As physicians, we treat any number of illnesses, speak to patients about treatment options, and comfort families when bad news is given. Although we are sometimes held to a higher standard, held in high regard, or think very highly of ourselves, we are still only human. Every once and a while one of are own, family, friend or colleges, is struck ill or dies and it reminds us how human we are. We are not gods or immortals, but human.
One of our colleagues was affected this past Christmas eve. I will say a prayer for him and wish his family well. I will hug my children a little longer tonight.
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Thursday, December 27, 2007
As physicians, we treat any number of illnesses, speak to patients about treatment options, and comfort families when bad news is given. Although we are sometimes held to a higher standard, held in high regard, or think very highly of ourselves, we are still only human. Every once and a while one of are own, family, friend or colleges, is struck ill or dies and it reminds us how human we are. We are not gods or immortals, but human.
Monday, December 24, 2007
~Charles M. Schulz
To all that visit my blog, I wish You a Happy Holiday season. Here are a couple of humors holiday songs that take made me smile so I thought I would share.
OH HOLY NIGHT
TOM CRUISE CHRISTMAS
God bless you and yours.
Saturday, December 22, 2007
The other day I went to Starbucks before my clinic. The cashier asks me for my order and shouts it out to the person at the espresso bar. I said hello to the person behind me and walked to the pick up counter. My drink comes up. I thanked the barrister and went to the condiment bar. I smiled at another patron as we put cream and sugar in our caffeinated beverages. Walking to my car, I waved to the person in the car that let me cross the street. Then I was off to clinic. During this time, I counted no less than five interactions with people. For the most part, the day to day interactions with people on the street or in a store do not cause much of a problem. Knowingly or not, we all make quick judgments about people without consciously realizing it. It is human nature.
For the most part, physicians and nurses are well intentioned people. Everyday physicians and surgeons have multiple patient encounters. Just like the patrons of Starbucks or the people we may pass on the street, patients pass judgments on the physician based on a number of factors. Many of the factors used in making the prejudgment are out of the physicians control. Like patients, physicians also prejudge the patients. For the majority of encounters, there are no problems. Patients are either happy or indifferent, and we all go about our day. On other occasions, there are the interactions that don't go as we planned. Because of the volume of encounters physicians have, eventually there will be a bad interaction that cause a patient to fire the physician, or seek second opinions.
The other day one of my residents had a patient fire him. Understandably, he was quite upset. I heard his side of the story and witness' accounts of the interaction. To me, it sounds like the good intentions the resident perceived wrong and the questions of the patients were seen as hostile. I don't think that either party involved intended for this to be the case, but it is what it is. It brought up the topic of how do you deal with these situations. Anyone who has seen patients has had a bad patient encounter. There will be patients who will not be happy with what you say or the way you say it. People will go for second opinions. They will choose another doctor over you. It happens. It is a fact of life. How do we/you deal with it?
When doing an After Action Review (AAR) of the situation, the first step is not to take it personal. Of course, that is easier said than done. Don't blame yourself or the patient and above all, don't "blow off" the incident. Second, you must look at what role you played in making this a bad encounter. You must look at yourself critically and be brutally honest with yourself. Remember, for every bad encounter you have, there is only one common thread, you. Finally, you must look at what changes you can make to prevent a similar situation from happening. It seems like a lot to do, but it isn't. This is a simple exercise to improve your self-awareness. You must be self-aware and/or you must have people around you who will honestly tell you about yourself. This is not a time to have a "yes" man. Although a bad encounter is emotionally distressing and self-deflating, it provides the opportunity for the most growth as a clinician.
When I look at my personal experience and observation of others, the common flaw is communication. In the past, physicians were presumed to learn their "soft" communication skills at patients' bedsides, in their rounds as residents, and as students observing master clinicians and their interactions with patients. Today, the communication and interpersonal skills of the physician-in-training are no longer seen as immutable personal styles that emerge during residency but, instead, as a set of measurable and modifiable behaviors that can evolve. During the typical 15- or 20-minute patient-physician encounter, the physician makes immeasurable choices regarding the words, questions, silences, tones, and facial expressions he or she chooses. These choices either enhance or detract from the patient's perception of the physician's clinical skill. From obtaining the patient's medical history to conveying a treatment plan, the physician's relationship with his patient is built his/her ability to communicate. In these encounters, both verbal and nonverbal forms of communication constitute this essential feature of clinical practice.
What are some tips at improving the effectiveness of our communication?
- 1. Assess what the patient already knows
- Before providing information, find out what a patient already knows about his or her condition. It is important to determine what a patient already understands, or misunderstands, at the outset.
2. Assess what the patient wants to know
- Not all patients with the same diagnosis want the same level of detail in the information offered about their condition or treatment. Physicians should assess whether the patient desires, or will be able to comprehend, additional information. For the physician without advance knowledge of the patient, this level of need will emerge by degrees as the discussion unfolds and as the physician attempts to synthesize and present information in a clear and understandable manner.
One telling sign of whether the patient is understanding the information is the nature of the questions patients ask; if questions reflect comprehension of the information just presented, a further level of detail may be warranted. If questions reflect confusion, it is advisable that the physician return to basic information. If the patient has no questions or is obviously uncomfortable, this is a good opportunity for the physician to stop the discussion, ask explicitly how much information the patient desires, and adjust accordingly. Continuing to provide further information is not always the best approach.
3. Be empathetic
- Empathy is a basic skill physicians should develop to help them recognize the indirectly expressed emotions of their patients. Once recognized, these emotions need to be acknowledged and further explored during the patient-physician encounter. Further, physicians should not ignore or minimize patient feelings with a redirected line of inquiry relentlessly focused on "real" symptoms. Patient satisfaction is likely to be enhanced by physicians who acknowledge patients' expressed emotions. Physicians who do this are less likely to be viewed as uncaring by their patients.
4. Slow down
- Physicians who provide information in a slow and deliberate fashion allow the time needed for patients to comprehend the new information. Other techniques physicians can use to allow time include pausing frequently and reinforcing silence with appropriate body language. A slow delivery with appropriate pauses also gives the listener time to formulate questions, which the physician can then use to provide further bits of targeted information. Thus, a dialogue punctuated with pauses leads to deeper comprehension on both sides.
