font-family: Arial,Helvetica,sans-serif;">Here's
what I think. It sounds like you want to do primary care. If that is so, why go
to medical school? You might want to consider becoming a physician assistant
(PA) too. The NP or PA route will be far less expensive. You will be able to
start practicing sooner, which means earning real money and paying off any
debts instead of deferring. </span></div>
<div class="MsoNormal" style="line-height: normal;">
<br /></div>
<div class="MsoNormal" style="line-height: normal;">
<span style="font-family: Arial,Helvetica,sans-serif;">Future
doctor shortage or not, I think nurse practitioners and PAs will dominate
primary care and also be given more autonomy. It is inevitable. The truth is, many PAs and NPs are not very closely supervised even now.</span></div>
<div class="MsoNormal" style="line-height: normal;">
<br /></div>
<div class="MsoNormal" style="line-height: normal;">
<span style="font-family: Arial,Helvetica,sans-serif;">I
hope that others will comment.</span></div>
<div class="MsoNormal" style="line-height: normal;">
<br /></div>
Skeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.com77tag:blogger.com,1999:blog-2439171664390024694.post-77302425554427317872013-10-02T10:36:00.000-04:002013-10-02T10:36:03.238-04:00Umbilical hernia repair: Choosing a surgeon and more<!--[if gte mso 9]><xml>
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<span style="font-size: large;"><span style="font-family: "Times New Roman","serif";"></span><span style="font-family: "Times New Roman","serif";">A reader
writes (in italics). My comments are in normal text.</span></span></div>
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<span style="font-size: large;"><span style="font-family: "Times New Roman","serif";"> </span>
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<span style="font-size: large;"><i><span style="color: windowtext; font-family: "Times New Roman","serif";">I am writing on
behalf of an otherwise healthy 30-ish-year-old relative, who was recently
diagnosed with an umbilical hernia, and another “just above it”.</span></i></span></div>
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<span style="font-size: large;"><i><span style="color: windowtext; font-family: "Times New Roman","serif";">She was diagnosed
about a month ago, and was sent to see a surgeon (not sure what kind). The
surgeon suggested a repair using mesh. She’s apprehensive moving forward with
surgery based upon several reasons:</span></i></span></div>
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<span style="font-size: large;"><i><span style="color: windowtext; font-family: "Times New Roman","serif";">She felt rushed
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procedure, wasn’t prepared with many questions, and failed to voice her
questions/concerns. She has since tried to contact the office to get some
questions answered but hasn’t gotten a response.</span></i></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal">
<span style="font-size: large;"><span style="font-family: "Times New Roman","serif";">This is
not medical advice. For that, I would need to examine your sister.</span></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt;">
<span style="font-size: large;"><span style="color: windowtext; font-family: "Times New Roman","serif";">It was probably a general surgeon. You have
mentioned three red flags—she felt rushed, she wasn't given much information,
and the office has not called her back. I would suggest you get another
surgeon.</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt;">
<span style="font-size: large;"><i><span style="color: windowtext; font-family: "Times New Roman","serif";">She consulted
Google and has read “bad things” online. She is concerned with the probability
of having to have repeat surgeries. </span></i></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt;">
<span style="font-size: large;"><span style="color: windowtext; font-family: "Times New Roman","serif";">Recurrence may occur after any hernia
operation. For a small umbilical hernia, the risk should not exceed 5%. The
infection rate for umbilical hernia repair is also fairly low, but if an
infection occurs, a recurrence is likely.</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt;">
<span style="font-size: large;"><i><span style="color: windowtext; font-family: "Times New Roman","serif";">Can you offer real
information regarding the types of procedures out there? Are there superior
methods, as suggested by many of the “scholarly” looking articles, which eventually
turn into advertisements? Many tout methods such as Shouldice, Bassini/McVay,
Tension-Free, etc. The info I have come across is conflicting and confusing.</span></i></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt;">
<span style="font-size: large;"><span style="color: windowtext; font-family: "Times New Roman","serif";">The information on the Internet is
confusing. The methods you mentioned are eponyms for groin hernia operations. They
do not pertain to umbilical hernia repairs. There are three currently accepted
methods of repairing an umbilical hernia—open suture repair, open mesh repair,
and laparoscopic mesh repair. The mesh repairs involve insertion of a piece of
artificial material to reinforce the abdominal wall. The theory is that the
patient's tissue broke down once so why rely on it to fix the hernia?
Recurrence rates (at least rates that are published) tend to be significantly
lower when mesh is used.</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt;">
<span style="font-size: large;"><i><span style="color: windowtext; font-family: "Times New Roman","serif";">I am unaware if
there is a hernia sub-specialty, but if there is, what would be the best way to
find such a surgeon? If not, is there an existing database that provides
information that details the number of hernia surgeries performed by a surgeon?</span></i></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt;">
<span style="font-size: large;"><span style="color: windowtext; font-family: "Times New Roman","serif";">There are some surgeons who specialize in
repairing hernias. I don't know of a database listing the number of hernia
operations performed by individual surgeons, nor is there any information on
individual surgeons' recurrence rates. The latter information is usually unknown
even to the surgeon because patients with recurrences tend to go elsewhere for
repeat surgery.</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt;">
<span style="font-size: large;"><i><span style="color: windowtext; font-family: "Times New Roman","serif";">Can you list
questions she should ask her surgeon that will aid her confidence in the
decision-making process? Her pain symptoms started about 2 years ago, and I
fear what she risks by continuing to delay.</span></i></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt;">
<span style="font-size: large;"><span style="color: windowtext; font-family: "Times New Roman","serif";">Questions that should be asked include the
following: what type of repair should I have, how many of these repairs have
you done, do you know your recurrence rate, what if I need to contact you at
night or on a weekend.</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt;">
<span style="font-size: large;"><span style="color: windowtext; font-family: "Times New Roman","serif";">Because she is symptomatic, she probably
should have elective surgery. Not having surgery runs the risk of
incarceration, or the trapping of a piece of intestine in the hernia. If this
happens, pain would be severe and the hernia would not be reducible. Emergency
surgery would be required and the risk of recurrence would be higher. If the
bowel's blood supply is irreversibly damaged, some of it may need to be
removed. This also increases the risk of complications.</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt;">
<br /></div>
<span style="font-size: large;"><span style="color: windowtext; font-family: "Times New Roman","serif";">I would find
another surgeon to do the operation, preferably a general surgeon with
expertise in hernia repairs. If the two hernias are not close together, the
laparoscopic method might be best provided she has not had extensive prior
abdominal surgery. </span></span>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal">
<span style="font-size: large;"><span style="font-family: "Times New Roman","serif";">I hope
this helps.</span></span></div>
Skeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.com4tag:blogger.com,1999:blog-2439171664390024694.post-39624364040107737392013-10-01T12:34:00.002-04:002013-10-01T12:34:40.055-04:00A UK Med Student Discovers Surgery, Has Questions<!--[if gte mso 9]><xml>
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<![endif]-->Gareth (not his real name) writes
<br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">I
came across your blog a few days ago and I have been reading it since. I am a
third year medical student studying in the UK. I am writing to you because I
would be grateful if I could get some advice. I have always wanted to become a doctor,
since I was veryyyyy young, but I never ever considered a career in surgery.
