A Chance to Cut is a Chance to Cure

Background Knowledge of the physiological effects of extended (24 hours or more) work shifts in postgraduate medical training is limited. We aimed to quantify work hours, sleep, and attentional failures among first-year residents (postgraduate year 1) during a traditional rotation schedule that included extended work shifts and during an intervention schedule that limited scheduled work hours to 16 or fewer consecutive hours.

Methods Twenty interns were studied during two three-week rotations in intensive care units, each during both the traditional and the intervention schedule. Subjects completed daily sleep logs that were validated with regular weekly episodes (72 to 96 hours) of continuous polysomnography (r=0.94) and work logs that were validated by means of direct observation by study staff (r=0.98).

Results Seventeen of 20 interns worked more than 80 hours per week during the traditional schedule (mean, 84.9; range, 74.2 to 92.1). All interns worked less than 80 hours per week during the intervention schedule (mean, 65.4; range, 57.6 to 76.3). On average, interns worked 19.5 hours per week less (P<0.001), slept 5.8 hours per week more (P<0.001), slept more in the 24 hours preceding each working hour (P<0.001), and had less than half the rate of attentional failures while working during on-call nights (P=0.02) on the intervention schedule as compared with the traditional schedule.

Conclusions Eliminating interns' extended work shifts in an intensive care unit significantly increased sleep and decreased attentional failures during night work hours.

Background Although sleep deprivation has been shown to impair neurobehavioral performance, few studies have measured its effects on medical errors.

Methods We conducted a prospective, randomized study comparing the rates of serious medical errors made by interns while they were working according to a traditional schedule with extended (24 hours or more) work shifts every other shift (an "every third night" call schedule) and while they were working according to an intervention schedule that eliminated extended work shifts and reduced the number of hours worked per week. Incidents were identified by means of a multidisciplinary, four-pronged approach that included direct, continuous observation. Two physicians who were unaware of the interns' schedule assignments independently rated each incident.

Results During a total of 2203 patient-days involving 634 admissions, interns made 35.9 percent more serious medical errors during the traditional schedule than during the intervention schedule (136.0 vs. 100.1 per 1000 patient-days, P<0.001), including 56.6 percent more nonintercepted serious errors (P<0.001). The total rate of serious errors on the critical care units was 22.0 percent higher during the traditional schedule than during the intervention schedule (193.2 vs. 158.4 per 1000 patient-days, P<0.001). Interns made 20.8 percent more serious medication errors during the traditional schedule than during the intervention schedule (99.7 vs. 82.5 per 1000 patient-days, P=0.03). Interns also made 5.6 times as many serious diagnostic errors during the traditional schedule as during the intervention schedule (18.6 vs. 3.3 per 1000 patient-days, P<0.001).

Conclusions Interns made substantially more serious medical errors when they worked frequent shifts of 24 hours or more than when they worked shorter shifts. Eliminating extended work shifts and reducing the number of hours interns work per week can reduce serious medical errors in the intensive care unit.

As intern is preparing to perform a thoracentesis on the left side of the patient’s chest, the senior resident enters the room and informs the intern that the pleural effusion is on right side of the patient’s chest.

Patient with defibrillator implanted on left side urgently needs central access for ionotropic support. Intern inserts a central venous catheter in the left subclavian vein. Not recognizing that the vein contains the wire from the defibrillator, the intern is having repeated difficulty advancing the introducer. In the middle of the placement, the cardiology fellow enters and asks the intern to abort the procedure immediately. The catheter is removed before it can interfere with or dislodge the defibrillator wire.

A right-sided tension pneumothorax develops after a technical error during placement of a subclavian venous catheter leads to pleural-space puncture.

The attending physician devised a plan to transfuse a patient for a hematocrit of <30. Despite these instructions, the intern fails to check laboratory results for 36 hours. When the laboratory results are finally checked, hematocrit is found to have been 26 in the interim. The patient has tachycardia for a protracted time as a consequence.

The "bad" weekend is coming up: the pre-call resident is off today, because she is on long call on Saturday and will have to come in post-call on Sunday. She also happens to be post–short call from yesterday, and her absence today means she won't be part of attending rounds when her new cases are presented. Her interns, on the other hand, are here today but will not come in post-call on Sunday; only the resident will come in, and she will round only on the new admissions from Saturday, not the rest of her service. The long-call team must cease taking admissions at 6 p.m. and leave the hospital by 9:30. Night float picks up the admissions from 6 p.m., with a second shift of night float starting at midnight. Thus, there are many more night admissions handed off to the day team on short-call days, which are beginning to resemble long-call days in heft and complexity. The short-call team that is accepting admissions today needs to present its cases to me today instead of tomorrow (in addition to the cases being presented by the resident-less team that is post–short call from yesterday), because they need to be off tomorrow because they are on long call on Sunday.

