Category Archives: Surgical Education

Surgical Education

Educating Future Physicians

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The role of medical schools in educating our physicians of the future has undergone some significant changes over the last 25 years. For most of the twentieth century, many medical schools had their own hospitals and the faculty were tasked with teaching and research. Most of the clinical activities were focussed on the difficult cases and there was little incentive to see and treat more patients other than to generate income for research and teaching activities. The academic faculty were salaried and the salary was not related to the generation of clinical income.

Medical schools would often provide faculty to the the charity hospitals and Veterans hospitals where medical students and residents would get exposure to patients. Teaching and training was at a high level; the faculty could focus on the patients as could the trainees and there was no rush to see more patients. Care was thoughtful and teaching was meaningful.

Just a few decades ago, it was common for professors to have dedicated teaching rounds either in the mornings or in the evenings and often on weekends. Residents and medical students would present recent cases and there would then be questions, using the Socratic method, where care was discussed in detail. The trainees were taught to think like doctors. They learned professionalism, mainly from emulating their mentors. There was no rush to see more patients and there was no limit on the time spent with each patient.

Often, these teaching sessions were followed by actual rounds where the trainees and the attending would actually see, examine, and discuss the patient’s findings. The patients and their families would look forward to these sessions as they felt they were getting individualized attention by the “best” and they were fulfilling their role of helping to educate the future generation of physicians. It was a “win-win” situation.

When the government got involved in health care with programs like Medicare and Medicaid, physicians and hospitals learned there was money to be made under the “fee for service model.” The more patients seen and procedures done, the more income was generated. Third party payers followed the model of the government and costs skyrocketed.

As the costs of health care continued to rise, forms of managed care took on increasing importance to limit these rising costs. Medical schools and their teaching hospitals found that they were ill-equipped to compete in this type of market. In the 1990’s, it was thought that many medical schools along with their teaching hospitals would have to close as they were not competitive with the private and public hospitals. In an effort to survive, medical schools decided to expand their faculty practices.

Based on the recommendations of paid outside consultants, most of the medical schools decided to change their business model away from the scholarly model of research, teaching, and clinical care of the complex patient. The expansion of the clinical practice was done in two ways. The first was to have their academic faculty see more patients and they did this with financial incentives. The second was to join with public and private hospitals and use the clinicians in those facilities to help generate income to help keep the medical schools solvent.

The attending teaching rounds had to be shortened or even curtailed so that more time could be spent in seeing patients and generating more income. The education component was no longer valued and the teacher’s income was dependent on his clinical practice. Some schools would provide some salary support for educational activities and research but not nearly to the level as it was prior to the advent of “managed care.”

The medical schools supplied the hospitals with resident coverage and with clinical faculty whose credentials could be used as a marketing tool for the hospitals and practice plans. The new clinical faculty were given academic titles from the medical schools and they were given access to residents who would help take care of the patients so that the faculty could see more patients and generate more income.

With this new model predicated on generating more clinical income for the school and the hospitals, it was foreseeable that the scholarly activities related to teaching students and doing research would suffer. Clinical dollars were being spent to keep the medical centers solvent and subsidies ear-marked for research and teaching declined.

By the beginning of the twenty-first century, a career as an academic physician was becoming far less interesting. Funding opportunities for research were declining, teaching activities were not being rewarded, and income was being tied to clinical activities alone. In fact, many medical schools began to hire new faculty whose sole role was to practice medicine and generate clinical income. Investigator-teachers and clinician-teachers were no longer high priorities for medical school hiring even though they were essential for the schools to meet their original missions of research and education.

Sometimes, the missions of the hospitals and the medical schools conflicted. On these occasions, it was common for one or the other entity to hire their own providers without the shared input that was the original intent of the mergers. Since the academic titles bestowed were the province of the school as was the use of the residents, some new hospital hires found that some of their expected benefits were not forthcoming as promised. Also, the medical schools could not hire their own faculty unless they got buy-in from the hospital and practice plan up front; otherwise, the new faculty could find himself without a clincal venue in which to practice.