In situations involving the delivery of bad news, the technique of simply stating the news and pausing can be particularly helpful in ensuring that the patient and patient's family fully receive and understand the information. Allowing this time for silence, tears, and questions can be essential.
5. Tell the truth
- It is important to be truthful. In addition, it is important that physicians not minimize the impact of what they are saying.
6. Keep it simple
- Physicians should avoid engaging in long monologues in front of the patient. Far better for the physician to keep to short statements and clear, simple explanations. Those who tailor information to the patient's desired level of information will improve comprehension and limit emotional distress. It is wise for the physician to avoid the use of jargon whenever possible.
7. Be hopeful
- Although the need for truth-telling remains primary, the therapeutic value of conveying hope in situations that may appear hopeless should not be underestimated. Particularly in the context of terminal illness and end-of-life care, hope should not be discouraged.
8. Watch the patient's body and face
- Much of what is conveyed between a physician and patient in a clinical encounter occurs through nonverbal communication. For both physician and patient, images of body language and facial expressions will likely be remembered longer after the encounter than any memory of spoken words. It is also important to recognize that the patient-physician encounter involves a two-way exchange of nonverbal information. Patients' facial expressions are often good indicators of sadness, worry, or anxiety. The physician who responds with appropriate concern to these nonverbal cues will likely impact the patient's illness to a greater degree than the physician wanting to strictly convey factual information. At the very least, the attentive physician will have a more satisfied patient.
On the other hand, the physician's body language and facial expression also speak volumes to the patient. The physician who hurriedly enters the examination room several minutes late, takes furious notes, and turns away while the patient is talking, almost certainly conveys impatience and minimal interest in the patient. Over several such encounters, the patient may interpret such nonverbal behavior as a message that his or her visit is unimportant, despite any spoken assurances to the contrary. Thus, it is imperative that the physician be aware of his or her own implicit messages, as well as recognizing the nonverbal cues of the patient.
9. Be Prepared for a Reaction
- Patients vary, not only in their willingness and ability to absorb information, but in their reactions to physician communications. Most physicians quickly develop a sense for the various coping styles of patients, a range of human reactions that has been categorized in several specific clinical settings. Patient responses may range from no response, to blaming the physician and medical team. There may be a display of emotion that rages from the mild depression and anxiety to the extremes of emotions with displays of crying, denial, or anger
In responding to any of these patient reactions, it is important to be prepared. The first step is for the physician to recognize the response, allowing sufficient time for a full display of emotions. Most importantly, the physician simply needs to listen quietly and attentively to what the patient or family are saying. It is extremely important to acknowledge their feelings and emotions. The physician's body language can be crucial in conveying empathic concern in these encounters.
- Using technical language or jargon,
- Not showing appropriate concern for problems voiced by the patient
- Not pausing to listen to the patient
- Not verifying that the patient has understood the information presented
- Using an impersonal approach or display any degree of apathy in communications
- Not becoming sufficiently available to the patient
In the end, the patient-physician dialogue is not finished after discussing a diagnosis, tests results, or proposed treatments. For the patient, this is just a beginning. As a surgical sub-specialist, we are not typically the most effective communicators. It is not uncommon for the surgical sub-specialist to be seen as an uncaring technician. In today's ever changing medical world, we need to be better. With internet access to information, patients are becoming more educated consumers. Many patients are not acutely aware of a physician's technical skills, but they do know how a physician makes them feel. Regardless of how technically skilled you are, it is you communication skills that will be remembered.
People in the service industries understand the importance of the initial consumer perceptions. At Starbucks, the young cashier greets you with a smile. Takes your order, asks if you would like anything else, gives you your change, and tells you to have a nice day. We expect this as a consumer. The medical field is a service industry and patients the consumers. Should they expect anything less?
Saturday, December 8, 2007
It is cold, but not cold enough for snow. It is freezing rain cold. The kind of weather that brings rain and sleet. The kind of weather that covers the road and your car with ice. Driving is hard in this weather. With experience and patience, a driver can learn to prevent the skid into the side rail or another care during a sharper turn. Although you can read about how to drive on ice, many of us have learned more from the experience of driving in icy weather than any book can teach.If you ask someone in the medical field to describe a surgeon, they may tell you that a defining characteristics of a surgeon is "arrogance". Of course this does not speak to all surgeons, but it is one of those stereotypes people have about surgeons. As a medical student I even asked a attending surgeon the question, "does the surgery residency make you an @$hole?" Okay I probably didn't use those specific words, but you get the picture. Her response was, "no, but it will amplify it if it already exists." Although the prevailing view of surgeons is that they are arrogant, my slightly biased view is that not all are arrogant, but their confidence is perceived as arrogance. I personally believe to be a surgeon it is important to have confidence; it is important to believe in your skill set and decision making ability. Who wants a wishy washy surgeon? There is a fine line between confidence and arrogance. It is arrogance that can get a surgeon into trouble; it is arrogance that can make you dangerous.
I drive a Subaru. The all wheel drive that provides me with the capability to move quickly on the icy roads, but does not give me improved stopping ability. I am aware of the limitations. Unlike the 18 year old with his dads SUV who speeds past me, I am patient. My speed is tempered by my previous experiences and fluctuates based on the number of curves in the road and cars on the road.
Driving on icy roads is much more difficult than new snow or even packed snow. Driving on ice or a zero friction surface makes the ability to stop and/or maneuver very difficult. There has to be anticipation and patience. It is not a time to multi task in the car. Full attention must be given to the road. There should be no quick movements, no sudden stops, no quick turns.
What is the actual difference between arrogance and self-confidence?
- Arrogance: an attitude of superiority manifested in an overbearing manner or in presumptuous claims or assumptions.‘Arrogance’ is an attitude of overbearing, proud, self-importance that shows itself in contempt or disregard for others and their opinions.
- Self-confidence: self-confidence is an attitude which allows individuals to have positive yet realistic views of themselves and their situations. Self-confident people trust their own abilities, have a general sense of control in their lives, and believe that, within reason, they will be able to do what they wish, plan, and expect.
In icy weather, I drive cautiously. I don't fear the weather or road, but respect it. I understand that not respecting it can lead to disaster. We have an unspoken understanding.