Before medical school, I believed that surgeons were like butchers, not capable
of any human attachment for the patient etc etc. I believed I would not be able
to bear the responsibility to cut someone open given the fact that I am a very
emotional person. However, my perspective changed when I was in the OR and saw
my first surgery. It was a coronary bypass surgery and I loved it, I loved the
idea of making the patient better in such short time and the fact that the
surgeon was the one responsible for it, I suppose it must be very satisfying.
Therefore, I have started to consider a career in surgery, however, I am still
very unsure of whether I have the right personality type and skills to become a
surgeon. I still tend to get very attached and moved by patients' stories and
experiences and I don't know whether that would help me detach myself from the
patient whilst operating. Also, most surgeons seem to be extremely confident
and outgoing whereas I tend to be shy and not confident, even though I'm quite
good academically. So I am really confused right now. Also, I have never had
great hand skills, even though I took some introductory surgical skills courses
and they went quite well. I seem to get a bit of tremor when I do practical
stuff though, I guess that's because I get nervous. </span></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">I'd
like to ask you one more thing. If I do decide to go for a career in surgery,
is there any point for me to try and take the USMLE and apply for a US
residency after graduation? I heard surgery it's really competitive, I guess
many schools don't even accept international applicants?</span></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">Thank
you very much for your time and dedication. I admire the passion that you show.</span></i><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;"></span></div>
<div class="MsoNormal">
<br /></div>
Thank you for reading my blog and for writing. I am glad that you have realized what a rewarding career surgery can be.<br />
<br />First let's talk about the "surgical personality." There was a time when most surgeons could have been categorized into a couple of personality types. Those days are gone. Now that 40% of all surgical residents are women it is no longer necessary to be a certain type of individual. I know many surgeons who are quiet, thoughtful and introspective. You need to dismiss any thoughts about your personality type being incompatible with a career in surgery. Also it is not a bad thing for a surgeon to identify with and become attached to his patients.<br /><br />The next myth is that one must have great dexterity to become a surgeon. In the old days some residency programs use to screen applicants by making them build model airplanes. I don't believe anyone still does that. Now it seems that video game skills are much more important since so many procedures are done laparoscopically. I believe that anyone can become a more than decent technical surgeon through practice. We all get nervous. This is a real person you are operating on. I have written that there is more to surgery than manual skills. It is very important to know who to operate on and when to operate on them as well as who not to operate on.<br /><br />I have written before about the decreasing chances of graduates from non-US medical schools obtaining residencies in the United States. US medical schools are expanding their class sizes and a new schools are opening. It is not even clear that all us graduates will be able to obtain residency positions in the future. The most recent statistics from the match show that only about 5% of non-US citizen graduates of foreign schools matched into categorical general surgery positions. However, I do not believe you have anything to lose by trying. You will need to get an excellent score on the USMLE and of course, have good grades and recommendations. Although it is difficult, some trainees from the UK have been able to find fellowships in the US. I do not know how easy that will be in the next few years.<br /><br />Good luckSkeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.com8tag:blogger.com,1999:blog-2439171664390024694.post-3910356356556823852013-09-24T15:43:00.000-04:002013-09-24T15:43:25.770-04:00A pre-med student asks some probing questions<!--[if gte mso 9]><xml>
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<div class="MsoNormal">
Here are some questions from Lionel, a pre-med student.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">What
is something you wish you had known before entering medical school?</span></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">It would have been nice to have known what changes
were going to occur over the 40+ years since I graduated. </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">If
you had the opportunity to choose a specialty all over again, would you do
surgery again?</span></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">Yes. While I have often envied the controlled
lifestyles and flexibility of radiologists and anesthesiologists, I don't think
I could have stood the sitting in the dark all day (radiology) or utter boredom
95% of the time (anesthesia).</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">If
not medicine, what other healthcare occupation would you consider to be more
rewarding?</span></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">It depends on how you define rewarding. It seems to
me that being CEO of a hospital is more rewarding financially these days. I
have </span><a href="http://skepticalscalpel.blogspot.com/2012/05/i-missed-my-calling-hospital-execs-pay.html"><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">blogged</span></a><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">
about that. Is it more satisfying on any other level? I don't think so. </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">Is
it possible to carry a healthy relationship where the significant other is not
a medical student? Would it be more/less difficult in residency compared to
medical school? [this is one I'm mostly interested in especially since you are
a surgeon]</span></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">I am living proof that it is possible to have a
healthy relationship with someone who is not a med student or physician. I met
my wife, who is a nurse, when I was an intern. We were married when I was a
third-year resident and still going strong at 39 years.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">What
implications have enduring medical school/residency had on your personality?</span></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">I was always kind of a pessimist, but med school
and beyond amplified that trait a lot. As some people have written about
lately, med school and residency can induce cynicism, and I'm afraid I am a
classic example of that.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">Does
every single day of the year feel stressful or are there days where you feel in
control and free to relax?</span></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">Since I retired late last year, the days are not
particularly stressful right now. When I was an active surgeon, just about
every day was very stressful. It took at least the first five days of every
vacation to unwind, longer if I had gone away and left a sick patient to be
managed by someone else. Here's a </span><a href="http://skepticalscalpel.blogspot.com/2012/06/patient-complications-surgeon.html"><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">link</span></a><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">
to a post I wrote about "collateral damage," which is about how
complications affect surgeons.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">I
have always dreamed that being a physician would help me feel more connected
spiritually to god/universe by seeing all the unfortunate people and being able
to lend compassion. However, does being under constant stress distract a
physicians focus from that feeling and does it make you just want to finish the
job and go home?</span></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">There were many days when I just wanted to finish
the job and go home. I would like to think though that I was able to get past
that and offer my patients the compassion and support they needed.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">What
do you like/dislike the most about your journey thus far?</span></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I liked the challenge of figuring out what was wrong with a
patient and having the ability to fix it. I liked the feeling of satisfaction
after helping someone who was really sick get better. Today I got an email from
a former patient who is 10 years postop from breast cancer surgery and disease
free. Hearing that is hard to beat.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I took every complication, whether it was my fault or not,
very personally. That can wear you down. I didn't like the empty feeling that I
got when I operated on a patient and found something like incurable cancer. It
was frustrating not to be able to do anything about it. It is very hard to look
someone in the eye and tell him that the surgery did not solve the problem.</div>
