Tuesday, March 31, 2009

Grand Rounds Vol V, No. 28
Grand Rounds hosted by Paul Levy at Running a Hospital.

Monday, March 30, 2009

The Gang's all Here...
Maybe it has to do with spring but thanks to GruntDoc I find that both Panda Bear and my old group-blogging buddy Galen have returned.

Now if Grunt Doc will only take me off the dead blog list.

Sunday, March 29, 2009

The Surgical Blog Carnival..
Surgexperiences 2:20 hosted this week at Vagus Surgicalis.

Thursday, March 26, 2009

On the Wagon...
First off, thanks for all of those who have welcomed me back after my hiatus.

Why so long away? After boards some other things came up and I didn't have the time. Then Mrs. Parker got on Facebook and got me hooked too.

Then I realized that the time spent on Facebook could also be spent on Blogger.

I dislike the new Facebook format, BTW.

I'm still spending time on sidebar maintenance, I would greatly appreciate any link ideas.
Tales from the Trauma Service XVIII

Patient comes in after a motor vehicle collision, intubated in the field for combativeness. Undergoes the Full Body Irradiation WorkupTM. Images and unpleasant surprise follows:

You can see the contrast within the subclavian vein.

Contrast and air within the superior vena cava.

Contrast and air within the right ventricle.

Contrast and air within the pulmonary outflow tract.

The patient experienced an air embolism, apparently from the power injector. The usual treatment is to insert a central line to extract the air as well as trendelenberg and left lateral decubitus position. Unfortunately the air had already passed into the pulmonary artery. The patient was placed on 100 percent oxygen. The classic exam finding of the "mill-wheel" murmur was absent. Sometimes a pulmonary artery catheter can be used to extract the air. The patient was asymptomatic, and was extubated the next day.

What amazes me is that according to this, air embolism occurs in about 12-23 percent of patients.



Wednesday, March 25, 2009

Did the Medical School in Athens just Hit a Snag ???
Word out today that Medical College of Georgia president Dan Rahn has accepted the position of chancellor of the University of Arkansas for Medical Sciences.

Dr. Rahn was one of the driving forces behind MCG expansion to Athens and beyond. How will his departure , along with the tough economic times the state is experiencing, affect the new medical school?

Dr. Rahn's move to Little Rock has yet to be scheduled. Some Augusta-area politicians want to him to go ahead and pack the U-haul:
When Dr. Rahn will become a chancellor is still an open question. He said Arkansas officials have assured him that they will be flexible and that it could be any time between July 1 and the end of the year. There are many projects at MCG, such as finalizing funding for the new building for the School of Dentistry and firming up plans for new student housing, that he wants to complete.

"There are a number of things that I really want to see through to finish well in my current position," Dr. Rahn said, "and then have a smooth transition as the search goes forward for the next president at MCG."

It is for those same reasons, however, that state Sen. Ed. Tarver, D-Augusta, would like a shorter process. Mr. Tarver said he didn't know whether "in this instance a long goodbye is in the best interests of MCG, with the number of extremely important decisions that are being made regarding the future of MCG both in Augusta and statewide. It raises the question of whether or not moving forward as quickly as possible to select new leadership would be a better strategy in this case."....

...."I would like to see the search started as quickly as possible," Mr. Tarver said. "And that a new leader be identified for the Medical College of Georgia at the earliest possible date. And if necessary that the institution move as quickly as possible to identify an interim while their search is ongoing."

The Augusta community is not happy about the potential for a medical school in Athens. Those who are familiar with both cities will agree with me that Athens provides a more "student friendly" environment than does Augusta.

The Board of Regents website about the expansion is here.

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Epic Admissions Committee Fail....
From today's New York Times:A Quandary in Sweden: Criminals in Med School
A year ago, Sweden’s most prestigious medical school found itself in an international uproar after it unknowingly admitted a student who was a Nazi sympathizer and a convicted murderer, then scrambled to find a way to expel him.

It is hard to imagine how the case could get any more bizarre. But it has

The 33-year-old student, Karl Helge Hampus Svensson, having been banished from the medical school of the Karolinska Institute in Stockholm on the ground that he falsified his high school records, has now been admitted to a second well-known medical school — Uppsala, Sweden’s oldest university.

The details of his crime:
Mr. Svensson, who has not responded to numerous attempts to reach him over the last year, was convicted in the 1999 hate murder of a trade union worker and was paroled after serving 6 ½ years of an 11-year sentence — a typical penalty for murder in Sweden. He entered Karolinska in fall 2007 while still on probation; he had earned credits for medical school while in prison.
It seems that the admissions committee was too busy to ask about his past:
The disclosures about his past proved deeply embarrassing to the institute. Among other things, two senior faculty members on the admissions committee that interviewed him failed to ask for an explanation of the six-and-a-half-year gap in his résumé, the period he was in prison.

But since Dr. Parker applied to medical school a long time ago the likelihood of Charles Manson serving as a dissection partner has fallen:
In the United States, the chances of a convicted criminal’s being admitted to medical school were reduced in 2002, when the Association of American Medical Colleges’ standard application form began requiring answers to questions about felony convictions. In 2008, questions were also added about military discharge history and misdemeanor convictions.
So all you premeds getting ready for spring break, be careful.

