skeptical-scalpel

Skeptical Scalpel, MD

I’ve been a surgeon for 40 years and was a surgical department chairman and residency program director for over 23 of those years. I am board-certified in general surgery and a surgical sub-specialty and have re-certified in both several times. Last year, I retired from clinical practice to devote more time to blogging and tweeting. I have over 90 publications including peer-reviewed papers, case reports, editorials, letters and book chapters. I have been blogging and tweeting for over three years. My blog has had more than 1,000,000 page views. I have over 9,500 Twitter followers.

http://skepticalscalpel.blogspot.com/

Which Type of Surgery Residency Should You Choose?

A reader asks if I have “any advice on choosing a surgery residency, e.g. academic, community, hybrid?” I’m not sure what a “hybrid” residency is, but I think he meant a university program with extensive exposure to community hospital rotations. Having been a community hospital residency program director for many years I was always partial to that type of program. I felt that we trained people who got more operative experience and were more confident in their skills. A paper in the Journal of the American College of Surgeons co-authored by [believe it or not] surgeons from Yale, Memorial Sloan Kettering Cancer Center and the American Board of Surgery validated my impression. The paper was a survey of 4282 residents, who comprised 80% of all categorical surgical residents in 2007-2008. Table 2 of that paper shows that residents at community hospitals are 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. [I have blogged before about resident lack of confidence.] Surprisingly, they were also happier with the level of didactic teaching than university-based residents. Of course, the choice of where to train depends on what the prospective trainee wants to do with her career in the long term. If one wants to be an “academic surgeon,” one might overlook...

Tired Residents or Too Many Handoffs? Which is Worse for Patients?

As a former surgical residency program director for more than 23 years, I am worried about the way we are training residents today. Some history. In 1984, an unfortunate young woman died at a prestigious hospital in New York. The case was followed closely by the media. Several important issues relevant to her death were under-reported. She had taken illicit drugs on the night of her death and she withheld this fact from her doctors. Because of this, she had a reaction to sedation that was administer which led to her death. There was a suggestion that the residents may not have been properly supervised. The residents who treated her had been on duty for less than 24 hours. Her father, a reporter for the New York Times, started a crusade against what was perceived to be the main cause of her death, doctors-in-training working long hours. This case resulted in the creation of the Bell Commission which formulated regulations limiting residents in New York State to a maximum of 24 hours of work per shift and 80 hours per week. [Note to any non-physicians reading this: being on-call for 24 hours straight does not mean that one is necessarily always awake for all 24 hours.] Several years later, the national organization that governs medical resident training, the Accreditation Council for Graduate Medical Education (ACGME), adopted similar rules. The...

Questions You Need to Ask When Interviewing for a Surgical Residency

You have talked to your medical school’s faculty and checked out med student websites and forums, but how can you find out the real scoop on other surgical programs? You medical school’s faculty may have no insight into the inner workings of other residency programs, and information on the Internet can be tainted or outdated. It is very difficult for an applicant to gain insight into a program’s real nature in a half-day interview. Obviously programs try to spin things in the best light possible. Unless they have a death wish of their own, even the residents who show you around may not tell you the unvarnished truth. The downside would be that they will hurt themselves by denigrating their program because fewer good candidates might rank it highly.   Ask more than one resident some of these questions when the program’s faculty is not present: 1. Are most of the residents happy? 2. Are residents or attendings doing the most of the cases? 3. Do PGY-1 and 2 residents get to do any cases as the operating surgeon or are the first two years spent covering floors and/or admitting patients? 4. Are any residents finishing the program not having performed enough complex procedures? 5. Are the busiest attending surgeons letting the residents do meaningful portions of their cases? 6. How much autonomy do the residents have regarding postop...