Older physicians like to think of themselves as the last of the “triple threat” clinicians; they have made meaningful contributions as health care providers, researchers, and teachers. Their younger colleagues are more likely to think of them as “dinosaurs” doomed to extinction. It does not matter who is right as we are still faced with the problem of young, bright, and dedicated medical students and residents who should be provided with the education and training they deserve.

It is time to recognize that we owe our future generations a dedicated medical workforce interested in advancing medical knowledge, teaching, and enforcing the standards of care our people have come to expect. We must resolve our conflict between medical education and the new environment of health care delivery dependent on generating income and cost containment.

The missions of the hospitals and clinics are different from the missions of the universities as it relates to a professional education. If we do not resolve this conflict, training physicians will become no more than an apprenticeship which is the way it was prior to the advent of university-based medical schools. Proprietary medical schools did not work very well in the past which is why the original Flexner report recommended a switch to university based medical education. If America is to continue providing the best health care in the world, educating future providers must be a high priority. The American Public deserves no less.

by Darryl S. Weiman, M.D., J.D.

Professor, Cardiothoracic Surgery, University of Tennessee Health Science Center and Chief of Surgery, VAMC Memphis, TN

MORE ABOUT THE AUTHOR: Darryl Weiman is a featured expert in www.healthcaredive.com on February 17, 2016. 

Affordable Care Act, Surgical Education

Not Enough Academic Faculty

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A friend of mine who is an Assistant United States Attorney recently called me to ask for help. He was trying to get a primary care provider and was unable to find any group in town that was willing to take on new patients. I was taken aback by this request since his insurance, as a federal government employee, was probably pretty good. Fortunately, I was able to make a phone call and get him an appointment with one of the groups in town; it is one of the perks of being in practice in the community for a long period of time.

The plight of this attorney made me reflect on the increasing mismatch between the ever growing patient population coupled with the rapidly rising patient population reaching the age where health care is often needed, compared to the number of health care providers.

A recent report from the Association of American Medical Colleges entitled The Complexities of Physician Supply and Demand: Projections from 2015 to 2030, predict that there will be a shortfall in primary care providers in the range of 7,300 to 43,100 by 2030.

Projected shortfalls in non-primary care providers is even more worrisome; the range predicted is between 33,500 and 43,100 with most of the deficit accruing from the surgical subspecialties. With our current methods of training new surgeons we are only able to keep up with the attrition rate of surgeons retiring or dying. With the United States population predicted to grow about 12% between now and 2030, this will amount to about 40 million more people with no increase in the number of surgeons that can take care of them.

It can be argued that increasing the number of Nurse Practitioners and Physician Assistants can help with the patients needing primary care providers. However, these providers cannot do what surgeons do. In the population over 65, which is projected to grow by 55% by 2030, many operations are needed on an urgent or emergent basis. There may not be enough trained surgeons to meet the needs of our country. We either need to train more surgeons or admit that some patients who need surgery will not be able to get it.

I am painfully aware of how difficult it is to convince bright college students to consider medicine as a career. Even my two daughters have told me that they are just not interested in working day and night as I have done. Nor are they willing to make the sacrifices necessary to get the education and training required for the profession. It seems that many students who may have been interested in a career as a physician or other type of health care provider are now looking at careers in investment banking, law, business, or the computer sciences.

Recent data shows that the average retirement age for a surgeon has dropped to 57 years. Many explanations for this drop are being given, but the most likely reasons relate to the increased overhead costs emanating from the Affordable Care Act (ACA) coupled with the decreases in payments being given by the third party payers. There comes a point where the hard work of being a physician just does not seem to be worth the income earned. Of course, there are many non-financial rewards of helping someone who is sick, but these rewards are not be enough to pay the bills of staying in practice and raising a family.

Another recent survey from the Association of Academic Health Centers (AAHC) revealed that impending faculty shortages may lead to a crisis in training the next generation of health care providers. Without enough teachers, there will not be enough trained health professionals to take care of the patients flooding the system. This will add to the impending shorages described above.

The influx of “Baby Boomer” patients is not the only problem. A recent article in the Wall Street Journal (WSJ November 21, 2017, VA Chief Wants More Private Health Care) describes a new strategy where veterans will be allowed to seek care in the private sector instead of using the VA’s hospital system. This may lead to 10 million more patients seeking care in an already over-stressed system where getting an appointment to see a provider is already very difficult. There is no data to show that VA physicians will migrate to the private sector to help ameliorate the shortage in providers.