<div class="MsoNormal">
<br /></div>
<br />Skeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.com22tag:blogger.com,1999:blog-2439171664390024694.post-26241743937912784842013-09-19T08:35:00.002-04:002013-09-19T08:35:56.354-04:00Is medical school worth it?<!--[if gte mso 9]><xml>
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<br />
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<span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;"></span><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">A woman writes</span>
</div>
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<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">I came across your blog as I was looking for "doctors with good
hours." Here's my situation:<br />
<br />
I'm a female currently applying to medical school. Besides the question of
"Can I get in?" (which is haunting me right now since my MCAT score
of 31 is scaring me...all my friends have gotten interviews but I still haven't
heard a thing), I'm wondering if it's even worth it to go to med school.</span></i></div>
<div class="MsoNormal" style="margin-bottom: 12.0pt;">
<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">The biggest things concerning me:</span></i></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">1)
The money. I have no idea how I'm going to pay that all back.</span><span style="background: white; color: black;"> If I get into my state med school, my
estimated cost for tuition is $120,000. If I get into an out of state school,
I'm looking at minimum $200,000 for tuition alone. I didn't calculate school
fees, test fees, books, transportation, or car payment (I'll probably have to
buy a car) into either my state or out of state costs.</span></i><i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;"></span></i></div>
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<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">2)
The inflexibility. I have a boyfriend, we're planning on getting married, and
he has his career too. It seems like the next four years + 3 years + ? =
uncertainty since I don't know where I'm going to med school, where I'd match,
etc, and where he'd work in that meantime.</span></i></div>
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<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">3) The time. I'd also like a family. I don't know how fair it is to get
through med school and residency and then do a part time physician thing.
Doesn't seem very smart to me.</span></i></div>
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<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">My
question is, Is there light at the end of the tunnel? Am I just imagining
trouble, or is medical life as a physician not worth it? My alternate career is
to become a nurse--get my master's in about two years (through an accelerated
program), work, and advance upward, maybe to a Nurse Practitioner level.</span></i></div>
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<span style="background: white; color: black;"><br />
Thanks for writing. </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="background: white; color: black;">You have nicely listed
some of the major challenges facing most women who are considering medicine as
a career.<br />
<br />
</span>You are the only person who can decide if medical school is worth it for
you, but let's see if we can think it through.</div>
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<br /></div>
<div class="MsoNormal">
My first instinct is to tell you to carefully reread your
email as if it had been written by someone else. After doing so, what is your
reaction? After you do that, resume reading my reply.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Not being a woman, I decided to outsource this. One of my
daughters who is not a doctor, but has a master's degree in a science, is
married and has two children said,</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
"It sounds like she doesn't really want to be a
doctor..."</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
My wife, who is a nurse, agreed and said nursing is a career
that allows you to do the things you wrote about. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Here are three posts I have written about this subject. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<a href="http://skepticalscalpel.blogspot.com/2011/07/choosing-medical-specialty-is-difficult.html">Choosing
a medical specialty is difficult</a>. And note the comments.</div>
<div class="MsoNormal">
<a href="http://skepticalscalpel.blogspot.com/2012/07/surgery-work-home-conflict.html">Surgery
and work-home conflict</a>.</div>
<div class="MsoNormal">
<a href="http://askskepticalscalpel.blogspot.com/2012/09/a-college-student-has-second-thoughts_13.html">A
college student has second thoughts about medical school</a>.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I will also ask my Twitter followers to read this and
comment. I hope they do.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
Skeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.com15tag:blogger.com,1999:blog-2439171664390024694.post-59851070099395616212013-09-11T13:02:00.000-04:002013-09-11T13:02:41.807-04:00Is it possible to live a full life as a surgeon?<!--[if gte mso 9]><xml>
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<br />
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<br /><span style="mso-bidi-font-weight: bold; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;"></span><span style="mso-bidi-font-weight: bold; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;"></span><span style="mso-bidi-font-weight: bold; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">Neymar (not his real
name) writes</span>
</div>
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<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">Dear
(Dr.) Skeptical Scalpel:</span></i></div>
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<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">I'm
writing this evening as a fourth year medical student wholly committed to
pursuing a long and fulfilling life as a general surgeon. It's what I got into
medicine for, and my love for the profession has only heightened in the arduous
years of preparation and (nascent) training I've undergone thus far. I have had
the fortune of living a very full life—travel, adventure, and a broad milieu of
individuals have all shaped the form of the man I am now, and greatly influence
the man—and surgeon—I hope to be in time. </span></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">Like
many people in and outside of medicine, I reflect on what has been lost or what
might have been lost along the path. At present, the balance sheet reflects a
clear net gain. The opportunity cost, however, can be measured in the loss of
time in wilderness, love and relationships and socializing that adds richness
to my life. How do you advise young physicians pursuing such an ambitious and
all encompassing professional course to maintain richness and fullness in their
lives? How do you reconcile the personal forfeitures with the professional
gains? And, most importantly, if one hopes to be a surgeon, are these questions
worth considering or best left in the recesses of the mind?</span></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">Thanks
for being a mentor to an entire generation of aspiring surgeons. </span></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Thank you for writing and for the kind words. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The questions are definitely worth considering. I am not
sure that my response will be applicable to your situation or anyone else's.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I chose surgery because it appealed to me more than any
other specialty. Like most others of my era, I was young and had gone the
traditional route—four years of college followed immediately by med school. I
had experienced few adventures [in fact, none] and had not yet met my
wife-to-be.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I never even considered what impact my choice would have on
my personal life. The subject simply did not come up. I worked hard in medical
school but had a great time. I think I had more fun in med school than I did in
college.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
My residency prepared me well for the rigors of a surgical
career. I spent the first four years of my training taking call about half
every other night and half every third night. As a chief resident, I was in
call every night. Somehow I found the time to have a relationship and got
married at the end of my third year.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
My wife of 39 years is a saint. I have wonderful children
and now grandchildren too.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I was fortunate in my career to have had the opportunity to supervise
the training a number of surgeons who are helping people every day. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Although I'll never climb Everest, go an African safari, ski
the Swiss Alps or do many other things that might be important to others, I've
had an interesting and fulfilling life. Wilderness? Not so much. But love and relationships?