Seventy-five years ago, your next partner would have been described as male and self-sacrificing. He would have done a residency that required that he literally live at the hospital with no time for any other activities and no remuneration. He would have operated in a less-than-sterile environment with a small staff and little more than scalpels and ether with which to work. A surgeon who was just entering practice 10 years ago would have been described slightly differently. Potential partners at this time could have been either male or female. These individuals would have been accustomed to operating in a sterile operating room with many technological resources and a large operating team at the ready. However, one adjective would have remained the same over the years. Surgeons of 10 years ago continued to be seen as self-sacrificing. They would have gone through residencies that still offered minimal remuneration and punishing hours that left little time for family life or other interests. Through the years, these rigorous training regimes were believed to be vital in the production of competent surgeons.

So what will potential partners look like in this century? Everyone hopes for a partner with cool confidence, high-tech capabilities, incisive decision making capabilities, and a slavish devotion to work. A futuristic "Star Trek"-like physician comes to mind. But, with new regulations affecting the number of hours residents may work, the image may be different than expected. The new generation of surgeons will have had limited work hours and will have been required to take less call. They will have been forced to take a day off every week and will have been permitted to sleep after long nights awake. All of these new ways of training residents will definitely affect the way surgeons approach

Whenever change occurs, naysayers start raising their objections. Skeptics of work-hour reform have voiced a multitude of reasons why the reforms are bad for surgical training, including the lack of continuity of care, an erosion of the work ethic, lesser quality of care, a poorer educational experience, weakened skills, and inadequate readiness for practice. These critics portray your next partner as a buffoon with Frankenstein's hands, Homer Simpson's brain, and SpongeBob Squarepants's sense of responsibility.

It is our contention that if surgical educators make the system more humane, more caring and well balanced surgeons will emerge, and, ultimately, we will see improved patient outcomes and increased student interest in surgery.

1. Embrace the work-hour regulations as a step in the right direction toward fulfilling our duty to produce whole physicians, ones who heal with compassion and humanity.
2. Look into other ways to promote resident well-being.
3. Study New York City residents to see whether the 405 regulations have affected them.
4. Revamp the education process for residents to fit into the ACGME regulations.
5. Use the changes to attract a broader scope of medical students.

Labels: Future of Surgery

I really enjoy your blog. I was wondering if surgical
residencies are offered to older, non-traditional medical students. I would be starting medical school at 36. Thanks for your time.

Chief Justice William H. Rehnquist, the second-oldest man to preside over the nation's highest court and its premier conservative figure, is undergoing treatment for thyroid cancer.

Rehnquist, 80, underwent a tracheotomy at Bethesda Naval Hospital in suburban Maryland on Saturday, the Supreme Court announced Monday. It said he expects to be back at work next week when the court will next be meeting to hear cases.

The Selective Service and the current administration deny, of course, that any such plan will ever be implemented, but contingency plans are not made for non-existent contingencies. The daily reports of the Army's personnel shortages and the "back-door draft" (the stop-loss policies) already implemented by the Bush administration suggest that some form of draft is a real possibility, regardless of what this President says. (Bush's willingness to mislead the American people is no longer in doubt.)

I would imagine a significant number of health care professionals-<>doctors, nurses, etc.-would fundamentally be opposed to being sent to war on ethical grounds: that whole concept of “killing people” and “causing harm” don’t really go too well with the Hippocratic Oath.

BACKGROUND: The Forward Army Surgical Team (FST) was designed to provide surgical capability far forward on the battlefield to stabilize and resuscitate those soldiers with life and limb threatening injuries. Operation Iraqi Freedom represents the largest military operation in which the FST concept of health care delivery has been employed. The purpose of our review is to describe the experience of the 555FST during the assault phase of Operation Iraqi Freedom. METHODS: During the 23 days beginning 21 March 2003, data on all patients seen by the 555 FST were recorded. These data included combatant status, injuries according to anatomic location, and operative procedures performed. RESULTS: During the twenty-three day period, the 555 FST evaluated 154 patients. There were 52 EPWs, 79 U.S. soldiers, and 23 Iraqi civilians treated. Injuries to the lower extremity and chest (48% and 25%) were the most common in the EPW group. Upper extremity and lower extremity injuries were the most common in the civilian (57% and 39%) and U.S. soldier groups (32% and 30%). The number of injured regions per patient were 1.14 for U.S. soldiers, 1.33 for EPWs, and 1.52 for Iraqi civilians (p <>Majority of the life threatening injuries evaluated involved EPWs. A combination of body armor and armored vehicles used by U.S. soldiers limited the number of torso injuries presenting to the FST. Early resuscitation and stabilization of U.S. soldiers, EPWs, and civilians can be successfully accomplished at the front lines by FSTs. Further modification of the FST's equipment will be needed to improve its ability in providing far forward surgical care.

Update: Medpundit and Gruntdoc both say it’s all over-reaction. I’m sure it’s easy much easier to downplay the concerns of young polyglots, computer network engineers, and medical students when you’re over 35, and not at risk of being drafted.