There are several reasons which may account for this lack of faculty. First, the level of interest in academic careers is decreasing among those who are now entering the health professions. There are significant disparities between the salaries of those who go into private practice, industry, and academics. The cost of getting a medical education is high and the debt facing recent graduates is a driver to choose a private practice career instead of an academic one. The average debt for a graduating medical student in 2015 was $180,000!

Of those who participated in the AAHC survey, 20% reported that they will have to make changes in their training programs in order to make ends meet. There will be fewer training programs for radiology, rehabilitation medicine, allergy, pediatric pulmonary medicine, anatomy, and pharmacology. There will also be cut-backs in medical school class size and other residency training programs. Of all the strategies listed by the survey participants, “limiting student enrollment” was most often cited.

Of major concern, a decrease in nursing school enrollment was listed most often as the area where cutbacks in enrollment would be made. In a hospital setting, you have to have the nurses to take care of the patients. Physicians cannot admit patients to beds that are not staffed by nurses.

It is clear that we need to train more health care providers if we are to adequately care for the anticipated rise in the number of patients needing care. It is also clear that we just do not have enough teachers to adequately train the people looking to go into health care as a profession.

Hiring physicians from other countries is an option, but steps will need to be taken to assure that those providers have the education, knowledge, and training that we have grown to expect in our system.

Since most of the training of the health care work force is dependent on funding from the government, there needs to be ongoing communication from the schools and the government to come up with a strategy to build and sustain our health care educational pipeline. This is a national interest and yet, not much is being written about it in the national press. It is time for this pending crisis to be brought forth in the public arena so that our children and their children will not be left with too few physicians, nurses, and other ancillary health care personnel to take care of them when they need it. This problem will not be fixed overnight.

 

by Darryl S. Weiman, M.D., J.D.

Professor, Cardiothoracic Surgery, University of Tennessee Health Science Center and Chief of Surgery, VAMC Memphis, TN

MORE ABOUT THE AUTHOR: Darryl Weiman is a featured expert in www.healthcaredive.com on February 17, 2016. 

Affordable Care Act, Surgical Education

Free Legal Advice

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I am a lawyer but not an attorney. According to the Black’s Law Dictionary, a lawyer is a person who is licensed to practice law. I attended and graduated from the Cecil C. Humphreys School of law at the University of Memphis and I passed the Bar Exam for the State of Tennessee. I have even been sworn in by the Supreme Court of Tennessee so I am truly licensed to practice law in this state.

On the other hand, the legal definition of an attorney is a person who practices law. Notice that the legal definition does not even require licensure. I do not practice law so I do not fit the definition for being an attorney. It is not surprising that most people do not know of this legal distinction; I have even been in court where it became obvious that even the lawyers did not know the difference. I make my living as a surgeon and have done so going on 40 years.

Since it is common knowledge at our medical center that I have a legal education, I am often asked legal questions by my medical colleagues. These questions usually relate to medical malpractice issues, informed consent doctrine, medical ethics such as end of life issues and futile care, and contracts. Whenever approached for such legal advice, I first acknowledge that, even though I am a lawyer, I do not practice law. This disclaimer is important because I do not want to ever be accused of malpractice as a lawyer; it is enough that I have to deal with possible medical malpractice on a daily basis. I pay a significant premium for medical malpractice insurance and have no desire for similar payments as a practicing attorney.

When residents or fellows are finishing up their programs, they look for jobs and, eventually decide to take a position. For most, it will be their first job as a attending with the rights and privileges and pay commensurate with that position. Many will be given an employment contract which, for a physician, can be difficult to understand. For those who come to me for advice, the first thing I recommend is that they hire an attorney who is familiar with contracts dealing with physician issues. This true legal advice may be expensive but it is worth it. It would be a mistake for a physician to review the documents on his own as the legal language may be difficult to understand and it may have clauses that may come back to haunt him in the future.

There are three main areas that I look at if I am reviewing a contract; compensation and other benefits, termination clauses, and restrictive covenants.

