Physicians

GundermanDo physicians in training take better care of patients or perform better on their exams when their work hours are restricted?  Two recent studies in the Journal of the American Medical Association suggest that the answer is no.  In one, patients of surgery residents showed no difference in morality or postoperative outcomes after duty hour restrictions were implemented.  Their test scores did not improve either.  In the other, hospitalized Medicare patients being cared for by physicians working shorter hours experienced no improvement in mortality or readmission rates.

US resident duty hour restrictions were born in 2003, when the ACGME, the organization that accredits medical residency programs, capped the work week at 80 hours.  It also mandated that residents have 10 hours off between duty periods and a 24 hour limit on continuous duty, with 1 day in 7 free from patient care.  In 2011, the organization revised its policy, further restricting the total number of continuous duty hours for physicians in the first year of training to 16.

How could well-intentioned attempts to ensure that hardworking young physicians get sufficient rest fail to benefit patients?  To begin with, simply restricting duty hours does not guarantee that residents will use their extra off-duty time to sleep.  They might, for example, use it to study, exercise, or socialize.  It is also possible that the outcomes being assessed by these studies are influenced by so many factors that merely changing duty hours is insufficient to cause a change.  Yet if such changes do not benefit patients, how strong is the case for their implementation?

Some educators worry that duty hours restrictions are undermining the quality of medical education.  For example, a survey of surgery program directors published last year showed that 21% believe that residency graduates are unprepared for the operating room, 30% believe they cannot independently remove a gallbladder, and 68% believe they cannot perform a major procedure unsupervised for more than 30 minutes.  Another survey showed that 38% of residents themselves lack confidence in their preparation even after 5 years of training.

Continue reading “Does Restricting Physician Duty Hours Improve Patient Care?”

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New York Post reporter Susan Edelman revealed on January 4 the name of the unfortunate anesthesiologist allegedly present on August 28 at Yorkville Endoscopy, during the throat procedure that led to the death of comedian Joan Rivers. She is reported to be Renuka Reddy Bankulla, MD, 47, a board-certified anesthesiologist from New Rochelle, NY.

Having her name made public will be a nightmare for Dr. Bankulla, as investigators will certainly target her role in Ms. Rivers’ sedation and the management — or mismanagement — of her resuscitation.

When the news of Ms. Rivers’ cardiac arrest and transfer to Mt. Sinai Hospital became public, many of us guessed that there might have been no qualified anesthesia practitioner — either anesthesiologist or nurse anesthetist — present during the case. The gastroenterologist and then medical director of the clinic, Dr. Lawrence Cohen, argued famously that the sedative propofol, which Ms. Rivers received, could be safely given by a registered nurse under his supervision, and that no anesthesiologist is necessary.

However, with the publication of the Centers for Medicare & Medicaid Services (CMS) report of September 5, it became clear that an anesthesiologist was definitely present. The anesthesiologist was identified only as “Staff #2″ in the report. She was interviewed by the CMS surveyors four days after the event, but said she was “advised by her legal representative not to discuss the case.”

Key pieces of information about what happened still haven’t been made public. Nonetheless, the surveyors gathered enough information to reach this conclusion:  “The physicians in charge of the care of the patient failed to identify deteriorating vital signs and provide timely intervention during the procedure.”

By any standard of care, the anesthesiologist clearly would be one of the physicians in charge.

Continue reading “The Anesthesiologist’s Story: New Details Emerge In the Joan Rivers Case”

By MARTIN SAMUELS, MD

Martin SamuelsI am a doctor today because of Dr. J.W. Epstein, my pediatrician in Cleveland in the 1950s.   An immigrant from the Nazi terror in Europe, he had trained in Vienna and   spoke English with a Germanic accent.  His house calls are etched permanently in my memory.  His visits were heralded by a fury of activity, led by my mother.  “The doctor is coming!  Put on clean underwear.  Clean the house.”  Water would be set to boil on the stove, in case the doctor should need to sterilize a needle for an injection.  Up would drive his broken-down jalopy, which he would park directly in front of the house.  No need to worry about getting a ticket.  The police knew his car and would never issue a citation to The Doctor.  No one – not the mayor, not the governor, not even Al Rosen, the venerated third baseman for the Indians – would have received such a royal welcome.

In he would come, wearing a suit and hat, carrying a worn black doctor’s bag.  “Mudder, ver is da boy?”  ”He’s in his room upstairs with a rash and sore throat.”  He would put down his bag, sit on my bed, and ask me if the teacher had sent home the homework.  He wouldn’t want me falling behind in my school work.