Under the plan, Mr. Flahavan said, about 3.4 million male and female health care workers ages 18 to 44 would be expected to register with the Selective Service. From this pool, he said, the agency could select tens of thousands of health care professionals practicing in 62 health care specialties.

A Colorado man underwent surgery for a new kidney Wednesday in what was believed to be the first transplant brokered through a commercial Web site a transaction that has raised a host of ethical and legal questions.

Presbyterian/St. Luke's Medical Center spokeswoman Stephanie Lewis said the operation on both the donor and recipient was going well.

Bob Hickey, who lives in a mountain town near Vail, has needed a transplant since 1999 because of a kidney disease. He met donor Rob Smitty of Chattanooga, Tenn., through MatchingDonors.com, for-profit Web site created in January to match donors and patients for a fee.

There are no laws against soliciting an organ donation, but by using the Internet, Hickey bypassed the United Network for Organ Sharing, the nonprofit group that works under government contract to allocate all organs donated from the dead. It doles out organs, in part, according to which patients need them the most.

The network does not oversee the increasing number of live donors, such as Smitty. Last year, there were 6,920 living donors compared with 6,457 dead ones.

UNOS came out against MatchingDonors.com in June, saying it "exploits vulnerable populations and subverts the equitable allocation of organs for transplantation." UNOS spokesman Joel Newman said the network is concerned when anyone puts his or her need for an organ above others.

"An organ that becomes available with certain medical characteristics should be offered equally to the people that could benefit from it," he said.

University of Pennsylvania bioethicist Arthur Caplan said the first ethical issue raised by Internet donations is financial: Not everyone can afford to pay MatchingDonors.com's fees or donor expenses.

"Those who are better off are going to have access to people as potential donors that the poor or the shy won't have," he said.

Todd Krampitz essentially bought his liver and screwed who knows which patient likely to be far sicker than Todd out of a chance for a cure of their liver disease and the addition of many years of life. Organ donations that specify the recipient are rare (only about 50 out of thousands of transplants each year) because cadaver organ donation is almost always an anonymous process. Unlike most transplant patients and their families, Todd Krampitz (who owns his own digital photography company) had enough money to pay thousands of dollars for billboard and other ads.

Labels: Transplantation

STEVE INSKEEP, host:

This is MORNING EDITION from NPR News. I'm Steve Inskeep.

For most students, autumn is about buckling down to another year of studies. But fourth-year medical students have to think much further ahead. They have to make decisions about what kind of doctors they want to become. Today more and more medical students are opting to become specialists, raising predictions of a shortage of primary care doctors. To find out why, NPR's Julie Rovner traveled to Mt. Sinai Medical School in New York.....
JULIE ROVNER reporting:

It's been a long day for Bill Stebbins. He's a fourth-year medical student who's just started a new hospital rotation in internal medicine. During a brief break, Stebbins chugs the last of his umpteenth can of soda, delivering another dose of caffeine to his flagging system.

Mr. STEBBINS: And even though you know it has no calories, you know you're feeling good about yourself, that five years down the road you're probably going to die from whatever else is in here.

ROVNER: Stebbins' skin is about the same color as his green medical scrubs, thanks to a combination of a lack of sleep and the overhead fluorescent hospital lights. He looks older than his 26 years, but even with his deadpan delivery, he betrays his amateur status as he prepares to draw an arterial blood gas on a patient.

Mr. STEBBINS: Having blood drawn is not bad but when you dig for the radial artery and you have a moving target who's screaming, you're dealing with a needle as a med student, you know, the pressure's on.

ROVNER: The pressure's on in another part of Stebbins life, too. He has only a few weeks left to decide what kind of medical residency to apply for; in other words, how he wants to spend his medical career.

Mr. STEBBINS: It's a really tough decision to make and it's something that I think about every day and it's causing me mind-blowing amounts of stress, really. Like I've never felt more stressed in my life.

ROVNER: It's a big decision because switching specialties later is hard.

Mr. STEBBINS: My opinion wavers a lot on a day-to-day basis. If I had to get my obligation in tomorrow, I would specialize in dermatology. I would say that a lot of my decision is based on trying to find a field where I can have enough time to spend with patients and also spending time with my family and raising a family.

ROVNER: And he wants time for two of his other passions, music and tennis. Bill Stebbins thinks dermatology's nine-to-five schedule will offer him lifestyle heaven. Dr. Larry Smith says he's seeing more and more students like Bill Stebbins. Smith is dean of students at Mt. Sinai on Manhattan's Upper East Side.

Dr. LARRY SMITH (Dean, Mt. Sinai Medical School): I was really unaware of the almost Machiavellian thinking trying to scope out, you know, future incomes, future work hours, preservation of personal time. I realize that something had dramatically changed.