15 Helpful Hints for New Residents

I was a general surgery residency program director for 24 years. I’ve seen them come and go. Here is some advice for those of you who are beginning residency training.   1. Never be afraid to say “I don’t know.”   2. Never be afraid to ask for help. Some of the worst disasters I have ever seen were because a resident didn’t want to bother a more senior resident or an attending and blundered badly.   3. Respect your colleagues and your patients.   4. Until you gain a great deal of confidence, do not manage things over the telephone.   5. A patient who is restless or anxious may be hypoxic. Make liberal use of the pulse oximeter. Do not sedate a restless patient without personally seeing him.   6. Sometimes postoperative abdominal pain is due to urinary bladder distension. Learn how to use the bladder scanner yourself. 50 mL of urine output could be overflow incontinence.   7. Trust, but verify. [Or better yet, at first trust no one.] For example if someone tells you a lab result, say thanks and look at all the lab results in the computer yourself. Many times the nurse will say, “The labs are normal” and later you will find that the serum CO2 was 15. 8. Listen to the nurses (if they seem to know their stuff). They can...

To Tweet or Not to Tweet?

A while back, a very active tweeter/blogger, who just graduated medical school and was about to begin a residency, suddenly disappeared from the Internet. A few of us who followed him discussed the situation online but no one knew what had happened. After hearing that we were concerned, he emailed me that the administration of the hospital in which he was training had announced at his orientation that tweeting and blogging were prohibited, citing fears of information leaks, HIPAA concerns and nebulous “liability” issues. I am somewhat ambivalent about this. While I certainly support freedom of speech, I also recognize the hospital administration’s position. I believe discussing patients [even disguised] on line is potentially dangerous. Even an anonymous blogger can be unmasked if he is not careful or if someone is determined to discover the blogger’s identity. There is the famous case of a Boston blogger known as “Flea,” who was “outed” on the witness stand during a malpractice trial. He had been blogging about the trial while it was in progress. [Digression: Interesting interview with “Flea” after the trial.]     Another problem is the tone of some medical tweeters/bloggers. As some have commented, the output of many medical tweeters/bloggers does not pass the “elevator test” [would you say what you just tweeted in a hospital elevator?]. In fact, a lot of it doesn’t even meet the standards...

New Diseases Discovered by Hospital Clerical Personnel

Here is a list of illnesses and terms found on actual patient admitting medical records at a hospital which shall remain nameless. The “illness” or term is followed by a translation when possible. Fibial Fracture There’s a tibia and there is a fibula, but no fibia. Subcutaneous hematuria Hematoma (bruise) under the skin. Hematuria means blood in the urine. Urinary constipation Patient unable to pee. Intelligent gait Antalgic (a change in the way one walks to avoid pain) gait Bilateral sore throat Last time I looked, the throat was not a paired structure. Gullstones What you would throw at a bird at the beach. Umbilectomy Umbilical hernia repair? Protruded appendix Perforated appendicitis. Gastropsoriasis Gastroparesis, slow emptying of the stomach. Sphincter of Jedi Sphincter of Oddi, a structure that controls the flow of bile into the duodenum. Necrotizing fibromyalgia (just love that) Pelvic encephalopathy ??? Strangulated labia  I’m not sure about that one.   I’m sure you have a few of your own. Feel free to add them in the “Comments”...

Patients Are NOT Like Airplanes

As promised in my post “Surgeons Are Not Pilots,” I will address the issue of whether patients can be compared to airplanes. Honestly, I cannot think of even one thing that patients have in common with airplanes. Unlike an airplane, each patient is unique. If a pilot sits at the controls of any Airbus A320 aircraft, he can be reasonably sure that pulling back the stick a certain amount will result in a very consistent response from the plane. Therefore, practicing on a simulator will enable the pilot to prepare for any emergency with the knowledge that what he did on the simulator will in fact be reproducible in a real emergency. Contrast that with a patient. Often patients with similar illnesses will behave very differently because human beings are not engineered like airplanes. For example, let’s say I am performing a difficult laparoscopic cholecystectomy (removal of the gallbladder) and I am having trouble locating the cystic artery (artery to the gallbladder). I know that the anatomy of the cystic artery is highly variable. This link illustrates 11 of the most common anatomic variations in the location of that vessel. This means that there is not a simple maneuver that will help me find the artery in every case. A pilot can be confident that a 5% increase in power will result in a very predictable response in airspeed....

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