I got 'em.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
But it is different for the millennial generation. What I
consider interesting and fulfilling might not be to you.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Surgery continues to evolve. I think it may be possible in
the near future to have a career as a general surgeon and also have a
manageable lifestyle. By the time you finish training, everyone will be in
group or hospital-based practices. Or you could be an acute care surgeon with
fixed hours.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
You will have to decide what compromises to make such as
deciding if leaving work at 5 pm is more important than staying late to operate
on your patient who has a complication you created.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
No one talks about this part—you will have to find partners
you can trust with the lives of your patients. The roadside is littered with
the corpses of group practices that didn't last because of productivity issues,
attitudinal and/or philosophical differences among the surgeons.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
For many surgeons, fulfillment is measured by the
satisfaction of knowing you made a difference in someone's life.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Can you be a surgeon and have a rich and fulfilling life?
You can, but it depends on how you define rich and fulfilling.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
If you haven't read this <a href="http://skepticalscalpel.blogspot.com/2011/07/choosing-medical-specialty-is-difficult.html">post</a>,
you should. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
Skeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.com5tag:blogger.com,1999:blog-2439171664390024694.post-63706968612077994272013-08-14T09:21:00.001-04:002013-08-14T09:23:56.807-04:00How can I overcome a low USMLE Step I score?<!--[if gte mso 9]><xml>
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<![endif]-->Nemanja (not his real name)
writes:<i style="mso-bidi-font-style: normal;"> I am a fourth year medical
student at a US school. I am planning on applying to general surgery in the
next month. I have a few concerns and questions about my application and
competitiveness. </i><br />
<div class="MsoNormal" style="line-height: normal;">
<br /></div>
<div class="MsoNormal" style="line-height: normal;">
<i style="mso-bidi-font-style: normal;">I did very well years 1 and 2, all but one honors. I got a 209 on USMLE
Step 1 and a 243 on step 2. The caveat about my step 1 score is as follows. I
had a family tragedy 1-2 months prior to taking step 1. In retrospect I
probably should have deferred and not taken it but hindsight is 20/20.</i></div>
<div class="MsoNormal" style="line-height: normal;">
<br /></div>
<div class="MsoNormal" style="line-height: normal;">
<i style="mso-bidi-font-style: normal;">After that poor step 1 score, I did well on my clinical rotations. I
received a high pass in surgery and honors in 4 other clinical rotations with
no grade less than a high pass. I expect to receive strong letters of
recommendation from my program director and clinical faculty. I am interested in
applying to programs in the northeast portion of the US. </i></div>
<div class="MsoNormal" style="line-height: normal;">
<br /></div>
<div class="MsoNormal" style="line-height: normal;">
<i style="mso-bidi-font-style: normal;">How can I let a program director know about
my situation (e.g., in my personal statement, in my dean's letter). Some of the
people at my institution have led me to believe that this is an important part
of my story and something that may provide an explanation for a below average
step 1 score. I am afraid that I will be filtered out due to my step 1 score
from many university based programs. What do you think is my best approach to
this situation? </i></div>
<div class="MsoNormal" style="line-height: normal;">
<br /></div>
<div class="MsoNormal" style="line-height: normal;">
Your question is a good one. I am
sorry about your family tragedy. </div>
<div class="MsoNormal" style="line-height: normal;">
<br /></div>
<div class="MsoNormal" style="line-height: normal;">
I suggest you explain it in your
personal statement and ask the dean to mention it in his letter too. You need
to emphasize the fact that your Step II score is very good. Strong letters of recommendation
will help.</div>
<div class="MsoNormal" style="line-height: normal;">
<br /></div>
<div class="MsoNormal" style="line-height: normal;">
If you search PubMed for "USMLE
Step I," you can find a fair amount of information about the weight
program directors put on it. One <a href="http://www.ncbi.nlm.nih.gov/pubmed/21292219">paper</a> says it is the single most important
factor used by PDs to screen applicants. <a href="http://www.ncbi.nlm.nih.gov/pubmed/20855755">Another</a> says that a Step I score of < 200 is associated with a higher risk of failing part I of the general surgery board exam.</div>
<div class="MsoNormal" style="line-height: normal;">
<br /></div>
<div class="MsoNormal" style="line-height: normal;">
Here is a <a href="http://www.nrmp.org/data/chartingoutcomes2011.pdf">link</a> to a PDF from the
NRMP about match outcomes. If you go to page 84, you will find some interesting
data about the 2011 general surgery match.</div>
<div class="MsoNormal" style="line-height: normal;">
<br /></div>
<div class="MsoNormal" style="line-height: normal;">
I have some screen shots for you. </div>
<div class="MsoNormal" style="line-height: normal;">
<br /></div>
<div class="MsoNormal" style="line-height: normal;">
Here's a table listing some
summary statistics.</div>
<div class="MsoNormal" style="line-height: normal;">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7f-F3kyRvINI21YiYAhXzQTImGvZKF6dosgTcnNPDUCDQodhd5S5Gj6r112TE8xejUtzxH0bC6O3BtOWSyJn-c7cHC07M-S5RUf-CUDws4dwZn-hbTFDbKfZpMvkgoLhF0_pnl1K47GqG/s1600/GS+Summary+Stats.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="377" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7f-F3kyRvINI21YiYAhXzQTImGvZKF6dosgTcnNPDUCDQodhd5S5Gj6r112TE8xejUtzxH0bC6O3BtOWSyJn-c7cHC07M-S5RUf-CUDws4dwZn-hbTFDbKfZpMvkgoLhF0_pnl1K47GqG/s640/GS+Summary+Stats.jpg" width="640" /></a></div>
<div class="MsoNormal" style="line-height: normal;">
<br /></div>
<div class="MsoNormal" style="line-height: normal;">
This is a graph indicating that a
USMLE Step I score of 209 gives you about a 75% chance of matching in surgery. </div>
<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgRIOdMKfDxqrKvEQSoYBeHnnbYWFhAZvekDBqTktL0Vy903tqQIFTtiuANMDegPlaO0mqhY3689ZZi898WSr9KzJChM5fEa_2e4_r55LNIiZagJDkj0EagMdC-4-bFb7TuFZQnGMUIm4Gy/s1600/GS+USMLE+Graph.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgRIOdMKfDxqrKvEQSoYBeHnnbYWFhAZvekDBqTktL0Vy903tqQIFTtiuANMDegPlaO0mqhY3689ZZi898WSr9KzJChM5fEa_2e4_r55LNIiZagJDkj0EagMdC-4-bFb7TuFZQnGMUIm4Gy/s640/GS+USMLE+Graph.jpg" width="640" /></a></div>
But here is a chart showing that
a Step II score of 243 gives you a very good chance of matching. No graph was provided.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQg-Zi5XUfqnjwNc9gSTcZaXV5ELFerVtnfeLUEW6bizxNvnTInbeUG7uba8m9cYH5dy-8PeKfeMYO-TTYovahihecHhAKidydgbLiF0z1S7Ons1h42WZSMbqSJOuSyxsuDD74cxQ_Btnb/s1600/GS+By+scores+II.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="233" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQg-Zi5XUfqnjwNc9gSTcZaXV5ELFerVtnfeLUEW6bizxNvnTInbeUG7uba8m9cYH5dy-8PeKfeMYO-TTYovahihecHhAKidydgbLiF0z1S7Ons1h42WZSMbqSJOuSyxsuDD74cxQ_Btnb/s640/GS+By+scores+II.jpg" width="640" /></a></div>
The message is very clear. Get
the PDs to look at your Step II score<br />
<div class="MsoNormal" style="line-height: normal;">
<br /></div>
<div class="MsoNormal" style="line-height: normal;">
You may want to apply to some community
hospital-based programs to be safe. I think you will match in a categorical