ROVNER: So Smith set out to find out what. He read a series of studies by sociologists done for industry about intergenerational tensions in the workplace. And he discovered that what makes this generation of young doctors different is that they have very different priorities than their baby boomer parents.

Dr. SMITH: They are very much striving for balance. They saw the bad parts of open-ended commitment, which was what it did to their parents. I think the baby boomer generation had a lot of people who went for it 100 percent and became extraordinarily burnt out, were never home and if you just looked at, you know, the current 50-year-old physician, I mean, there's enormous discontent with their life.

ROVNER: Smith says, as a result, students are avoiding time-intensive generalist careers like internal medicine or pediatrics. They're gravitating instead towards specialties like dermatology, radiology and anesthesiology. Those offer more predictable working hours. But Smith says the unpopularity of primary care is about more than not wanting to be on call 24-7.

Dr. SMITH: I think the issue is, I'll be training a generation of doctors who are afraid to become people's doctor, as opposed to the specialist for a disease they may have or a procedure they may need. For a large number of the young physicians, they're fearful of that commitment. And this is really in stark contrast, I think, to a generation before, where, in fact, the concept of being someone's doctor was absolutely at the core of why most people went to medical school.

ROVNER: Back at the hospital, Bill Stebbins career conflict had intensified. He's just experienced for the first time the kind of excitement he's only ever seen on TV.

Mr. STEBBINS: That was a pretty wild scene. It was my first time ever being part of a code.
ROVNER: A code meaning the patient's heart had stopped. Bill and the rest of the team went to work.


Mr. STEBBINS: It was really exciting. You could feel your heart beating, sweaty, knowing that, you know, it's a time line of minutes.

ROVNER: The patient survived and was sent to recover in the intensive care unit. Bill knows he'd never be part of saving a life that way in dermatology and that's a hard thing to accept. On the other hand, he also knows that being a primary care physician has its own downside.

Mr. STEBBINS: The joys of being an internist when you were the--you know, that person's one doctor are now gone, because you are now the person standing in the way of them getting to the specialist. You know, when anything exciting comes up, your job is to send them to somebody else.

ROVNER: To some extent, today's medical students' desire to have a life outside of medicine is medical schools' own fault. Schools have recruited liberal arts majors like Bill Stebbins. The thinking was that a student with many interests makes a better doctor. Suzanne Rose is Mt. Sinai's associate dean.

Ms. SUZANNE ROSE (Associate Dean, Mt. Sinai Medical School): We have world-class musicians. We've had world-class athletes, somebody that went to the Olympics a few years ago. And some of them are reluctant to give up some of their passions and talents that they had prior to coming here.

ROVNER: Baby boomer Rose is a gastroenterologist by training, one of the first women to pursue that demanding specialty. And she says she went after it with everything she had, sacrificing her other priorities.

Ms. ROSE: I have missed many events in my kid's life. I missed my son's first haircut, which is on video. He's now 19 years old and is doing well. And sometimes he jokes with me that I wasn't really his mother. It was some other nanny that took care of him.

ROVNER: Rose says she's exactly the role model many of today's students don't want. But she's also afraid the balance may be shifting too far in the other direction; that today's students aren't willing to push themselves enough. She recalls one very bright student last year who was looking at some of the easiest programs available.

Ms. ROSE: And I said to him, `Why don't you go to the most academic program you can go to?' And he said, `I don't want to work that hard.' And to me that was shocking. And I said, `What do you mean by that? Don't you want to be the best doctor you can be?' He said, `I'll be great but I don't need to do that. I don't need to work as hard as you worked.'

Two years ago Shelly Thompson-Mooney, a 35-year-old mother in Texas, died of a cerebral aneurysm. Attorney Roy Key thought her case was a good candidate for a medical-malpractice suit.

Her common-law husband, Robert Mooney, told the attorney she was brought to the emergency room with substantially the same symptoms she had suffered once before when a blood vessel ruptured in her head. Mr. Mooney said she went three hours without proper treatment. Just over two days later, she died, leaving Mr. Mooney to raise their 4-year-old daughter.

But Mr. Key and other attorneys passed on the case. Ms. Thompson-Mooney was a homemaker, so she had no income the suit could seek to recoup. Her medical bills were covered by insurance, eliminating another potential claim in a lawsuit. That meant a suit probably would need to seek payment for "pain and suffering" -- traditionally a rich vein. But Texas recently had capped awards for such noneconomic damages in the vast majority of medical-malpractice cases at $250,000.


"From an emotional standpoint, I wanted to take the case," Mr. Key says. But he says the cap prevented him from doing so. A case like this one might cost his firm $100,000 to prepare for trial. That is more than the firm had any hope of collecting, since its fee is one-third of any award. "If there was no cap in this state," says Mr. Key, "we would have taken it -- I can say that unequivocally."