Self-confidence is an important trait for a surgeon to have. Having self-confidence does not mean that individuals will be able to do everything. Self-confident people have expectations that are realistic. Even when some of their expectations are not met, they continue to be positive and to accept themselves. When a surgeon is self-confident, he/she is able to look critically at their decisions and adjust based on their outcomes (good and bad). They possess the "force of character" to take ownership of both their successes and their failures. Arrogance prevents a surgeon from having the insight to correct their own errors and thus, their growth will be stunted. The acceptance of newer ideas and other's insight into a disease or procedure is key in ones growth, both as a clinician and surgeon. Having self-confidence allows for growth; having arrogance prevents growth.
I have driven many nights on icy roads. I personally don't like doing it, but I am confident in my ability to perform the task. I respect ice. I am aware the obstacles it provides. I drive confidently on the road. It is not the time for risk taking. Unlike the teenage driver, I drive respecting the road.
As I write this post, I look back at my own career and can make note of countless times were I have been wrong. Knowing how people have taken other posts, I must state that I am not immune to being arrogant. I am not perfect. I write this to because I believe that the line between arrogance and self-confidence is extremely thin. We all must remain self aware. We must be willing to continue to grow and look at ourselves as lifetime students. I continue to grow both as an educator and learner. My views are constantly being reshaped and molded. Do you have the "force of character" to do continue or do you believe you know the right answer already?
Friday, November 23, 2007
So many people ask the question, what does it take to get into orthopaedics? I have posted before some statistic on what many programs look for in an applicant. But, my view of this is like drafting in the NFL. The statistics do not give you the intangibles. Randy Moss and Terrel Owens are great receivers; but if they are in the wrong system or with the wrong combination of players, they don't do well. And, who can forget the Ryan Leaf or Akili Smith. Then there are players that put in the right systems they flourish, Willie Parker and Tom Brady. With that prospective, I believe that there are people and programs that are a better fit. That is not to say that if you have some of the basic stats (USMLE, Grades, etc) you are or are not a shoe-in to a program. But, I do believe that there are better fits.
From the program end, what we try to do is know who we are. We understand what type of program we have an what residents do particularly well and which don't. We can look back over years and know what is our normal pattern of applications. We know what schools and states we receive a lot of applicants from and which ones we do not. This makes that application selection process different. In our program, we are not necessarily looking for some statistical wonder or the ugly duckling. What we generally prefer is a solid individual that fits what we feel is our personality profile.
From the applicant prospective, I believe that best approach to applying is to be realistic with yourself. Know what you strengths and weaknesses are (yes we all have them) . This is an important inventory but difficult to do, well. Next, you need to see where you would like to be located regionally, and look at you school's history of placing people in programs in that location. Then you should look the programs in that area and evaluate how they fit into your personality profile. This will help you in choosing the best program that will help you flourish.
In the end, most of those that obtain a residency will complete and become an orthopaedic surgeon. The more important question is will those same people have a positive experience and become the best with their abilities. My view is that not every flower will be beautiful in every soil; but, given the right soil, every flower can be beautiful.
Thursday, November 22, 2007
It is your typical stuffy airport. We arrive early Friday morning. The team assembles. It is a long fight (1hr to Detroit, 14 hrs to Tokyo, 3 hrs to Shanghai, and a 2 hr car ride to Suzhou). All of the members of the team except one know each other. We are excited and anxious. Many questions flutter through our minds. What cases will we do? What equipment will be available? Did we bring enough to do our cases? What are the facilities like? Etc.
We arrive in China at night. There is a large greeting party with a sign that says WELCOME HTC, and has all the members names. We are all dragging, but there is still a 2 hour car ride to go. We receive a welcome packet and the agenda for the week. Hmmm ... the agenda is pretty packed.
Sunday is a recovery day. A little site seeing. We are introduced to old China, through a tour of a several century old garden. I feel a bit jet jagged. We are taken for a traditional Chinese dinner with the president of the hospital, head of the CDC, and the head of the pediatric orthopaedic department. Dinner was very interesting, especially the jellyfish.
Monday was a clinic day. All of the perspective patients were viewed. The pace was different than I am use to, not the usual 35-40 patients in the morning. Patients were brought in and examined, decisions were made, and surgeries planned. We took breaks for tea. I spoke with one of the Chinese pediatric orthopaedic masters. He is greater than 80 years old and still his mind is vibrant.
“One generation plants the trees, and another gets the shade”
The inpatient facility was not attached to the operating rooms. Therefore, the patients would have to be transported across the small street post operatively. The inpatient unit was filled with beds. There were beds everywhere. They lined the hallways and filled the rooms. We walk past children in skin traction for elbow fractures. We learned that the patients care on the floor is rendered by the family. The family changes the beds, provides the food, and does the primary observation of the child. We learned that in the Chinese system there is no rush for people to be discharged. The hospital stay is relatively inexpensive for the families (about $5/day). These were slight differences from the US system.
During our first day, we were also introduced to a number of residents. I learned that their system is similar to the British system, yet different. There are 2 tiers, an academic path and what I would call, a "worker" path. In the Chinese system, medical school is 5 years. After medical school, you can do a residency and start to practice. To receive you license and become officially a "doctor" then you must obtain a masters to sit for the licensing examination. In this path, the "worker" path, you will not be considered for the higher level positions within the hospital. This is good for some, but if you desire to have a higher level position, you must do more formal classroom training. Those in the academic path continue schooling and receive a Ph.d. in medicine. Now, my understanding of the registrar and resident roles is fuzzy. I am not sure if they are like junior attendings or high level residents. But, the registrars and residents are guided by a senior attending and appropriate cases chosen for them. Needless to say, in every case, we had 4-7 residents, registrars, and attendings in the room. This hierarchy took a little getting use to.
We operated from Tuesday through Thursday. Our cases varied from Scoliosis (idiopathic and congenital) to clubfeet. During the first day, we operated primarily with our team. For the subsequent days, we operated in tandem with the physicians from China. It was a wonderful experience. The hardest part was communication. Many of the physicians understood some English, but not enough to fully describe surgical procedures. So, there were a lot of hand signals. We learned a little mandarin. Just enough to get by. (You know, yes, no, ok, and like a good American, we learned a couple swear words.)