position.</div>
<div class="MsoNormal" style="line-height: normal;">
<br /></div>
<div class="MsoNormal" style="line-height: normal;">
Good luck. Please let me know how
things turn out. </div>
<br />Skeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.com42tag:blogger.com,1999:blog-2439171664390024694.post-29175087671161442442013-07-30T10:11:00.003-04:002013-07-30T10:11:57.441-04:00Are program directors the reason that surgical residency training is a mess?
<div class="SubTitle">
<span id="ctl00_ContentPlaceHolder1_lblSubTitle"></span><em>A
resident writes: "You have been a program director (PD). I read your
article about residents not being confident about surgical skills and
you conveniently blamed resident work hours limits/resident work ethic
for this. I ask you how come PDs are not responsible for the training
they provide? How can they get away with telling residents/fellows on
what the residents/fellows can say/write on evaluations that accredit
the program? How can they get away without providing adequate
training/exposure in lap/robotic surgery? How come we don't teach
surgeons how to teach surgical skills? Just because one is a good
surgeon does not mean they can teach surgical skills to others. After
all Michael Jordan was a great basketball player, but that does not
necessarily imply he would make a good coach. In fact I would argue that
average basketball players make better coaches."</em></div>
<div class="SubTitle">
<em> </em> </div>
<span id="ctl00_ContentPlaceHolder1_lblBody">Great questions. Let's see what I can do to answer them.<br />
<br />
I
"conveniently blamed resident work hours limits/resident work ethic"
for the lack of confidence in their skills that >25% of general
surgery residents have. That problem was not created by program
directors. Most PDs hate it. It certainly is a contributing factor to
the lack of resident confidence.<br />
We are responsible for
the training we provide. We must sign a form attesting to the competence
of our graduating residents. I cannot speak for current PDs, but I felt
very responsible for the residents when I was a PD.<br />
<br />
I never
told a resident what to write on an evaluation. I understand that may
happen, but the evaluations are submitted on line anonymously to the
accrediting body, the Residency Review Committee for Surgery. The
residents are free to say whatever they want and no one will be able to
trace it back to an individual. In my experience, the residents did not
hold back on their complaints.<br />
<br />
I agree with you that we are
obviously not training residents well enough in some areas such as
advanced laparoscopic surgery. That is difficult to understand and
explain. It must be true because so many graduates of five-year programs
feel the need to take extra training. I think it is somewhat harder to
teach minimally invasive surgery. I always felt I could control what the
resident was doing during open operations; for laparoscopic procedures,
not so much. But we should be doing a better job in that area.<br />
<br />
And
it's not just laparoscopy or the American College of Surgeons wouldn't
have established "Transition to Practice" fellowships. See my previous <a href="http://skepticalscalpel.blogspot.com/2013/04/what-american-college-of-surgeons.html">blog</a> about this. There is also the problem of too much supervision which I mention in that blog.<br />
<br />
I
have news for you. In most cases, surgeons are not taught how to teach
anything, let alone surgical skills. For many years, it has just been
assumed that any surgeon (or any doctor in any specialty) is an
excellent teacher. Of course, this is not so.<br />
<br />
However, teaching is not
particularly valued or rewarded an academic medicine. On the other hand
research is, especially research that brings in grant money. <br />
<br />
Teaching
is also a problem in community hospital programs because attending
surgeons are busy trying to stay afloat financially.<br />
<br />
I agree
with you that Michael Jordan and most other superstars of sport would
not make good coaches. It may be similar in surgery. I don't think that
has been investigated, nor is such a study likely.<br />
<br />
In case you haven't read any of my previous posts (search "surgical education" on the Skeptical Scalpel <a href="http://skepticalscalpel.blogspot.com/">blog</a>) on this subject, I am pessimistic about the future of surgical education.</span>Skeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.com0tag:blogger.com,1999:blog-2439171664390024694.post-33954166795117473372013-06-05T09:53:00.000-04:002013-06-05T09:53:10.781-04:00A med student with issues wants to be a surgeon<!--[if gte mso 9]><xml>
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<i>An osteopathic medical student writes that she is older than
most students, failed a course in her first year of med school, had to take the
COMLEX (osteopathic equivalent to USMLE) several times before passing. She has
earned good grades in her third-year rotations. </i><br />
<i></i><br />
<div class="MsoNormal">
<i>She said, "I found your blog one night earlier this
week while doing research on obtaining a surgical residency. After reading your
blog, I thought you might be able to help. What can I say to programs and put
in my application to make me stand out as someone who they would value and
honestly consider?"</i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I appreciate your reading my blog. As you have correctly pointed
out, you have some problems. I hope you can handle the truth (from the movie
"A Few Good Men").</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
1. You are an osteopathic student, which may adversely
affect your ability to obtain a general surgery residency by a little to a lot,
depending on where you<span style="mso-spacerun: yes;"> </span>apply.</div>
<div class="MsoNormal">
2. You are a non-traditional student (not so bad) but your
age of 33 is another issue. Should it matter? No. Does it matter? In my
opinion, yes.</div>
<div class="MsoNormal">
3. You had some trouble in the first year of school. That is usually a red flag, and many program directors would not get
past that part of your dean's letter and transcript.</div>
<div class="MsoNormal">
4. You have "struggled with the COMLEX and have had to
take it multiple times" and you have not taken the USMLE.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
With the disclaimer that this is strictly my opinion and I
cannot say how you would be viewed by other PDs, your chances of matching to a
categorical position in general surgery are slim. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
What can you do to improve the odds? Here's what I would suggest.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
To counteract the COMLEX issue, try to take at least USMLE
Part I and do very well on it.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
In your personal statement, you should own up to the concerns
just as you did in your email to me except that you need to condense everything
into a much shorter document. You should emphasize that you have conquered
these shortcomings. You need to find med school teachers, particularly
surgeons, who know you well and are willing to write exceedingly strong letters
of recommendation. A letter from someone who a PD might have heard of would not
hurt.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
You then have to wait and see if you are invited for any
interviews. If you are, you need to impress everyone with your charm, work
ethic and intelligence.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
You also need a "Plan B." Would you take a
non-designated preliminary slot hoping for someone to falter or quit so you
could transfer into a categorical position? It is risky because you might end
up wasting a year or two and have to take a residency in something else anyway.