Amid the fierce debate over limits on medical-malpractice suits, many states have enacted limits of their own that are having a sweeping impact. One of the most common types -- caps on damages for pain and suffering, or so-called noneconomic caps -- is turning out to have the unpublicized effect of creating two tiers of malpractice victims.

Cases involving high earners or big medical bills move ahead. Lawyers can still seek economic damages for the wages these patients lost or to pay for continuing medical bills. But lawyers are turning away cases involving victims that don't represent big economic losses -- most notably retired people, children and housewives such as Ms. Thompson-Mooney.

The effect of such caps became clear to Donald Costello, a lawyer in Santa Cruz, Calif., after he handled two virtually identical breast-cancer cases. Both involved married mothers in their 40s who had two children and died from the disease. One plaintiff was a housewife and her case was settled for $300,000. The other was a Silicon Valley executive whose family won a $2 million settlement....
One case in Pasadena decided last year involved a mother of two who held a master's degree and worked as a school administrator. She died of an infection following a gastric bypass, and her family won $1.6 million in economic damages.

In the other case, decided this year in San Bernardino County, an unmarried woman on welfare with two minor children died of an infection during a stillbirth after the doctor ignored the patient's symptoms until it was too late. In that case, $200,000 in economic damages was awarded.

Paula Sweeney, a Dallas trial lawyer who has been handling medical-malpractice cases for 23 years, says the caps have already slashed her business. Since the beginning of the year, she's filed only one case. In a normal year, she would have filed 12 to 15 by now. "The economic feasibility has changed," she says. She says she believes the new restrictions will eliminate about 85% of medical-malpractice cases in the state.
Trying a case typically involves hiring half a dozen expert witnesses and costs about $100,000, she says. Under the state's new pain-and-suffering cap, that essentially eliminates any case where the victim had no income or no continuing medical expenses. Lawyers use economists to try to quantify "mommying activities," such as chauffering and cooking, to argue for economic damages, but that can be difficult and often doesn't amount to much

Over time, Mr. Edwards became quite selective about cases. Liability had to be clear, his competitors and opponents say, and the potential award had to be large.

"He took only those cases that were catastrophic, that would really capture a jury's imagination," Mr. Wells, a defense lawyer, said. "He paints himself as a person who was serving the interests of the downtrodden, the widows and the little children. Actually, he was after the cases with the highest verdict potential. John would probably admit that on cross-examination."

The cerebral palsy cases fit that pattern. Mr. Edwards did accept the occasional case in which a baby died during delivery; The North Carolina Lawyers Weekly reported such cases as yielding settlements in the neighborhood of $500,000. But cases involving children who faced a lifetime of expensive care and emotional trauma could yield much more.

For plaintiffs' attorneys, the primary question in cases involving babies and others without income is whether medical needs are continuing. That boosts a potential award because it wouldn't be limited by the cap on noneconomic damages. The question proved crucial for Brenda Stoltz, of Leesburg, Va. Ms. Stoltz says a botched delivery last year left her daughter, Zoe Elizabeth, severely brain damaged.

During delivery, there were signs that the baby was in distress, including an extremely slow heart rate over an extended period of time, according to Ms. Stoltz. Yet no emergency C-section was done. This lack of action and other errors, says Ms. Stoltz, left Zoe deprived of oxygen during a critical period. She was born with severe brain and other organ damage.

Last September, Ms. Stoltz and her husband decided to sue the doctor involved and they retained a Maryland law firm that specializes in medical malpractice. Zoe was facing a lifetime of expensive medical care.

But on Oct. 21, Zoe died. Ms. Stoltz says she told the lawyers of her baby's death the next day. Shortly after that, the firm dropped the case. A lawyer for the firm wouldn't comment.(emphasis mine)

It was suggested as recently as 1998 that most leading surgeons in the country still believe that broad surgical training is superior and should be maintained. It is not surprising that a group (79%) of surgeons older than 50 years would support the regimen that molded them!

The general surgeon, the hallowed product of surgical training in this country, is a vanishing breed. More than 70% of surgeons completing general surgical residency opt for subspecialty training immediately after residency, and an even greater majority self-differentiate by the time of first recertification.

Those surgeons who remain as classic general surgeons have a practice that barely resembles what they were trained to do. A recent analysis of the workforce patterns of rural surgeons in West Virginia suggested that more than half were so discouraged that they would not encourage a young person to pursue a career in medicine. More than one third of these surgeons practiced some general medicine daily, and the surgical caseload varied by community size. In communities of fewer than 10,000, they listed obstetrics and gynecologic (9%), urological (5%), otolaryngology (9%), and orthopaedic (4%) procedures as part of the regular caseload. Endoscopic procedures comprised 17% to 24% of total procedures regardless of community size, which is clearly not a focus of the current general residency education program.