When I review contracts for these young doctors, the first thing I look for are the terms for employment. How long is the contract for? Is there an automatic renewal or will written notice be required? Is the salary spelled out and is it guaranteed for the terms of the contract or is it dependent on income generated?

Since the Affordable Care Act went into effect, the overhead costs of a medical practice have gone up significantly. An electronic health record (EHR) is now required to practice and they are expensive. The documentation requirements for payment and quality improvement, also required under the law, usually mean that people will need to be hired for to keep the medical records up to date; it is just too time consuming for the physician to do everything himself. I once was considering joining a private practice group but the negotiations broke down when I learned my overhead costs would be $30 thousand a month.

Because of the overhead costs, most physicians have left private practice and joined hospitals or clinics which pay for this infrastructure. The physician becomes an employee under contract and the pay is usually good for the first term of the contract, usually for two years. However, the payment may go down significantly or the physician terminated if he does not generate an income to justify the salary over the term of the contract.

Other compensation issues to consider are bonuses, how are they calculated; benefits, such as vacation time; costs of continuing medical education, and malpractice insurance. If joining a group, the contract should be clear on what needs to be done to become a partner; is there a “buy-in” fee? It is common for the employer to keep renewing the physician’s contract but then terminate before he can become a partner. This does not seem fair, but the employer is out to make a profit and the mission of taking care of patients may not be the primary goal.

There are usually termination statements and it is important to note if the termination can only be “with cause” or “without cause”. If termination can be without cause, the employer can terminate the contract for any reason. This is harsh and it would be wise to have a notice requirement of 3 to 6 months so that there will be some time to look for another job. It is nice to have income while looking for a new position.

If the contract can be terminated “with cause” it is important that the reasons for termination be spelled out. Reasons for termination such as loss of a state license, inability to obtain Board certification, loss of medical malpractice insurance, or a felony conviction are understandable for termination. The new attending should be aware of vague terms such as “disloyalty to the practice” as this is open to wide interpretation and may lead to high legal bills if the clause is invoked and the court is asked to decide what the term means.

There is usually a non-compete clause, often termed a “restrictive covenant.” This clause is meant to keep the new attending from stealing patients from the group if he decides to leave within a set time-frame. No new employer wants to set up a new practice for a new hire only to have that hire leave and take those patients with him to a new, competing practice. Many states do not allow restrictive covenants as they have deemed that to be a restraint of trade and anti-competitive. Even states that do allow for these non-compete clauses will usually have limits on the prohibition of setting up a competing practice; these limits are related to duration and the distance from the original practice.

If there is a restrictive covenant, the new attending should be aware of the time and distance restrictions as they may not allow him to take on another potential job in that area, even if he has been successful in growing the practice. Physicians who sign a contract with a non-compete clause would be wise to hold off on buying a home in the area until he is certain that his relationship with his new employer is likely to be long term.

There are other issues emanating from employment contracts such as severance pay, reimbursement clauses if you leave the group early, and what happens to income coming to the group after termination. All can be complicated and further justifies the hiring of a competent contract lawyer. If any of the contract issues become grounds for future litigation, having an attorney to fight for your rights is worth the costs. It is also beneficial if it is the same attorney who has been with you from the beginning.

by Darryl S. Weiman, M.D., J.D.

Professor, Cardiothoracic Surgery, University of Tennessee Health Science Center and Chief of Surgery, VAMC Memphis, TN

MORE ABOUT THE AUTHOR: Darryl Weiman is a featured expert in www.healthcaredive.com on February 17, 2016. 

Surgical Education

Morbidity and Mortality Conference

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Being a surgeon is more than just operating on patients. Life-long learning is a requirement of the profession. One of my favorite ways to learn is participation in the Morbidity and Mortality (M&M) conference which most departments of surgery conduct on at least a monthly basis. Although it is important to learn from your own mistakes, it is even better to learn from someone else’s mistakes.

The purpose of the conference is to discuss surgical complications (morbidity) and deaths (mortality) so that any mistakes, technical, judgmental, or systems based, can be learned from. Hopefully, mistakes made will not be repeated and the advancement of surgical knowledge can occur. The discussions are the hallmark of the conference and need to be open and critical. Truthful discussions are unlikely to occur if there is fear that the minutes could be used by plaintiff’s counsel in a malpractice action. Most states recognize a “peer-review” privilege which is equivalent to the attorney-client privilege; in most states, this privilege will protect the work-product generated from the conference.