All of the surgeries went well. There were no immediate surgical complications. Overall, the surgical experience was good. We didn't take on any cases that we couldn't handle. We kept it simple. Of course, our ultimate goal was to DO NO HARM. We hoped for a good learning experience. Our education did not come in the form of surgical procedures or clinical cases; it came from learning a different culture. We learned a different approach to medicine. We saw some older techniques and treatments that we typically do not use. The patients were very appreciative. They even came in their best clothes to the appointment. This was a great experience.
On the final day of our mission, we were able to do a little more site seeing. Then back on the the plane for a full flight and a long night. Was the trip worth it? I would say without a doubt. It reminds you of the basics of medicine, the practice of medicine. The worries of documentation, malpractice, billing, hospital administration, and university policy, were gone. All we thought about was treating patients. It was nice.
“Happiness is the meaning and the purpose of life, the whole aim and end of human existence”
Thursday, November 15, 2007
Monday, November 12, 2007
As we go through residency and then become attendings, we like look up to those educators that we respect and would like to emulate and discard those things that we felt were unimportant or "bad" characteristics that we would not like to emulate. If we choose to be come an educator of sorts, our teaching style will mimic many of those characteristics for educators that helped you. You will infuse your own personality into this teaching style and create your own flare. But, no one actually explains to you what makes a good educator. What characteristics made these influential people in your education? What are the techniques that they used to achieve their ultimate goal of educating the learner? I look back at my own education as an example of how to educate others. But not every technique that was effective at teaching me will be effective at teaching everyone.
I have been to a number of conferences and been inspired by most of them. At every meeting, there is something that gets my mind stimulated. I routinely come home with a number of ideas for projects. The orthopaedic educators course was a wonderful forum of people who come for the similar purpose of learning to better educate. As the days went on, there were dedicated lectures to help us understand theories of education. What became evident early in the course was as much as we were learning from the instructors, we learned from each other. The course consisted of both new and old practitioners, as well as, program directors, new attendings and residents. There were people from very academic programs and very community based programs. We were in lecture from 8:30 am to 8:30 pm. We ate breakfast, lunch, and dinner with one another. I thought this would be over powering and rather boring. My experience was just the opposite.
During the week, I had discussions with many of the attendings about our concerns and problems. What I realize was that no matter where you lived or where you taught, we all had many of the same questions. We all have problem residents; we all don't quite understand some of the ACGME guidelines; and we all don't quite understand how to systematically educate residents. Who in college, medical school, or residency, teaches you adult education theory? You get the term of "professor" and all of the sudden you know how to teach. Now, I understand that this has been done for years and has produced thousands of good to excellent practitioners, but I think that we are in a time where we must become more efficient at educating.
With the restrictions in hours, decreases in both surgical and clinic time, and increases in both the numbers of diseases we treat and procedures we perform, we need to be more efficient with the time we are given. There needs to be reason to our madness. My experience is that like there are some educators that have the knack of efficiently conveying information that is retained by the learner. These people generally keep your attention by their presentation techniques or their enthusiasm about the subject matter. But, more commonly a lecture is given and the educator is teaching but nothing is being learned.
I think that education theory should be a requirement for anyone who is educating medical students, or residents. For some reason, physicians are given the opportunity to educate without any guidance to how to educate. You may be given a handbook of guidelines and techniques, but many physicians are placed in the educator role without any idea of how to teach in a way that people with learn. In my experience, we treat medical education like parenting. We teach by trial and error. We are given guidance from those elders (parents) and occasionally follow the advise from these elders (our mother in-law). This does not have to be so hap hazard. In this day and age where we are require to be more efficient, our approach to educating the learning must change. We must have an organized approach to educating the learner. We must communicate our goals for the learner to give them an understanding of what our intentions are. I am particularly bad at letting folks know what my intension or expectations are. You (I) assume that they have ESP and can read your (my) mind. I have made a secret pledge to my self to improve on this. I hope that all of you that are educating will join me in this pledge as well.
Monday, November 5, 2007
It was an interesting question that I asked myself. Looking back at residency, we are immediately placed in situations where we are supposed to be teaching/educating both medical students and junior residents. We are given this task without any clue on how to educate.
I am now in a room filled with people who are interested in the how of education; how do we teach the information so that the learner will learn and retain the information. We all have our biases about what is important and what is not. The tools and techniques that we all yous are slightly and sometimes vastly different. Our common purpose is to be better teaching our learners.
As the week progresses, I will try to convey some of the information I learn.
Monday, October 29, 2007
~Robert M. Hutchins
Long ago, I remember sitting in an interview for medical school and the interviewer asked me, "what do I want to do?" A typical question that most applicants get. I had already decided on orthopaedic surgery as a specialty, but I still had the idealistic views that I could make a difference. My answer was like so many others who said in some way, shape, or form that they wanted to help the "world." This idealistic views do change as time goes by and we realize that this is a business and that money makes the world go around. In medical school, especially at an academic powerhouse, no one ever talks about the financial side of medicine. It is money that fuels the machine and without it the machine does not run. So, why is it that there is such a lack of training on the business end of medicine?
I began to write this post about a month ago and Howard J Luks, MD posted before I could complete the thought. He raises the same question that I have. When is it that we talk about business? (which really means talking about money)
No question that our students are well trained in the science of medicine. Unfortunately, very few students prove to be well trained in the business of medicine. Many students are even embarrassed to ask questions pertaining to the business of medicine because they are afraid they will betray their idealistic or altruistic beliefs that made them commit to a career in medicine in the first place. What do I mean? A student who recently rotated with me felt she could not discuss the business aspects of a career in medicine with her professors or colleagues in fear that she will appear to be cold or unfeeling. I had a student rotating on my service recently who wanted to go into Cardiothoracic surgery because it was "really cool." He had no idea how much their reimbursement has been cut. He had no idea that their case load has diminished dramatically over the years and he had no idea that true cardiac centers were performing some "pretty cool" new cardiac procedures. Some women are afraid of a career in ortho because they are petite. Some think that a pediatrician makes 300-400k per year.