Other general surgeons believe that they should be trained and encouraged in all surgical practices, particularly gastrointestinal surgery. Academic reports and societal demands, however, emphasize that the casual operator has morbidity and mortality rates unacceptable for major procedures such as esophagectomy, pancreatectomy, and liver resection. High-volume surgeon and institutional experience improves operative mortality, morbidity, and long-term survival. That 25% of patients undergoing pancreatectomy are operated on by surgeons who perform less than 1 procedure a year, and that 96% of surgeons who performed a pancreatectomy in the State of New York between the years 1983 and 1991 performed 1 or fewer annually, is hardly desirable patient care.

Is it possible or even appropriate to train generalists to do such procedures when so few exist in the majority of residency training programs in this country? The converse argument is that while we wish that complex procedures be performed in high-volume centers, it will just not happen; eg, in a study of Medicare patients undergoing pancreaticoduodenectomy 28% of patients had their procedure performed at an institution that did less than 1 a year and 80% had an operation in an institution that did less than 5 a year. However, because it is so does not mean it is the desired aim. Ask the patient! It is becoming clear that when patients have information and the possibility to choose, they will choose centers with better outcomes. Analyzing this issue from the pure perspective of where the operation has been performed is flawed, because it incorrectly assumes that patients had both information and the possibility to choose.

The generalist is in part damned because he or she is judged against the outcome results of the specialist.

The general surgeon, even in the absence of any fellowship training, self-differentiates. Of surgeons presenting at 10 years for recertification, the average number of hepatic and pancreatic procedures per year was less than 1, 86% did no liver procedures, and 79% had not performed a pancreatectomy. Procedures for which the median annual experience was zero included esophagus, liver, any transplant, splenectomy, and any complex vascular procedure. Even if we believe that the generalist should do it all, the general surgeon and the patient have decided otherwise.

It is clear that we cannot mandate where common operations be performed. It is estimated that if colectomy was limited to hospitals doing a minimum of 15 procedures in 5 years, 1400 patients (5% of the total) would be redirected and 263 hospitals (45%) would discontinue the procedure, and the operative mortality would fall from 4.59% to 4.44%.

More frightening is the question of where might these procedures be performed in sufficient volume to train anyone? In a previous study, only 27 hospitals in the nation did more than 16 pancreatic resections a year, which strongly argues for using these uncommon cases to train only those who will fully embrace this type of practice.

What are the recertifying general surgeons doing? In part, it depends on the population, but in the main, it is endoscopy, breast, cholecystectomy, hernias, and appendectomy.

The need for general surgical leadership in clinical practice is very real. It is clear that the general surgeon, whether practicing in small communities or large, remains an important bastion in emergency management of inflammatory conditions such as acute cholecystitis or acute diverticulitis and in initial management of the burned or otherwise injured patient. All of these areas progressively demand the resources of specialized centers and specialized surgeons so that patient outcome can be maximized.

Seventy percent of male surgeons and 50% of female surgeons completing a surgical residency go on to subspecialty training. Many argue that the general surgical experience provides little beyond a basic understanding of surgical principles that prepares them for a subsequent career in a focused discipline. Urology, orthopedics, and neurosurgery take a 1-year internship and then move directly to their own discipline. Would it not be better if we served the needs of all potential surgical faculty with a structured introductory surgical component and then allowed early differentiation?

The demand for greater cultural training in communication and humanistic as well as technical skills is increasing, but does the dedicated cardiothoracic surgeon need to do one pancreatic resection or total gastrectomy to prepare him or her for a career in which he or she will rarely, if ever, see the organ, let alone operate on it? Many surgical residents who go on to specialty training see at least 2 of the 5 years spent in general surgical training as a waste of the most productive years of their lives, which could be dedicated to their specialty or to research within that specialty. Plastic surgery has experimented with 1, 3, or 5 years of a general surgical program before moving on to a dedicated 2- to 3-year course in plastic and reconstructive surgery. An analysis of the participants in each of these pathways would provide great insight into the merits of each approach.

Advances in science and technology are forcing the melding of specialist practices. The training required in vascular surgery needs to be meshed with that of interventional radiology, and combination residencies have been promulgated. A similar dilemma will exist in other image-guided therapies. Conversely, if one wishes to practice general surgery in addition to the specialty field, as has been suggested by one third of current vascular surgeons, how do we address the need for the vascular surgeon to be appropriately and adequately trained for the general surgery practice that he or she desires to pursue?

The demands for analysis of competency, whether in training, generalist, or specialist practice, will add further burdens to the limits to which comprehensive all things to all people training can be maintained. How appropriate is it to demand of a vascular surgeon that he or she be recertified in general surgery, or that a general surgeon be recertified to include the elements of vascular surgery that he or she no longer practices? What of the person who has dedicated his or her life to the management of breast disease, who is asked to be recertified in the broad discipline that he or she initially embarked upon? Testing surgeons in areas in which they do not practice defeats the goal of recertification or continuing education. How much does recertification in a comprehensive generalist sense, when personal focus is highly specialized, deter re-evaluation and assessment of competency?