In 2005, the United States Congress passed the Patient Safety and Quality Improvement Act. The main goal of this law was to encourage health care providers to present their errors without fear of reprisal. The idea was to improve the quality of care for all patients; this is an important public policy interest. The errors reported would eventually be listed in a database created by the Department of Health and Human Services. This database could be accessed and medical errors could be analyzed, to hopefully develop best practices that would result in a decrease in similar types of errors in the future. There are currently some databases available for review, but the product envisioned by the law has not yet been realized.

Discussions at M&M are often heated, personal, and critical. The presenter often gets very defensive and sometimes angry when questioned about their judgment and actions on the case being discussed. Only physicians are supposed to attend so as to keep the “peer review” privilege; even medical students are not supposed to be in the conference as the law does not yet recognize them as peers of the surgeons.

At programs which have a surgical residency, it is the resident who usually presents the case. As the story unfolds, various surgical attendings in the room will start to grill the resident as to his thought process or technical skills. The questions and innuendos are often nasty. Where I did my training, the attendings would advise us to fight back if we felt the attacks were unjustified. “Fighting back” often became “overly defensive” as it was not easy to disagree with an attending, many of whom were known as being among the best in the world.

I have advised my residents to maintain their composure no matter how angry or fearful they become. They must know the facts of the case and they must project confidence. This is also something they teach you in law school but there are no classes for how to present a case in medical school. I also advise them to own their mistakes, learn from them, and be resilient.

Presenting at M&M requires good communication skills. The case being presented had a bad result, a death or a significant complication. Under questioning, the presenter may become angry, frustrated, or indignant. These emotions are normal and expected, but they must not show it. They must maintain their professionalism and they must be truthful. No matter how stressed out they feel, they must remain calm, speak clearly, and be respectful to the inquisitors. After all, the attendings asking the questions have spent years acquiring the skills, knowledge, and experience to be in their positions.

I have noticed that several of the younger surgeons in the audience have their lap tops open and they have “googled” the entity being presented. Some have asked questions meant to put the presenter on the spot and, in my opinion, make the questioner appear to have more knowledge than they may have had a few minutes prior. This behavior is obnoxious, but that’s the way some surgeons are.

Some of the residents in the audience will try to get a quick course on the problem from their computers, but they are unlikely to put one of their colleagues on the spot; they are probably trying to prepare in case one of the attendings hits them with a question to see if they have been listening.

The “straw-man” argument is often used to try and discredit the presenter at this conference. This happens when a questioner changes the facts of the case in such a way as to make the presenter’s argument seem unreasonable. When presented with a “straw-man,” I advise the resident to point out the differences in the fact scenario in the hypothetical and then do their best to answer the question. This is another thing that they teach in law school that is lacking in surgical education.

Another thing they teach in law school is to stop talking when you are interrupted by a judge who wants to ask you a question. I have found this stategy to be very effective at M&M. If I am talking and someone interrupts, I immediately stop talking and I listen to the interrupter closely. This usually results in a period of silence where the whole room is waiting to hear what I was going to say. Being interrupted by a judge is accepted policy in court; it is rude if you are speaking at M&M.

Knowing the facts of the case is required but is not sufficient for a good presentation. The resident also needs to be up to date with the literature pertaining to the patient they are discussing. It is especially beneficial if they cite literature that has been written by one of the attendings who is sitting in the audience; this is actually not too difficult to do if it is a residency at a major university. The endgame is to keep cool, maintain professionalism, and be correct.

Presenting a complication or a death at the M&M conference can be a stressful experience. It is meant to be that way so that the resident can learn to think on his feet and be able to articulate an answer or a plan that is reasonable. If they cannot present well at M&M, it is unlikely that they will perform well when all hell breaks loose in the operating room with a real patient. Being grilled at M&M and learning how to handle this stress is an important part of becoming a surgeon.

by Darryl S. Weiman, M.D., J.D.

Professor, Cardiothoracic Surgery, University of Tennessee Health Science Center and Chief of Surgery, VAMC Memphis, TN

MORE ABOUT THE AUTHOR: Darryl Weiman is a featured expert in www.healthcaredive.com on February 17, 2016. 