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Tuesday, March 24, 2009

R-E-S-P-E-C-T..(Part Two)

A commenter on this post exposes what could be the dark underbelly of the whole issue of inter-specialist respect:
This leads to a another point. Could it be this very sense of superiority, that drives the attitudes of some of our surgical colleagues, and is influencing our medical students as they make their way through their training?
Could that be behind their reluctance to accept that primary care be paid at parity with them?
Do surgeons have a sense of superiority? For the most part, yes. Why? It probably goes back to training. Now my residency may have been unique in the quality of categorical IM residents it hired, but I don't think so. As surgery residents we did all the lines in the hospital. Many times I and other surgery residents beat on the call room door of an IM resident to get their lazy ass out of bed to do their own damn line. We ran our own ventilators, wrote our own TPN, managed our own antibiotics. Sepsis was not something we consulted Infectious diseases for. Renal failure not requiring dialysis was not something we consulted nephrology for.

IM had a night float, we did not.

The IM/FP residents did all sorts of stupid, silly and dangerous things in the middle of the night, without staff supervision, and had no requirement to defend their decisions. Surgery residents did all sorts of stupid, silly and dangerous things in the middle of the night, sometimes with staff, sometimes not. And every week we had to defend our decisions and actions in front of everybody.

My program was very benign, yet some residents were let go. A FP resident at the same time was paying his colleagues to take his out-of-house call, so he could moonlight. This only came to light when he gave his "employees" 1099 forms so he could avoid taxes. He was not fired, and only suspended from moonlighting for awhile.

We were the cavalry called when all else had failed. Sometimes we got the bear, sometimes the bear got us. But we tried, cared, fought, bled, and sweat. We sacrificed family, social skills, and good hygiene. We complained, but we loved it because as Hyman Roth says the The Godfather: Part II
...this is the business we've chosen..
With all the things described above, how can your average surgical Chief Resident not feel like he/she is like Jules in Pulp Fiction?

In the not too distant past, the shoe was on the other foot. The really smart medical students went into internal medicine, not surgery or orthopedics. The old joke of you take the bottom 25 percent of a medical school class and those that can bench press their body weight go into orthopedics, those that can't go into OB/GYN. LOL!!! And there are those out there who view me and my ilk as mere technicians.

But when I finished, the economic and political realities of private practice revealed that the local cadre of FP and IM folks were pretty good and they would be oh so happy to assist in the medical management of patients. No problem. But the realities remain.

An admission for pneumonia can be handled over the phone, acute appendicitis cannot.
An admission for COPD exacerbation can be handled over the phone, a severely injured patient cannot.
An admission for DKA can be handled over the phone, acute extremity ischemia cannot.
An admission for abdominal pain can be handled over the phone, the surgical evaluation of same cannot.

The hospitalists take care of the admissions at night, no such thing for me.

And unlike some of my neurosurgical and orthopedic brethren, I have no midlevel to separate the sheep from the goats.

Yes I piss and moan and am reminded (by Mrs. Parker, no less) that that is what surgeons do, and I went into it with my eyes open.
...this is the business we've chosen..

So you have chose to go into a field, and/or modeled your practice where you are over-regulated, underpaid, overworked, under-appreciated and disrespected. You specialize in a field where others of your specialty state that individuals with about half your training can do "90 percent" of what you do you complain and wring your hands, remember:
...this is the business we've chosen..


Grand Rounds Vol. V No. 27
This week's Grand Rounds hosted at Codeblog.



Sunday, March 22, 2009

R-E-S-P-E-C-T.... (Part One)
Dustup over at Dr. Centor's about the age-old question: Do surgeons respect primary care?

In this he links to a post from the ACP advocate blog, in which the testimony of Dr. Preskitt, on behalf of the American College of Surgeons, is beaten about.

First the testimony:

With trauma care and surgical emergencies, there are no good substitutes or physician extenders for a well-trained general surgeon or surgical specialist. Surgical training is vastly different from other physician training programs. Mastery in surgery requires extensive and immersive experiences that extend over a substantial period of time. Surgical residencies require a minimum of five years and often several more years for specialties such as cardiothoracic surgery. However, the prospects of declining payment coupled with rising practice costs; increasing liability premiums and the escalating threat of litigation; a crippled workforce leading to more on-call time, higher caseloads, and less time for patient care; and an uncertain future for the U.S. health care system understandably deter would-be surgeons from making the extra sacrifices necessary to become a surgeon.

Then the response:
Is the American College of Surgeons really implying that there are good non-physician substitutes for primary care physicians, but not, of course, for surgeons because "mastery" of surgery is so much more difficult and takes so many more years of training than primary care?
The comments of both posts go back-and-forth between
"Most PAs and NPs can do about 90% of what I do"....

"Many simple Specialty care procedures can also be delivered by appropriately trained mid-level practitioners, in fact the CardioThoracic surgery PA in our hospital routinely puts in Chest Tubes and does many simple procedures, if that is the argument we wish to have we could each have counter points. Many cystoscopies, endoscopes, along with much else that occupies a surgeons time can be done by technically adept nursing staff with the appropriate training. In fact, they employ such a model in some European countries."