I must say that I feel we owe the students much more than a book based education about the science of medicine. They need to know about what a career in medicine entails. They need to know about some of the hardships we are experiencing now and some that we are afraid may materialize. They need to know about EMRs, P4P, reimbursement changes, and the people/organizations behind the push to change the way that medicine will be practiced in the near future. LEAPFROG, PROMETHEUS, CMS, Payors, PBMs, EMRs, PHRs etc should be terms the students should be comfortable with. Otherwise they will plod through their residency, learn little more about the biz of medicine than they already do and then they will be thrust into a practice environment they have no idea how to navigate through.
The other week I was sneaking some brownies in the general surgery conference room and all 30 of the medical students where present (okay that was an exaggeration, there were only about 5, but it seemed like 30). I asked them if they wanted a lecture on something. I was in between cases and would be glad to teach a little. Of course they said no, but I forced myself on them anyway. I asked what their plans were etc.. Some how we got on the topic of coding. I informed them by CMS guidelines the medical student note means nothing. For billing purposes, we can not "link" to their note and bill. They seemed astonished.
For about 20 minutes or so I went on about ICD-9 , E&M, and CPT codes. We discussed billing, overhead, and collections. We discussed what it means to "par" with insurance. I spoke to them about the differences in incomes between military, academic, employed, and private practice. I think I over loaded them. But, I think it was a conversation that they needed to have.
As Dr. Luks points out, many of those in medical school today do not get the training in business; yet, when they graduate medical school, they are asked to run a business. I hear so many medical students speak of the "salary" they will have when they are done. Unfortunately, in todays world, it is becoming more of an "eat what you kill" type of world. There is really no "salary" anymore. So, should the business side of medicine be taught? I would scream YES. The question then is when do we teach it? The information in medical school is already more than one can manage. Residency time (total hours) is decreasing yet the complexity is increasing. Where do we find the time? I wish I had the answer.
Thursday, October 25, 2007
Saturday, October 20, 2007
~David Starr Jordan
The 80 hour work week restriction has gotten a lot of attention over the past 5 years. Many believe that these are the only changes that have significantly affected resident and medical student education. Over the past 20 years there have been a number of things that have change the way physicians practice. As much as the 80 hour work week was a shock to the training system, there have been small changes in requirements for billing, resident supervision, and reimbursement, that have probably affected resident education in a more subtle way.
In the early 90's, many academic medical centers were evaluated by CMS and levied huge fees on a number of academic medical centers. From these evaluations, a number of new guidelines were set for billable encounters in teaching situations. The changes have require more of an attending presence in clinical and surgical procedures. Although this did not directly change resident education, it changed the attendings participation in patient care. The days of (billed) resident run clinics went away. The days of (billed) surgical procedures without attending presence are gone. These changes are good for patient care, but changed resident education. It increases the duration of the learning curve. There is no room for allowing the young surgeon to figure out how to get through the cases. I call this the "futz factor." Young surgeons need to "futz" to figure out what works best for them. With attendings present, they tend to become impatient with "futzing" and take over the case. Most young surgeons need to do, observation is not as helpful unless you have the experience on which to build. This change the resident attending interactions and cause many attendings to become more hands on.
Along with increased requirements for billing came a decreases in physician reimbursements. Decreases in reimbursements caused an increasing need for surgeons to become more clinically active. Department chairmans began to see the departments overall income decreasing. Systems to encourage increase clinical production (incentives) were set up. Now, you income became more like true private practice. The mentality of "you eat what you kill" began to creep into the mentality of new attendings. The days of seeing few patients, doing a couple of cases and getting a large salary are gone. With less overall (clinical) income, salaries became effected. It has caused attendings be like Snoop said, "with my mind on my money and my money on my mind."
The question may be posed, "why would this change resident teaching?" You would assume that more attending presence there should be better education. You would assume that more cases and more out-patient and in-patient experience would be better for resident education. Unfortunately, I don't see this as being the case. What I see is more patient being seen in clinic and less time for teaching. What I see is more cases being done with a limited amount of time, requiring more attending participation and less time to "futz". What I see in an increasing number of different procedures and increasing complexity of these procedures with less time to learn them. I see residents being over extended because of the increasing demand to produce clinically. I see the use of PA's and other physician extenders taking away residents ability to learn some of the basic skills, such as casting. With money being the driving factor, education suffers. Teaching does not pay, therefore education suffers.
So, as much as I harp on the "new generation" and on the 80 hour work week, I also think that our ability to educate well has also been affected. I think that we are not educating as well. Our ability to spend time educating our future surgeons has changed. We will have to develop new techniques for educating them. I fear things will get worse before they get better. I worry that we may be graduating future surgeons who are less prepared than in the past. Is this better for patient care?
Wednesday, October 17, 2007
Over the past 10 years, I have had the opportunity to work with residents from different backgrounds, undergraduate majors, and orthopaedic programs. I have worked in 5 different academic settings. I state these facts because my upcoming view is not based on a view of one way of educating (i.e. the Harvard or Duke Way), but based on an understanding of the differences in both teaching and learning styles, academic and clinical settings, and generational changes. In my anecdotal point of view, residents in today's residency setting are technically delayed. The technical skills that I observed in residents 5 years ago don't seem to appear in the residents until about 6 months or so later. Some people reading this may feel that it is a slam. It is not; it is just my observation. When I ask myself why has there been such a change across the board, the only significant change has been the institution of the 80 hour work week.
One of the main reasons I like teaching is because I like to watch the intellectual growth of young surgeons. I enjoy seeing their development from novice surgeon afraid of cutting too deep, to a confident graduating chief. It is almost like raising your kids. "Oh, look he is using the cob like a big boy, now. He makes me so proud." Recently I have begun to notice that some of the skills that I had, I guess, taken for granted are not being developed. Basic skills that many learned in their internship in the past are being learned as second year residents. I wonder if we are failing our residents by not providing them with the tools they need to practice on their own. Are we setting them up for failure?
When the 80 hour work week was initially proposed, many surgical programs and grey-haired, "old school" surgeons said this will never work. I believed and still believe that the change was necessary. I also believe that once all of the data comes out that there will be changes in the duration of residencies (increase in time), the operative logs will be used for hospital credentials (no enough cases in residency = no privileges), and increases in the requirements for initial hospital monitoring of new surgeons and board certification. This is what I see in my crystal ball; although, it is sometimes cloudy.