Labels: Future of Surgery

The malpractice issue has had a negative influence, however, in the kinds of learning opportunities medical schools offer. In years past, Halperin said, schools routinely let students do training stints at hospitals around the country. Now this practice is being curtailed, because medical schools are leery of carrying the liability for students working outside their hospitals.

Such subtle problems seldom get mentioned in the debate, but Halperin said the effect is long term. "It's inhibiting access to educational opportunities," he said.

Now, there is no shortage of students wanting to become doctors. At Duke University School of Medicine, 5,000 students applied last year for 101 slots; at UNC's medical school, 2,972 students vied for 160 slots; at East Carolina University, 705 competed for 72 openings.

For medical students, surgery has become an increasingly unappealing area of medical practice. The National Residency Matching Program suggests that from 1992 to 2000, the numbers ranking general surgery as a preferred discipline fell from 1950 to 1500, an overall decrease of approximately 23%. For US seniors, the fall has been more dramatic, on the order of 36%. The only increase has been in US citizens educated in international medical schools. This number reached a maximum of 140 individuals as of 2002 and, although its overall impact is limited, the impact in terms of the quality of applicants for surgical programs is real. An increase in international medical graduates can compensate for this shortage, but it has inherent problems in terms of the difficulty in evaluating foreign graduate medical education and increasing immigration service review of foreign access to US surgical programs. Active programs to improve international medical graduate performance are currently under way.

Students shun the rigors of surgical training and view the profession as too demanding and providing little opportunity for personal time. From 1996 to 2002, controllable lifestyle explained 55% of variability in specialty preference, controlling for income, work hours, and years of graduate medical education. Medical student choices have changed to user-friendly specialties. Currently, the median debt at completion of medical school is over $100,000 . Over 25% of medical school graduates of 2002 incurred a debt greater than $150,000.13 The prolonged length of surgical training, fellowship, and research experience, requiring 9 to 11 years post-MD at subsistence pay, is poorly perceived, and a strong belief that years are wasted in service without education is a strong disincentive.

A powerful factor in the choice of medical specialty is identification with role models. Role models are the impetus to entry into a surgical subspecialty in 56% of residents. What makes an ideal role model has been debated and defined Role models can be introduced at any point in a training program, perhaps best in medical school. How well do we as surgeons match up to the important attributes that emphasize, as in internal medicine, dedicated time as a teacher, doctor-patient relationships, the teaching of psychological aspects of care, and prior chief resident experience?

Whether surgeons of our vintage appreciate it or not, an inescapable change has taken place in today's residents with respect to their perceived needs for a balanced lifestyle that allows more time with families and free time to follow their interests. We dismiss the lifestyle needs of residents at the peril of our recruitment success.

Over the years, residents have accumulated more and more administrative chores, many of which make little sense in an environment that is so rich in information systems. Processes by which patients are admitted, cared for, and discharged are antiquated, take minimal advantage of information technology, and impose an unjustifiable burden on residents. These processes need to be totally revised and adapted to current needs. Surgical education has to be more about understanding, imagination, and communication as well as training and skill acquisition. Surgical training programs are perceived as being none of these, but rather focused on service delivery, particularly to the poor and underprivileged. At present, 20% of surgical residents taking the American Board of Surgeons Qualifying examination are female, whereas females constitute 50% of the medical school graduates. The overall contribution of women to the long-term workforce in surgery is limited appropriately by the desire and need for a lifestyle that can accommodate childbearing and childrearing without limiting professional satisfaction. Few residencies have innovative programs to address the important need of women residents and that of male-resident fathers whose spouses have a full-time professional career. The desire for women to enter surgical subspecialties is variable, with increases in female orthopaedic residents lagging behind increases in other areas. We need to recognize that many medical students approach residency together as a couple, requiring adaptability in the residency match. How well can we adapt to this 2-person professional medical family?

To compound this perception of too little time to learn too much, we impose volume requirements for each resident that are difficult, if not impossible, to meet. The extensive clinical spectra to be covered by any one resident make any proposed decrease in the length of training difficult. We have been reluctant to acknowledge that most institutions and residencies cannot provide the volume and breadth of clinical material that we demand they be exposed to!

The resident facing his board examinations may be justified in complaining when he or she is examined in technical aspects of pancreatic, esophageal, or infected aorto-iliac graft surgery that he or she has rarely seen and never performed.

Teaching can impose a degree of inefficiency in the provision of hospital services, and typically the cost structure of teaching hospitals is 25% to 30% higher than that of community hospitals. Thus, hospitals will scrutinize and demand appropriate reimbursement for the cost of this necessary inefficiency if they are to survive in an arena of brutal health market competition.

Faculty in medical schools already demonstrate a 30% level of high emotional exhaustion and burnout, with younger surgeons more affected! Given the current faculty workload of between 60 and 80 hours per week, it is unlikely they can absorb more teaching and clinical cases. Exhausted faculty are poor role models!