That's not a big deal if you are 26 when you graduate from med school, but for
you it would be.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Another option would be to do an internal medicine residency
and specialize in GI or cardiology which are procedure oriented. It's not surgery,
but it might be satisfying and certainly would be easier to achieve. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
You didn't mention whether you had significant student loan debt
or not. That needs to be factored in if you are considering the non-designated
prelim choice.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I hope this helps. Let me know how it turns out.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Good luck. </div>
<br />Skeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.com26tag:blogger.com,1999:blog-2439171664390024694.post-57745046482387010742013-02-25T14:29:00.000-05:002013-02-27T13:54:19.754-05:00Non-US citizen at a Caribbean med school wonders what his chances are for getting a surgical residency <!--[if gte mso 9]><xml>
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<br />
<div class="MsoNormal">
<i>"Leighton" (not his real name) writes,</i></div>
<div class="MsoNormal">
<br /></div>
<i>
</i><br />
<div class="MsoNormal">
<i>I'm a 4th yr medical student hoping to match into general
surgery in 2014. The only hurdle is that I'm an international medical graduate (IMG).
I'm a non-US citizen at a Caribbean med school. </i></div>
<i>
</i><br />
<div class="MsoNormal">
<i>I have done all my core rotations which include IM, Psych,
Gen Surg, Peds and OB/GYN. So far I have all As in my rotations. I did my
surgery rotation at Elsewhere General Hospital in the Midwest. It's a community
hospital without a surgery residency program.</i></div>
<div class="MsoNormal">
<br /></div>
<i>
</i><br />
<div class="MsoNormal">
<i>I have a pretty good USMLE step 1 score (247) and will be
writing step 2 in the coming months. Since you have been a residency director,
what can I do to improve my chances? What do residency programs look at? What
programs might be more IMG-friendly? Surgery is quite competitive, do I have a
chance as an IMG or should I focus my electives more for IM or Family med?</i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Data for the 2012 <a href="http://www.nrmp.org/data/resultsanddata2012.pdf">match</a> (page 5) shows
that general surgery filled 1143 (99.7%) of 1146 available categorical
positions via the match. Of the 1143 who matched, 57 (4.9%) were non-US citizen
IMGs.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
While your USMLE score is very good, I don't know if it puts
you in the top 5% of all non-US IMGs. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I'm afraid it is difficult to judge what
your grades mean, but that is also a problem with US med school grades. (See a
previous <a href="http://skepticalscalpel.blogspot.com/2012/10/medical-school-grading-and-t-ball.html">blog</a>
of mine.) Certainly, all 'A's are better than all 'B's in any school. But how
many students in your school get all 'A's?</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The only way to find out if a program is IMG friendly is to
go to each program's website and see where their current residents are from.
Here's a <a href="https://services.aamc.org/eras/erasstats/par/display8.cfm?NAV_ROW=PAR&SPEC_CD=440">link</a>
from ERAS, that gives the web addresses for all of the general surgery programs
in the US.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
See if your school has any
information on how many of its students matched in general surgery over the last two
or three years, what their records were like and where they matched. You might
also try to contact a couple of those students for advice too.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I'm not sure how to improve your chances. Doing research
never impressed me unless it was clinical research that resulted in a published
paper in a journal that I had heard of. You might explore elective rotations at
some programs that you know have taken non-US IMGs.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The way the match works favors the applicant. You have
nothing to lose by trying to match in surgery. If you fail to get a categorical
spot, you have two options. You can take a preliminary position and hope to
work your way into a categorical one. There were <strike>737</strike> 484* surgical prelim positions
open after the match last year. However, that can be risky if no categorical spots open up.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Or you could go into internal medicine, which had only 51
unmatched positions or family medicine which had 149. The link to the NRMP
match statistics shows all the specialties and how they fared in the 2012
match.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
If you decide to pursue surgery, you will need to tailor
your electives accordingly. I have written about fourth-year <a href="http://skepticalscalpel.blogspot.com/2010/08/medical-school-and-surgery.html">electives</a>.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I hope this helps. Good luck and let us know how it went
after next year's match.<br />
<br />
[*Number of unfilled prelim positions corrected on 2/27.] </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
Skeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.com4tag:blogger.com,1999:blog-2439171664390024694.post-63883544824645715812013-02-20T13:15:00.000-05:002013-02-20T13:15:51.355-05:00Does OR staff hair cause infections?<!--[if gte mso 9]><xml>
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<div class="MsoNormal">
“Zlatan” (not his real name) writes:</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman";">I
just recently found your blog and read about shaving patients and agree with
all that you said. My question is about the staff's hair. Sorry if you have
addressed this, I couldn't find it. </span></i></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman";">I
work at a VA hospital in surgery. I have been in the OR environment for 30
years and have seen quite a lot and been through many inspections. We had an
independent nurse evaluate us for upcoming JCAHO inspection. We 'failed' due to
not covering facial hair and chest hair with scrub attire and in addition were
told folks with hairy arms needed long-sleeve scrub tops. Of course this comes
from the all powerful AORN. Being an evidence-based person at heart, I began to
look for some evidence regarding covering up (that is how I stumbled onto your
blog). Do you have any knowledge of evidence based practice regarding hair
covering and infection rates? I appreciate your time.</span></i></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman";">Thanks!</span></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Great question. Where do they come up with these things?