So I guess we will all be out of jobs soon. Yes simple primary care can be handled by midlevel providers and yes portions of major procedures as well as minor procedures can be done by midlevel providers as well. But what of the other 10 percent? What if a complication occurs? What then?

I do respect primary care, they do an excellent job of managing chronic and acute medical problems.

The next post will discuss some of the reasons why we can't get along.

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Saturday, March 21, 2009

No "I" in Team...
Kevin points to a post by Duncan Cross in which he opines that the trial lawyers take care of our patients interests better than we do:
Now I don’t think trial lawyers are saints, but here’s the thing: when faced with their own mistakes, doctors can no longer be trusted to act in their patients’ interests. Trial lawyers may be working from craven self-interest, but that self-interest is better aligned with patients’ interests on this problem.

I must disagree, their self-interest is better aligned with their client's interest. Before you become their client, they have to believe that they can win and get enough money to make it worth their while. How do I know? Because they themselves say so.
Allen: Even before we request records, Alice and I will sit down and evaluate the case. The first thing we need to assess is the dollar value of the damage. If there's no damage, then there's no case for us, no matter how badly the doctor may have screwed up. I could be more compassionate about it, but that's the real basis for our decision: You establish the damage first, then the liability.

Burkin: Because of our time investment and costs, we really can't consider a case unless we can expect a payoff of at least $200,000 in damages, and even that's really not enough. If we end up taking the case to trial, we're probably going to spend $20,000 to $30,000 or more. So we have to make a business decision: Are the potential damages worth the time and expense we'll have to invest to win?

Q Isn't that a pretty cynical way to evaluate the claim of a badly injured patient?

Burkin: I'd say it's the only realistic way to do it, even though it's one of the sad things about the economics of this business. If the damage is, say, $50,000, that may be a big deal for many people, but it's not enough to make the case worthwhile for us. So we'll turn it down.
I also admit that physicians support tort reform out of "craven self interest". I do not enjoy paying an insurance premium higher than the average personal income in the U.S. But physicians also have concerns over access. If the only neurosurgeon within 100 miles gets sued enough and leaves, are the patients in that community better off or worse off? If liability concerns lead to closure of the maternity ward in a small-town hospital are those expectant mothers better off or worse off?

The commendable efforts that anesthesia made are also discussed in Dr. Cross' post.

I've discussed this before, and as per a commenter on my post:
I join the Journal in applauding our anesthesia colleagues in their success in increasing the safety of their profession. While reading the article yesterday, I was struck by the impression that the progress made was low hanging fruit; it describes that horrors that accompany esophageal intubation and then, voila, pulse-ox monitors and capnographs appeared, and now the problem has been virtually eliminated.

as well as Dr. Cross' post:
As it turns out, anesthesiology is well-suited to standardization. There are x number of drugs that can be administered to a person of y weight with a few variable multiplicands yielding a graph that one can pin on the wall as set standards. Much of medicine is not so simple.
The results that have been achieved with anesthesia may not be transferable to other specialties. Your mileage may vary.

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Friday, March 20, 2009

Match Stats 2009...
After neglecting my usual review of senior medical students voting with their feet last year, here we go again.

According to the NRMP a record 29,890 seniors partcipated this year. The breakdown...

General surgery:

Surgery offered fewer positions this year, with fewer positions filled by US graduates. Six programs did not fill.

Internal medicine:

While the fill rate for IM remains strong, fewer US graduates are choosing it. 25 programs did not fill.

Family practice:

Family practice offered 101 fewer spots this year. Total fill was up slightly, with a slight decrease in US graduate fill percentage. The trend of a majority of FP residents being non-US graduates continues. This trend has been going on long enough that the majority of residency graduating classes for the past few years have been made up of non-US grads. 88 programs did not fill. Family practice seems to be a job that "Americans won't do."


Higher fill percentage among US grads for pediatrics from last year, but still down from 2007. 29 programs did not fill.


More positions with higher fill with US grads than in the past few years. 5 programs did not fill

Emergency Medicine:

Higher total fill and US grad fill percentages. They added 73 more positions this year and filled more this year than their total last year. 5 programs did not fill.

Now for the residents who take the "road":


Increase of US grad fill percentage. Looks very similar to general surgery as far as total slots and percentages. Based on both PG1 and PG2 numbers. 5 Programs did not fill.

The "eye dentists" have their own match. The positions filled/total positions are 2009:458/459, 2008: 453/454, 2007:449/450.


Increases in US and total fill percentages. Given the large increases of positions filled, the supply of anesthesia slots seems to have leveled off. Again, very similar to surgery as far as numbers go. These numbers also combine the PG 1 and PG2 positions. 13 programs did not fill.


1 program did not fill. Dermatology remains insanely popular.

The trends remain stable among specialties with growth continuing the most in emergency medicine. US graduates continue to flee primary care. How many of these new IM and pediatric interns will be subspecialist fellows or hospitalists in three years?

See comment from Kevin here from the WSJ here.

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