Surgical Education

The Residency Match

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Becoming a physician is a long and difficult process. Although most people are aware of the competitive nature of getting into medical school and the long hours of study, class work, and laboratories that must be successfully navigated in order to graduate, they are not aware of the necessity of getting into and finishing a residency in order to get a medical license.

Graduating from medical school allows one to be called “Doctor” with all of the privileges associated with that degree, but there is more to do if one is to be licensed to practice medicine. The states require at least one more year after medical school whereby the graduate acts as a resident in a formal resident training program. Even those who want to be a general practitioner (GP) must go through a year of training and then must pass the third part of the United States Medical Licensing Exam (USMLE) in order to get a license. Most residencies require more than one year; for surgeons, most have to go through a five year program before they become “Board eligible” in their surgical specialty. In my case, I did five years in general surgey and later, two more years for cardiothoracic. So I was “boarded” in two specialties.

Senior medical students go through a matching process in order to get into a residency. First they must choose the type of residency they want, e.g., surgery, medicine, psychiatry, Ob-Gyn, pediatrics. They must then apply to a place that has a training program in their chosen field. Eventually, a computer will match the applicant to a program.

Based on the advice of Val Willman, then the Chairman of Surgery at Saint Louis University (my medical school), I did senior rotations at the University of Chicago and Northwestern University. I was hoping to increase my chances of getting accepted to those programs by letting them see what I could do in a hospital setting. I wanted to get back to Chicago, my home town, and these were good programs for surgery training. I also applied to Baylor in Houston, Rush, Loyola University, the University of Illinois, the Medical College of Wisconsin, and, of course, Saint Louis University.

I ranked the University of Chicago number one but felt my chances of getting into such a high-powered, prestigious place were very slim. Most of the residents I had met during my rotation there were from from very well-known medical schools such as Harvard, Hopkins, Yale, and the University of Chicago. I wasn’t sure they would give a slot to someone from Saint Louis University, but, I was advised to aim high and that’s exactly what I did.

I had a great set of interviews at Baylor and I felt that was where I would match. They seemed to be impressed with my undergraduate degree in Biomedical Engineering and they knew Dr. Willman who had written me a strong letter of recommendation. The Baylor program was run by Michael Debakey, a world renown surgeon. It was known as a demanding program. Residents rotating on the cardiac surgery service spent 2-3 months in the hospital and were not allowed to leave. In fact, there was a story told of a resident who went down to the parking lot to see his wife. He was fired the next day for exiting the hospital. I felt I could do well in that environment since I was not married. I ranked Baylor #2.

The day that the senior medical student learns where he will be doing his residency training is called “Match Day.” Usually there a few days before the match where students that have not matched are informed as is their medical school. The national residency slots that are still open become available for these unmatched students and a scramble ensues whereby the programs that have open slots are able to contact available students that they are interested in. If the student accepts the offer, that slot disappears. Slots that are still available undergo the same process in a precisely timed order and, again, available students are given offers. The process continues until all slots are filled and, hopefully, all medical students have a job lined up for the next year, at least.

The original matching is done with a national computer match. The students make a ranked list of their residency choices and the various programs make a rank list of the students they would like for their programs. The computer, through some mathematical magic, will link the students with a program in such a way as to get the best match for the student and the programs.

We all knew what day the unmatched students would be notified so those of us who did not hear anything at least knew we were going to some program that was on our rank list. On the day of the match, the senior class all met in one large room and envelopes were handed out in alphabetical order. Since my last name began with a “W”, I had to wait till near the end to get my envelope. I opened the envelope and found that I had matched to my first choice—the University of Chicago. I was going back home to Chicago, hopefully for five or six years—the time required to complete the surgery program.

“…immune to ‘paper’ achievements; it was the process that held my interest.

…I was taught to think and act as a surgeon, to be open, empathetic, to handle very stressful situations no matter how exhausted I may have been. I am the result of what my mentors trained me to be.”

In becoming a physician, there are many memorable dates that stand out. Getting the first letter of acceptance to medical school, the day of medical school graduation where we all took the Hippocratic oath, match day when we learned where we would do our residency, the day we learned that we had passed our Boards. In order to become an independent practicing surgeon, all of these tickets had to be punched. All of the hard work, sacrifices, and hopes would not matter unless these requirements were successfully met.