There has been a recent study that have noted a decrease in cases logged.
Weatherby and fellow researchers used ACGME case logs to study PGY2 and PGY3 students' operative experience gained in a two-person orthopedic residency program in 2002-2003 (before the 80-hour week) and in 2003-2004, after the longer week took effect. Researchers also gave junior residents logs in which to record subjective caseload information, Weatherby said.
In 2003-2004, PGY2 and PGY3 residents performed 759 operations, or 195 (21%) fewer than in the previous year, Weatherby reported. Cases per rotation averaged 79.5 in 2002-2003, compared to 63.3 the next year, showing a 20.44% decrease (P=.009).
"The trend is obvious," he said. "It is obvious that it is national, too."
Residents missed 9% to 13% of total surgical case volume between November 2003 and January 2004, with each resident missing an average 10.8% of cases, totaling 254 cases over 64 post-call days, Weatherby said.
"Our study shows that residents who have begun training after the 80-hour work week will do significantly fewer procedures, particularly at the PGY 2 and 3 level," Weatherby said. "This may result in a decreased level of skill acquired during training or it may shift the majority of operative experience to the PGY4 and 5 years, prolonging the learning curve."
Weatherby called for more research and more assessment of how the new hour regulations affect surgical training. He also voiced concern about residents having fewer opportunities to learn surgical procedures in a reasonable amount of time.
"We must ask ourselves if we will at some point, in fact, build up the skill of orthopedic surgery," he said. "This also supports the theory that operative experience is deferred ... throughout the year, thus prolonging the learning curve."
I ask myself, how do we accommodate for the decreased numbers? Years ago, many surgeons would practice at home. They would learn how to drill and sew outside of work. They always worked on their technical skills. In the current generation, I have not seen the desire to work outside of “work” to learn how to perform their craft. Technical skill can not be read, it must be practiced. My residents and medical students are well read. They can quote literature, know how to gather information, and put on a heck of a power point show; but operative skill "not so much." The chiefs feel the need to operate because they what to gather the skills before graduating (and they are avoiding clinic) and the juniors operate less because of floor, clinic, and ER responsibilities. Then the cycle continues the next year because the rising junior becomes a chief and needs the operative experience.
I can hear people now saying, "Well just let them operate and get PA's and NP's to manage the floors and clinic." That is not the answer either. One of the most important skills for a surgeon is making good clinical decisions. Decisions like when to operate and when not to operate; which patients are good candidates and which ones are bad candidates; and what your outcomes are realistic expectations from procedures. That experience comes from follow-up. As they say, there is nothing like follow-up to ruin your good outcomes. We haven't even addressed billing, coding, and the other business aspects of a practice that are barely taught in residency.
As I look forward, I wonder if we are failing them by not providing them with ways to develop technical skills without actually operating on a patient. I know that there are simulators that are being used to help address these deficits (arthroscopy simulators), but are they being utilized appropriately? How can we accommodate for a decrease in case volume without increasing residency time? Maybe some of you have ideas. For now, I am still trying to keep from getting frustrated.
Thursday, October 11, 2007
I received this in an email today. I thought I would pass it along to all of my friends in the blogsphere. Enjoy.
TWO FRIENDS WERE WALKING
THROUGH THE DESERT.
DURING SOME POINT OF THE
JOURNEY, THEY HAD AN
ARGUMENT; AND ONE FRIEND
SLAPPED THE OTHER ONE
IN THE FACE.
THE ONE WHO GOT SLAPPED
WAS HURT, BUT WITHOUT
WROTE IN THE SAND:
TODAY MY BEST FRIEND
SLAPPED ME IN THE FACE.
THEY KEPT ON WALKING,
UNTIL THEY FOUND AN OASIS,
WHERE THEY DECIDED
TO TAKE A BATH
THE ONE WHO HAD BEEN
SLAPPED GOT STUCK IN THE
MIRE ! AND STARTED DROWNING,
BUT THE FRIEND SAVED HIM.
AFTER HE RECOVERED FROM
THE NEAR DROWNING,
H E WROTE ON A STONE:
"TODAY MY BEST FRIEND
SAVED MY LIFE ".
THE FRIEND WHO HAD SLAPPED
AND SAVED HIS BEST FRIEND
ASKED HIM, "AFTER I HURT YOU,
YOU WROTE IN THE SAND AND NOW,
YOU WRITE ON A STONE, WHY?"
THE FRIEND REPLIED
"WHEN SOMEONE HURTS US
WE SHOULD WRITE IT DOWN
IN SAND, WHERE WINDS OF
FORGIVENESS CAN ERASE IT AWAY.
BUT, WHEN SOMEONE DOES
SOMETHING GOOD FOR US,
WE MUST ENGRAVE IT IN STONE
WHERE NO WIND
CAN EVER ERASE IT."
LEARN TO WRITE
YOUR HURTS IN
THE SAND AND TO
BENEFITS IN STONE.
THEY SAY IT TAKES A
MINUTE TO FIND A SPECIAL
AN HOUR TO
APPRECIATE THEM, A DAY
TO LOVE THEM, BUT THEN
AN ENTIRE LIFE
TO FORGET THEM.
DO NOT VALUE THE THINGS
YOU HAVE IN YOUR LIFE, BUT VALUE
WHO YOU HAVE IN YOUR LIFE!
AND IF I HAPPEN TO GET IT BACK,
THEN I KNOW MY PLACE IN YOUR LIFE
"Be kinder than necessary, for everyone you meet is fighting some kind of battle."
...AMEN TO THAT
Tuesday, October 9, 2007
Alright, I know I am a big kid, but I use to love the Transformers. I use to watch them everyday after school. One of my residents showed me this, so I had to share. First, you need to see when Optimus Prime died.
What would happen if they brought him back? This is hilarious.
On Saturday, I was at the Chicago Marathon expo picking up my bib, chip, and T-shirt. there were people of all ages and sizes. All with a common goal, the Chicago marathon. Whether their primary goal was for a specific time and others for the spirit of completing, they were all there for the purpose of completing the 26.2 mile Everest. A video played on one of the screen showing the marathon from the previous year. It showed the winners sprint to the finish. Then, at the end of the video, the runners didn't have that thin marathoner build. They came in all shapes and sizes. They crossed the finish line at 5 or 6 hours, everyone so proud of completing their primary goal. I almost teared.For me, medical school wasn't that hard. That is not to say I had an easy time with it, but the material itself was not that hard. It was just a lot of information. Some people in medical school buckle under the pressure. They study too much or too little. They don't pace themselves through the mentally trying time of medical school. You must understand your strengths and weaknesses. It is not a sprint. Mental stamina was required for survival.