That might interfere with my becoming a doctor.  Then came the ritual of the examination.  Say aah; schtick out your tongue; take some deep breaths.  “Gut… gut…zounds normal” as he listened with his stethoscope, feeling gently on my belly and then finally tap on some reflexes with his tomahawk hammer.  “Mudder, it’s da measles, plenty of fluids, back to school in a few days.”  “Veel zee you in da office next fall for da usual checkup.”  “Mudder; don’t vorry, it isn’t polio.”  No time for a cup of tea today; too many other house calls for this afternoon and off he would go.  The enormous feeling of relief, transmitted from my mother to me, had me on the mend in no time.

This is what I wanted to do:  be the agent of relief, the repository of medical knowledge, the most respected figure in the community.  Some years later, as a teenager, I was waiting in Dr. Epstein’s office for my annual checkup before school started in September.  I was surrounded by little babies and I realized that I might be growing out of Dr. Epstein.  As he was tapping on my back in the usual reassuring fashion, I said to him,  “How long can you see me as a patient?”  “ Until you’re a doctor.”  How could I fail him?

Continue reading “Rediscovering Medical Professionalism”

flying cadeuciiI am a foreign born, foreign trained doctor, serving many patients from an ethnic minority, whose native language I never mastered.

So, perhaps I am in a position to reflect a little on the modern notion that healthcare is a standardized service, which can be equally well provided by anyone, from anywhere, with any kind of medical degree and postgraduate training.

1) Doctors are People

No matter what outsiders may want to think, medicine is a pretty personal business and the personalities of patients and doctors matter, possibly more in the long term relationships of Primary Care than in orthopedics or brain surgery. Before physicians came to be viewed as interchangeable provider-employees of large corporations, small groups of like-minded physicians used to form medical groups with shared values and treatment styles. The physicians personified the spirit of their voluntary associations. Some group practices I dealt with in those days were busy, informal and low-tech, while others exuded personal restraint, procedural precision and technical sophistication. Patients gravitated toward practices and doctors they resonated with.

Continue reading “A Doctor is a Doctor is a Doctor, Right?”

GundermanThe competition to get into medical school is fierce.  The Association of American Medical Colleges just announced that this year, nearly 50,000 students applied for just over 20,000 positions at the nation’s 141 MD-granting schools – a record.  But medical schools do not have a monopoly on selectivity.  The average student applies to approximately 15 schools, and many are accepted by more than one.  Students attempting to sort out where to apply and which admission offer to accept face a big challenge, and they often look for guidance to medical school rankings.

Among the organizations that rank medical schools, perhaps the best-known is US News and World Report (USNWR).  It ranks the nation’s most prestigious schools using the assessments of deans and chairs (20%), assessments by residency program directors (20%), research activity (grant dollars received, 30%), student selectivity (difficulty of gaining admission, 20%), and faculty resources (10%).   Based on these methods, the top three schools are Harvard, Stanford, and Johns Hopkins.

Rankings seem important, but do they tell applicants what they really need to know?  I recently sat down with a group of a dozen fourth-year medical students who represent a broad range of undergraduate backgrounds and medical specialty interests.  I posed this question: How important are medical school rankings, and are there any other factors you wish you had paid more attention to when you chose which school to attend?

Continue reading “Secrets to Choosing the Right Medical School”

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     Each year, over 20,000 US students begin medical school.  They routinely pay $50,000 or more per year for the privilege, and the average medical student graduates with a debt of over $170,000.  That’s a lot of money.  But for some who pursue careers in medicine, the financial cost has been considerably greater.  Melissa Chen, 35, a final-year radiology resident at the University of Texas San Antonio, calculates that her choice of a medical career has cost her over $2.6 million in lost wages, benefits, and added educational costs.  And yet in her mind, the sacrifice has definitely been worth it.

Continue reading “Is Becoming a Doctor Worth $2.6 Million?”

GundermanOne of the top students at one of the nation’s largest medical schools, Ishan Gohil has made an unusual – and to many of his colleagues – inexplicable decision.  Instead of seeking to train in one of medicine’s most highly specialized and competitive fields, he says, “I elected to pursue a career in family medicine.”  Many view his choice of primary care as ill-advised, largely because family medicine is one of the least competitive fields and ranks at the bottom for income of all medical specialties.

Until his third year, Gohil had planned to pursue orthopedic surgery, which is considerably more difficult to get into than family medicine.  In 2014, the average score on Step 1 of the US Medical Licensing Exam for students entering family medicine was 218, while for orthopedic surgery it was 245 (the overall average is 230).  Average annual salary levels diverge even more widely, at $122,000 for family physicians and $488,000 for orthopedic surgeons. Continue reading “Solving the Primary Care Shortage”

flying cadeuciiAfter more than a year of conspiratorial planning that would make Francis Underwood proud, California’s trial attorneys got a number assigned to an opaquely worded ballot initiative on Drug and Alcohol Testing of Doctors. Medical Negligence Lawsuits Initiative Statute As a result, “Proposition 46” could give California voters an unwitting hand in doing what this attorney group has been unable to accomplish after 40 years of inept legislative lobbying and dubious court challenges: undermine the state’s Medical Injury and Compensation Reform Act, or MICRA.