Chest hair? Arm hair? Long-sleeve scrub tops?</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
For the record, I am against wound infections. I would do
anything reasonable to try to prevent them.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I suspect your independent nurse evaluator may have
over-interpreted the rules. My distaste for the Joint Commission (by the way,
it’s no longer called “JCAHO”) runs deep, but I don’t think even they have
thought of those wrinkles to the hair issue.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
It is possible though as the JC and the AORN seemed to be
obsessed with hair. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
How does one define "hairy arms"? I assume long sleeve scrub tops would be for the circulating
nurse only. If the surgeon and the scrub tech wore long sleeves, they wouldn’t
be able to properly wash their hands and arms.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Regarding the chest hair, are we talking male or female
staff? (Just kidding.)</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
As far as I know, there is not one shred of evidence linking
shed skin or hair on the head, face, chest or arms of OR staff to patient infections. This
is after an exhaustive search of PubMed, CDC, and holding nothing back, I even
crowd-sourced the question on Twitter.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
In case some readers missed my post on the ritual of
clipping the hair of patients before surgery, the link is <a href="http://skepticalscalpel.blogspot.com/2012/05/rule-without-foundation.html">here</a>.
The post was about rules that people make up without any justification to drive
us all crazy.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I collected several such rules related to presumed infection prevention in the comments section of
that post and elsewhere. Here they are.</div>
<div class="MsoNormal">
<br />
No forced-air warming until patient is draped.<br />
No briefcases in the OR.<br />
No one may enter the room without the circulator's permission.<br />
No room warming as it may cause condensation on surgical instruments. (Children
and burn victims who may become hypothermic be damned!)</div>
<div class="MsoNormal">
Remove masks every time you leave the OR. And no letting
them hang down with just the lower tie done.</div>
<div class="MsoNormal">
Masks must be worn by anyone in the scrub sink area even if
that person is not scrubbing but just walking by.</div>
<div class="MsoNormal">
All OR personnel must wear long sleeves because of the
potential for "shedding skin."</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
But the independent nurse reviewer has spoken. I’m betting
that long sleeve scrub tops and chest and arm hair police will soon appear in your OR.</div>
<div class="MsoNormal">
<br /></div>
Skeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.com32tag:blogger.com,1999:blog-2439171664390024694.post-57477957820057013072013-02-14T08:01:00.000-05:002013-02-14T08:59:01.765-05:00A patient wants to know when to speak up<!--[if gte mso 9]><xml>
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Matthew writes:
<br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 12.0pt;">
<i style="mso-bidi-font-style: normal;"><span style="mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman";">My only experience with the medical profession is strictly as a patient.
I'm wondering what is an appropriate balance between being an educated patient
(willing to ask questions, make observations, etc.) versus being one of those
supposedly "self-educated" know-it-all patients that I'm sure are one
of the banes of a doctor's existence.<br />
<br />
We've all heard the stories of the patient whose doctor didn't listen to their
concerns until it was too late, but on the other hand, I don't deny that my
doctor knows worlds more about my body than I do, or ever will.</span></i></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman";">I
want to trust my doctor, but without having to blindly accept whatever he tells
me. Yet I've dealt with members of the medical community who see anything BUT
blind acceptance as a personal affront.<br />
<br />
As such, is there ever a time to research symptoms online before making an
appointment? Is there ever a time to disagree with a diagnosis? Is there ever a
time to request or ask about alternate treatments? And if so, how can this be
done in a way that is respectful to my physician?</span></i><span style="mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman";"></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
You ask some excellent questions.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I’m not sure I have all the answers. I hope some of my physician colleagues will comment. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
There is a fine and very fuzzy line between asking
good questions and being a pain in the ass. And that line is drawn in different
places by different doctors. It ranges from zero tolerance for questions (See
Dr. Sung on “Monday Mornings,” who, when asked a question about a procedure he
recommended, said, “Not do—dead.”) to the most open-minded, usually a primary
care doc or psychiatrist. There are issues of time, urgency, the physician’s
perception of the patient’s level of understanding, the complexity of the
disease or operation and many more.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I had no problem with patients who researched their symptoms
online. However, I would hate it when a patient brought a portfolio with 100
pages of downloaded material for me to comment on. There is a lot of garbage on
the Internet.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I think you should always ask what your options are.