Residency programs are the pride of academic surgical departments and provide the single most important focus for faculty unity. As reimbursements for physician services decline and faculty work longer hours and cope with increasing documentation, their ability to devote adequate time to teaching and other scholarly activities has been strained. Most departments do not make specific financial commitments for teaching. It is fortunate that faculty members receive gratification from teaching and their association with residents in the care of sick patients. The lack of specific compensation for teaching will in the long term degrade the learning environment and challenge the traditional ad hoc understanding under which surgical education is provided. How and by whom should surgeons be financially compensated for the teaching they do? How will we accept that the process of education is an equally fruitful source of research and evaluation? A desirable pathway to surgical fulfillment is currently poorly recognized and inadequately compensated.

Labels: Future of Surgery

Emory University Hospital has not adopted the most rigorous type of sterilization of surgical instruments after learning Sept. 15 that a brain surgery patient may have spread a fatal ailment that resembles mad cow disease to more than 500 patients, a federal health official said Friday.
The best medical sterilization measures call for a chemical Emory is not using, plus more intense heat, said Dr. Ermias Belay, an epidemiologist with the U.S. Centers for Disease Control and Prevention in Atlanta. Belay helped write the sterilization guidelines.
Emory also waited two weeks after the initial patient's probable diagnosis of Creutzfeldt-Jakob disease before informing other patients they may have been exposed, subjecting dozens of people to brain or spine surgery without their knowledge of the risk.

"I think we had every right to be informed," said Susan Nabulsi of Conyers, whose husband, Mike Nabulsi, had neck surgery Monday, long after Emory knew of the concern. "We were not given an informed choice."

In all, 516 patients are facing an uncertain future, knowing that years from now they could develop a fatal disease for which there is no treatment, even though the risk is small.

The No. 3 Bulldogs whipped No. 13 LSU in every aspect of a 45-16 victory in which their big-name players produced big-time in their biggest game this season. Making things sweeter for Georgia: It scored more points than any team LSU has faced since 1996, a testament to how explosive the Bulldogs can be when everything clicks.

The crucial issue for the patient may well be: Will there be a doctor to care for me?

It is now strongly suggested that by the year 2020, there will be a large shortage in the physician workforce, none more obvious than in the discipline of surgery. If one accepts the postulations based on gross domestic product increases, then by the year 2020, there will be an approximately 200,000 physician shortage in the United States. Although some of this shortfall can be made up by nonphysician clinicians, a serious shortfall in physicians, particularly specialist physicians, is projected.

A recent survey of 70 medical schools in 35 states reported shortages in surgeons that approximate 20%. A survey by the Massachusetts Medical Society suggests a physician shortage in general surgery of 32%, with orthopaedics, neurosurgery, and urology having even greater shortages.

Society's and the patient's perception of what he or she wants has changed. Given a choice between a specialist and a generalist, the patient chooses a specialist. This is compounded by ready access to available information from the Internet, much of it uncensored, colored, and often tainted with institutional, if not personal, claims of supremacy in the delivery of care. The media is vociferous in defining what the public should expect from their surgeons and voracious in its pursuit of perceived inappropriate care. How can we cope with the suggestion that sleep deprivation of residents equates to inebriation?

Some patients look only for a competent generalist. This may be by personal choice of time and access, of distance, or because of a lack of access to a specialist caused by societal, ethnic, financial, or language barriers. Patients roundly rejected the attempt of the managed care industry to create primary care physician gatekeepers for their care. The American public, often well informed about quality of health care, has decided it prefers to be treated within specialties.

Increasingly, patients and employees are asking to see the results of interventions before they select their doctors or hospitals. Clinical care is becoming patient-centered and outcome-based, and it is likely that both referral patterns and reimbursement rates will depend on demonstrated good clinical outcome Increasingly, patients will have more and more say in their own treatment. As they do, they will no longer accept to be treated by physicians-in-training and will demand that their care be provided by experienced practitioners. This raises the important issue of training by methods that do not involve direct patient care. How, if at all, is our training system prepared to deliver on these important issues?

State registries can identify and characterize the practice patterns of individual surgeons, the mortality, morbidity, length of stay, and other characteristics that track or evaluate some degree of competency of care. Increasingly, data is available for surgeon, by operation, for the cost and charges initiated by that provider. This is compounded by cost analysis and increasing demands to lower the cost of medical care when the demand for expensive technology is simultaneously increasing. Demand for technologically advanced clinical care is increasing as societal exposure and media promises escalate. The nexus of ever-increasing technology with ever-increasing demands by society for its use creates the impossible prospect of limitless expenditure, which is a prospect incompatible with the trends in the national economy. Why are we so unwilling to add cost-effectiveness to the evaluation of the clinical efficacy of each newly introduced technology?

Labels: Future of Surgery