MICRA was passed in 1978 by a Democratic-dominated legislature and signed into law by then-governor Jerry Brown in response to the collapse of the state’s medical professional liability insurance market.  MICRA didn’t change the right of injured patients to obtain unlimited economic damages for all medical costs, lost wages and lifetime earnings. What it did was limit was non-economic “pain and suffering” damages to $250,000. Up until 1978, California’s trial attorneys had used this highly speculative class of damages to rake in a third of the multi-million jackpot jury awards. That made California physicians’ malpractice insurance unavailable at any price, leading many doctors to close their practices and leave the state.

That ended with the passage of MICRA. The market stabilized and in the decades that followed, billions in health care savings from lower professional liability costs were passed through to California’s patients.

Early last year, California’s physicians had heard rumors that a ballot initiative to undo MICRA’s non-economic cap was being planned.  Little did they know that California’s trial attorneys would take their cue from political consultant-bully Chris Lehane by opening their campaign with a mass mailing of anti-MICRA cadaver toe tags. That was quickly followed by the neighbors of pediatrician and then California Medical Association President Paul Phinney receiving deceptive postcards implying he was a drug dealer.

Months later, the ballot initiative – that was 100% underwritten by the trial attorneys and their allies at a cost of $2.85 per signature – landed on California Attorney General Kamala Harris’ desk.  The initiative’s authors cleverly disguised its quadrupling of the MICRA cap to more than $1 million (“to account for inflation”) and cynically camouflaged it between two conversation-changers:  1) mandatory physician drug screening and 2) mandatory uploading of the narcotic prescription history of every California patient to an online database. Naturally, Ms. Harris rewarded her trial attorney donors by making a mockery of the state’s single-subject rule and okayed it.

Continue reading “California’s Proposition 46: Trial Attorneys Behaving Badly”

Joe FlowerPut the question in 1880: Will technology replace farmers? Most of them. In the 19th century, some 80% of the population worked in agriculture. Today? About 2% — and they are massively more productive.

Put it in 1980: Will technology replace office workers? Some classes of them, yes. Typists, switchboard operators, stenographers, file clerks, mail clerks — many job categories have diminished or disappeared in the last three decades. But have we stopped doing business? Do fewer people work in offices? No, but much of the rote mechanical work is carried out in vastly streamlined ways.

Similarly, technology will not replace doctors. But emerging technologies have the capacity to replace, streamline, or even render unnecessary much of the work that doctors do — in ways that actually increases the value and productivity of physicians. Imagine some of these scenarios with me:

· Next-generation EMRs that are transparent across platforms and organizations, so that doctors spend no time searching for and re-entering longitudinal records, images, or lab results; and that obviate the need for a separate coding capture function — driving down the need for physician hours of labor. Continue reading “Will Technology Replace Doctors?”

Jack CochranIn recent weeks and months a number of articles have delved into the issue with a sense of seriousness and purpose that the doctor crisis deserves. Progress on reducing unnecessary pressures on physicians is painfully slow, but the broadest possible recognition of the problem is an important step toward dealing with it effectively.

We hold a basic belief about the future of health care: Solving the doctor crisis is a prerequisite to transforming our delivery system to improve access, equity, quality, and affordability. How can we possibly achieve the overall excellence and affordability in health care if large numbers of doctors are alienated and burned out?

Let’s be very clear: This is not about coddling doctors.

It is about preserving the ideals of the physician as healer and enhancing the professional experience – essential elements to optimizing care for patients and families. It is about acknowledging an honorable profession whose members deserve an environment in which they can serve patients to the best of their ability; an environment in which physicians can aspire to continuous improvement as engaged learners who embrace their role as active members of the Learning Coalition.

Traced Back to Medical School

The problem begins as early as medical school. Richard Gunderman, MD, recently authored an article in the Atlantic arguing that medical students:

are suffering from high rates of emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment. College students choose careers in medicine because they care, because people matter to them, and because they want to make a difference. What is happening to the nearly 80,000 U.S. medical students to produce such high rates of burnout?

Dr. Gunderman argues that we “need to understand not only the changes taking place in medicine’s external landscape but the internal transformations taking place in minds and hearts. … In what ways are we bringing out the best elements in their character — courage, compassion, and wisdom — as opposed to merely exacerbating their worst impulses — envy, fear, and destructive competitiveness?”

Continue reading “Help the Doctor”

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