Informed consent discussions should include the risks, benefits and
alternatives for any procedure. The doctor should also tell you what the risks
and benefits of the alternatives are too.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Go with your gut. If what the doctor says to do does not
sound right, say you will think it over. Don’t be afraid to get a second
opinion. Run away quickly from any doctor who discourages second opinions. I
always encouraged second opinions for patients who were reluctant to have
surgery I recommended. I felt that if I was proposing the right thing, the
second opinion doctor would support me.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
One of the worst things a patient can do is be too
acquiescent to the physician. I used to tell patients “Don’t worry about
hurting your doctor’s feelings. This is your life we are talking about. The
doctor will get over it. If she doesn’t, you don’t want her as a doctor
anyway.”</div>
<div class="MsoNormal">
<br /></div>
Skeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.com11tag:blogger.com,1999:blog-2439171664390024694.post-38278358107935173162013-02-05T08:48:00.000-05:002013-02-05T09:33:30.520-05:00Another question about choosing a specialty, this time from a wife<i>I recently came across your blog, and I have found it very insightful. What you can recommend in terms of advice for my husband and me. My husband is a 3rd year medical student, and he is not sure what type of residency he wants to go into. He has finished most of the required clerkships (peds, surgery, surgery sub-specialty, and family). Currently, he is finishing up internal med, and will do psych next, then obgyn. We constantly check in on what he is interested in, and weigh the pros can cons of each in terms of possible residency choices. He loves ped surgery, surgery, emergency med, and certain aspects of internal med. What he and I find most challenging, is how does he pick between medicine and surgery, when you've only had limited exposure to both, and enjoy both? What type of advice can you give regarding this aspect? <br /><br />Also, what advice could you offer to the spouses of a medical student? I want my husband to be happy in his chosen field, but I just want to make sure that I AM happy as well. For instance, my husband LOVES peds surgery; however, it is a long road to get there and extremely competitive. If he did decide to go this route, then it would be years of general surgery residency, fellowships, research and with only 30 pediatric surgery spots in the nation, it might be near impossible to get into. If he did decide to do this, I would never see him (and I'm already finding medical school difficult because we hardly see each other). So, I'm hoping you have some insight or words of wisdom regarding what kind of advice and support will be beneficial for both of us during this difficult time? I don't want him to go through years of medical school, only to "settle" for a specialty that will not give him any joy or purpose. However, I want to make sure that I will be happy, and I know "settling" for certain specialties gives you a decent work/family balance. Is there any advice you can provide regarding this very important decision in his medical career, and any possible next steps?</i><br />
<br />
Good questions and I'm afraid there are no simple answers.<br />
<br />
Here's a <a href="http://skepticalscalpel.blogspot.com/2012/09/anguish-choosing-medical-specialty-is.html">link</a> to a blog I wrote (which contains a link to yet another) on the subject. Both pertain more to the situation with married female doctors but much is universal. <br />
<br />
Peds surgery is pretty competitive with about 2+ applicants for every slot. Last year there were 40 positions offered. Here's a <a href="http://www.nrmp.org/data/resultsanddatasms2012.pdf">link</a> to the data: <br />
<br />
Go to page 61 for the peds surgery stats. All other fellowships that are NRMP matched are in this report.<br />
<br />
Unless your husband does something that's a 9 to 5 specialty like derm (also very competitive) or radiation oncology, long hours are part of the deal. Also, the degree of boredom of a specialty is inversely proportional to the hours. For example, PM&R is very boring but the hours are short.<br />
<br />
I have always maintained that one must choose a specialty that one likes and not base the choice on money, prestige or hours. Your husband will have to go to work every day for 35-40 years. It's hard to do that if you hate it. There are a lot of unhappy docs out there and many of them did not choose their specialties wisely.<br />
<br />
I wish I had a magic solution for you and him. I regret I do not.<br />
<br />Skeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.com5tag:blogger.com,1999:blog-2439171664390024694.post-63166774525202163762013-01-28T07:37:00.000-05:002013-01-28T07:37:51.644-05:00Choices: University program with research or not?<!--[if gte mso 9]><xml>
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<br />
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">I am a 4th year
medical student who is going into general surgery, and I wanted to ask you a
question as I'm getting my rank list in order for the upcoming match.</span></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">I've been a good
student and hopefully have a lot of doors open for me for my rank list. I had a
few interviews at some "top-tier" programs (more research heavy, but
also big names) and plenty at very good "middle" programs. I'm pretty
confident that I want to be a community surgeon when all is said and done, but
I most definitely will want to do a fellowship. At this point, I think that
would be in colorectal surgery.</span></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">I feel conflicted
about my rank list, though. Several people have told me that it would be stupid
not to rank the top-tier programs first, and part of me feels like I should go
for these big names. However, at this point I don't think I want to do 2 years
of dedicated research during my residency, which is a requirement at these
top-tier programs. Unless, of course, colorectal fellowships are getting more
and more competitive and that's what it will take to get in them.</span></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">Plus, I feel deep
down that some of these middle programs actually have a better operative
experience, as there are busy county hospitals (giant trauma centers)
affiliated with them where I feel the residents get unparalleled opportunities
to operate more and with more autonomy. </span></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">Honestly, I think I
really want to rank some of these "middle" programs over the
"top-tier" ones, but I keep on trying to convince myself that I want
to "go-for-the-gold," as it is.</span></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">I fully plan on being
productive in clinical research during my residency (I have 3 publications
already) so I'll [hopefully] garner more publications during residency, but, in
your opinion, are 2 years of dedicated research something that I should really
be thinking about? Are more and more surgeons doing that type of dedicated
research work in order to get fellowships? At the end of the day, I just want
to be able to operate confidently, get the fellowship I want (no plans for surg
onc or peds at this point), and help patients. Any advice or comments you
have<span style="mso-spacerun: yes;"> </span>would be extremely helpful and
appreciated. </span></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">I
posted this email with a bit of editing for length and confidentiality but
wanted other readers to see what is going through your mind. It is a difficult
decision.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">Let’s
take the easy part first. The 2012 colon and rectal fellowship match <a href="http://www.nrmp.org/fellow/match_name/colon/stats.html">statistics</a>
show that there were 129 applicants for 90 positions and 73% of US med school
grads matched. With three published papers (two of which are in respected
surgery journals) already and probably more to follow during your residency, I
can say with confidence that you will have little or no trouble obtaining a fellowship
in colon and rectal surgery. Statistics are available <a href="http://www.nrmp.org/fellow/match_name/index.html">here</a> for most of
the other specialty matches too.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">Now,
let’s look at your personal situation. I share your concern regarding the two
major issues you raise. </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">If
you are fairly certain you don’t want an academic career, is spending two years
doing research worth it? As noted above, it is not a <i style="mso-bidi-font-style: normal;">sina qua non </i>for colorectal training. Also, should you change your
mind and decide later that you do want an academic career, you can do extra
research time in many fellowships.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">Operative
experience generally begins earlier and is more extensive in non-university
programs. This is not just my opinion. As I explained in a <a href="http://skepticalscalpel.blogspot.com/2012/01/which-type-of-surgery-residency-should.html">blog</a>
last year, a survey showed that residents in community hospital programs were
“statistically significantly more satisfied with their operative experience and
less likely to worry that they will not be confident operating by themselves
after they finish training than university trainees. Surprisingly, they were
also happier with the level of didactic teaching than university-based
residents.”</span></div>
<div class="MsoNormal">
<br /></div>
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<span style="mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">You
did well in medical school, have excellent scores on USMLE Parts I and II and
have less than $50,000 in student loan debt. You are in a position to do
exactly what you want.</span></div>
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<br /></div>
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<span style="mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">I
think you will probably match at every program on your list. General surgery
residency is a long and difficult time. You should pick the program that you
think you will be most happy in. </span></div>
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<br /></div>
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<span style="mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">I
hope this helps.</span></div>
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<br /></div>
Skeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.com5