On Sunday, we all walked to our positions. I stood next to a man and we talked. The marathon bound us. The national anthem was sung. At the end, we all clapped. The starter sounds and the crowed moves forward. Everyone was smiling. That wouldn't
last for long. I was already sweating. Step, Step ... Breathe.
Step, Step, .... Breathe. At the forth mile, I asked myself, Why? It is the same question that I ask every race. In a marathon, the question usually comes up somewhere between mile 16 and 22. This race it was at mile 4. I knew it was a going to be difficult and I adjusted my pace as well as water intake. I had a plan. You always need a plan. This was not the time to take risks. I knew this would not be a record setting pace. I just wanted to survive.Residency was different problem. It was particularly demanding. There was both mental and physical fatigue. At times, you had to sprint; other times, the pace slowed and you were able to take in the scenery and enjoy your time.
Step, step .... breathe. At the half way point, I was in the shade. My legs felt good. I was still well hydrated. I decided to quicken my pace to my usual marathon pace. That lasted for 2 miles until the shade ended. I came to the realization that to finish was an accomplishment. I slowed my pace again and decided to enjoy the spectators. I high five'd the little kids and asked the crowed for more cowbell. At one point, I was running with a man from New Zealand. It was his first marathon. It was winter in New Zealand. So, this weather was rather brutal on him. We ran and talked about rugby. Then we somehow got split up.Because of the harsh circumstances of the residency environment, I developed very close bonds with those in my residency and others from my internship. Had we not been in residency together, we may have never become friends. We all were very different. These differences ranged from our political views to religion to personal style, but the common bond of out harsh environment cemented relationships that survive to this day.
Step, Step .... Breathe. At mile 18, there were only 8 miles to go, but the heat was draining every ounce of mental fortitude out of me. I noticed that the general mood had changed. It was hot, there was no breeze, and no shade. The general flow of the runners went from a brisk pace at the beginning to almost a walk. I looked on as runner after runner looked for medical attention. It was more like a war zone than a race. There were IV bags hanging in the medical tents. I kept hearing the sirens of passing ambulances. Spectators attended to the fallen runners who did not make it to the aid stations. People showered the runners with the from their house. Spectators brought water from their own homes to help.When I completed residency, I thought I was finished. I would get a job and everything would be right in the world. I would be like the normal people. I would be like the "humans" who had regular lives. I would take weekends like regular people. The competing would be done and I would sail off into the sunset completing all of my goals.
Step, Step ... Breathe. I passed the mile 25 marker. It was hot. A man shouted, "the race has been cancelled." I thought my hearing must be going. So, I kept running like Forest Gump. People continued to cheer on the runners. The finish line was different from what I remembered. This time I actually saw all of the people cheering the runners on. I heard people shouting, "Keep running ... You can do it ... Your almost there." I crossed the finish line again. It was more gratifying than before because the obstacles were greater.Goals change as time goes on. My major academic goals accomplished, but I continue to be driven to find new adventures. As much as I like to challenge my mind, I also like to push my body to extremes. I have realized that normal is a dial on the washing machine. Normal for me is driving to the next goal or destination. It is what keeps me alive, what keeps me from getting stale.
I met up with my family at the meeting place. My kids were dirty from playing in the dirt. My daughter hands me a flower and gives me a hug. My son jumps in my arms. "I love you dad," my daughter says. We check out from the hotel and drive back home. In the car, we were already making plans for the next marathon. Step, Step .... Breathe.
Wednesday, October 3, 2007
So the other day, I had an anesthesiologist decide a patient I had scheduled was too unstable for transport to the OR and the procedure should be done in the ICU with the ICU team providing sedation. Now, it had been 3 days since the initial injury and the patient had been stable and transported for several studies without event. For some reason, this person thought the the patient was too "unstable." So, I went to the family and discussed the recommendations. I spoke with the ICU attending about it. The ICU attending the proceeded to ask me questions about why it couldn't be done in the OR, yada yada yada. I informed him it was not my decision. He then spoke with this anesthesiologist. In the end, anesthesia came and provided sedation and everything was fine. Days later, another case, same anesthesiologist, I hear that the anesthesiologist is trying to do the same thing. This time it was dealt with without confrontation or actual communication. This person just avoided me and passed it off to someone else. Hmmm, I thought that was strange. The avoidance of communication makes it all better.
Last week, we help out with a procedure with a patient in a halo. My team had explained to me that the patient needed a PEG tube and the person doing it said that the front had to come off. He spoke with my brace person, my chief resident, and the nurse in the OR. I heard the needs, but the kid is in a Halo for a reason. We can only do so much as far as providing space for the PEG tube. They informed me that he was adamant that he needed the whole front of the abdomen free. They actually said he was a bit of an A_ _, but that is hearsay because I did not witness it. So, at the time of placement of the PEG tube, we were all there. I was watching the neck and supervising the adjustments to the Halo. You know he did not say one thing to me. Hmmm, go figure. Yesterday, I was walking down the hall and I see the same physician. As you do, I looked up, we made eye contact, and I say, "morning, how are you?" He keeps walking and says nothing. Now, I was pretty sure that he wouldn't say anything because he never does. But, I keep trying. (With hands up in the air screaming to the sky) We are all on the same team.
Today, I am going to a faculty meeting. I am getting off of the elevator. The door opens, and a team (I assume surgical) is standing 1 foot from the door. I try to get out as the team rushed to get in and a medical student, in his short coat, bumps me. Not a little bump, a full shoulder to shoulder hit. I say, "excuse me." Again, nothing in return. Now, I thought, "OK, I am not in my white coat, but come on this is common courtesy. We don't live in New York City." (No slight to my NYC fans) This got me thinking. Do we create these people believe that they are better than the next person because they may have a little more knowledge? Why is it that in medicine we lose our ability to effectively communicate to one another? Does it have to do with the inherent hierarchy of the medical field or does it have to do with the god complex that some people develop? Why can't we just be civil? Ok, that was way too many questions. Just some thoughts I wanted to put out there to see if anyone else has any answers.
Tuesday, October 2, 2007
Monday, October 1, 2007
SurgExperiences 105 was posted yesterday by Rlbates on her site Suture for a Living. It was excellently done. It is worth a look. Please take the time to look through all of the great surgical blogs across the world.
Sunday, September 30, 2007
To Dr. Hibiclens,
Good luck with your new life. Thank you for your time on our service. You did a wonderful job. Remember to delegate to those below you and not to take all of the burden on yourself. You will be an excellent orthopaedic surgeon.
Saturday, September 29, 2007
Everyone has a certain perception of themselves. This perception may not be as others see us. Our perception can be clouded by previous experiences, gender deferences, and/or cultural differences. But as we all know, perception is reality.
The perception I have of myself is that I am a relatively level headed guy, very mild tempered, forgiving, hard working, affable, and loyal person. This perception has been verified by what many people have told me about myself (I do understand people do tend to hold back the bad things, not wanting to hurt feelings. Also, one of these people was my mother). One of my major flaws is my inability to forgive and respect someone I consider a "bully". In my value system, other than someone directly disrespecting me or my family, or blatantly lying to me, this is probably high on my list of things that will get my blood boiling. I lose respect for those that pick on the weaker or less powerful (physical, mental, or political) to get their way or things they want.
I understand my role in my group. I am a grunt. I personally have no aspirations of being famous or politically powerful. I do my work to the best of my abilities. I look at try to do what is in the best interest of the patient. All I ask is that all others do the same.
In the academic medical community, there are many bullies. Residents experience this on a daily bases. As a consult service, orthopaedics is not always but often abused. I am going to list a number of stories of blatant abuse by other attending staff towards residents. This is not to say that orthopaedics does not do it's share of consulting/dumping on other services. We are often the butt of jokes about consulting for things that many feel are routine medical issues, diabetes, hypertension, medications (beyond Ancef, Ibuprofen, and Tylenol). These are also stories of things that I have seen or been a part since medical school. These stories are not to pick on any service in particular or to speak of clinical acumen of the particular specialties. They are just stories from the orthopaedic point of view.
Story #1: An attending abusing status for no particular reason.
Ortho: This is Dr. boneStory #2: Crying wolf. Calling an emergent consult on something that is not emergent.
Dr. Iconsultforeverything: Yeah, this is Dr. Iconsultforeverything. I have a girl down here in the ER with an ACL tear. We would like an Orthopaedic consult.
Ortho: Uh, just put it in a knee immobilizer and send it to clinic.
Dr. Iconsultforeverything: We would like a you to come see the patient now.
Ortho: But, there is nothing to do. I am going to put them in a knee immobilized and have them follow up in clinic.
Dr. Iconsultforeverything: LISTEN, I AM THE ATTENDING AN I WANT YOU TO COME SEE THE PATIENT.
Ortho: Ok ....
(End result is the patient was sent home with a knee immobilizer, crutches, and an appointment for 1 week.)
Ortho: Hey, this is ortho returning a page.Story #3: Attending trying to get resident into trouble.
Dr. Ijustcompletedmyintenship: yeah this is the senior medical resident, Dr. Ijustcompletedmyintenship, and we would like to consult ortho for a possible compartment syndrome.
Ortho: I'll be right there.
(Stryker monitor in hand. Ortho resident runs up to the floor and walks into the Patients room)
Ortho: Hello, I am Dr. Bone, are you Mr. Igetadmittedalot.
(Patient looks up from his full lunch and takes his spoon out of his mouth)
Mr. Igetadmittedalot: Yes, I am Mr. Igetadmittedalot. (He takes another bite of mash potatoes)
Ortho: Does your leg hurt?
Mr. Igetadmittedalot: No.
Ortho: Has it ever hurt?
Mr. Igetadmittedalot: No. But, it is swollen.
Ortho: thank you.
(Resident walks out of the room and finds the senior medical resident)
Ortho: Hey, Dr. Ijustcompletedmyintenship. Why did you think this was compartment syndrome?
Dr. Ijustcompletedmyintenship: Well, his leg was swollen.
Ortho: Was there no other reason for this, like his renal disease, Diabetes, peripheral vascular disease, etc.. Oh, and if you thought it was a surgical emergency, why would you feed him?
(End result, the medical team receives an impromptu lecture on compartment syndrome)
Ortho Attending: (ring ring, answering phone) Hello.Story #4 (Break in Chain of Command)
Dr. Iconsultforeverything: This is Dr. Iconsultforeverything. I called your resident about a patient with back pain. The radiology report shows a possible coccyx lesion.
Ortho Attending: Well, get a CT scan.
Dr. Iconsultforeverything: Well, he has back pain after being hit in the back with a chair. The radiologist read a possible fracture or lesion in the coccyx. (Then going around in circles about something, ortho attending tunes him out for a bit)
Ortho Attending: What do you want us to do?
Dr. Iconsultforeverything: I just think someone from orthopaedics should see him.
Ortho Attending: Why? What are you concerned about?
Dr. Iconsultforeverything: Well there is a possible lesion or fracture of the coccyx and the patient has back pain.
Ortho Attending: Well what does the exam show?
Dr. Iconsultforeverything: He has back pain.
Ortho Attending: But, does he have @$$hole pain. What does the rectal show?
Dr. Iconsultforeverything: (silence) ... Well, I just think someone should see him.
Ortho Attending: Ok, Dr. Iconsultforeverything, I will send my resident down to do your examination.
(End result, patient was actually examined. He had back pain. Neuro exam negative including negative rectal exam)
I really don't have a story I can share. I believe in a chain of command. This probably has to do with my military background. I have been involved with many situations where the chain has been broken. It causes problems that are not needed and situations that are blown out of proportion. It is usually done by people that think they are "above" the chain, or forcing their perceived power.These are some basic stories that are not to say how good orthopaedics is or how much I am above other services. They are just stories. In residency and in practice, we all have them. I would like to open the comment box for more stories. Orthopaedic patient bashing stories welcome.