In my case, passing the Bar Exam many years later was also important but by then I had become pretty much immune to “paper” achievements; it was the process that held my interest.

For me, my match day was 39 years ago. Having been subsequently successful on those other noted critical days, I never had to consider alternatives and for that I am thankful. I often have time for reflection where I remember those who directed me to medical school, those who helped me get into the residency program where several mentors helped to mold me both professionally and personally. I was taught to think and act as a surgeon, to be open, empathetic, to handle very stressful situations no matter how exhausted I may have been. I am the result of what my mentors trained me to be.

I hope that the young medical school graduates who have recently gone through the match have the same types of career and life satisfactions I have been fortunate to experience. Young doctors, go forth and make us proud.

by Darryl S. Weiman, M.D., J.D.

Professor, Cardiothoracic Surgery, University of Tennessee Health Science Center and Chief of Surgery, VAMC Memphis, TN

MORE ABOUT THE AUTHOR: Darryl Weiman is a featured expert in www.healthcaredive.com on February 17, 2016. 

Surgical Education

The Third Year of Medical School

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I recently received an e-mail from the surgery clerkship director at our medical school reminding us that we were not to overburden our medical students with busy work on the wards. In particular, the students were not to spend time helping the post-operative patients get up and walk even though early ambulation has been shown to enhance recovery. I thought back to my time as a medical student and then reflected on how medical education has changed over the last 40 years.

The first real clinical experience for a medical student started with the third year hospital rotations in internal medicine, surgery, pediatrics, psychiatry, and obstetrics-gynecology. These rotations are still pretty much what third year students do today. The role of the medical student was to meet the patient and perform a history and physical exam (H&P). This would involve talking to the patient and learning about the chief complaint—the problem that caused the patient to come to the hospital in the first place. Pertinent questions relating to the chief complaint were asked such as when the problem started, what care had already been tried, and risk factors. Other required elements of the H&P were the review of organ systems, the past medical history, the family history, and then a full physical exam.

After doing the H&P, the student would present his findings to one of the lower level residents where the H&P would be refined. The resident and the student would then formulate a differential diagnosis—a list of things that might explain the cause of the chief complaint—and then order tests to better define what the problem really was. Once a working diagnosis was made, a treatment plan could be started.

The history and physical was very important. We learned that if we listened closely and examined carefully, the patient would eventually give us a good idea as to what the problem was.

The student’s responsibility did not stop with just the H&P. The students had to gather the lab data every day—sometimes more than once a day. They had to keep their residents informed with results and any changes with the patient’s status. There was an unwritten rule that we were never to surprise our residents, especially when an attending was present. In other words, any new lab data, x-ray results, or changes in the patient’s condition had to be communicated immediately.

When I was a student, the blood work had to be ordered and drawn by us. Any intravenous lines, bladder catheters, and naso-gastric tubes had to be done by the student. Only if the student was unsuccessful, would the resident step in and help.

Students would take night call which we looked forward to. The nights belonged to the residents as it was rare for an attending to come in unless the patient was really sick or needed an emergency operation. However, even if an operation was needed, it was usually done by a Chief Resident so long as the attending surgeon trusted him.

In the operating room (OR), the student would mostly just watch although he would be scrubbed and at the table. If the student had impressed his chief resident and attending with hard work and good presentations on rounds, he would be allowed to do some things of a technical nature in the OR such as tie some knots of a placed suture or even suture the incision at the end of the case.

Knot tying was a very important skill that had to be learned and practiced, especially if you wanted to become a surgeon. At the end of a case, the nurses would let us take some unused suture material so that we could go home and practice. I used to sew banana peels back together and would spend hours tying knots around stationary objects in my apartment. It is the rare student who is willing to do this extra work now.

Today, it is also rare for a student to do blood drawing, vascular access, pulmonary toilet, or tube placement as the hospitals now have teams of technicians or nurses to do these things. It is rare for a student to ever draw blood, start an IV, or place an arterial line; things we would fight to do when we were students. As a result, these necessary skill sets are not being learned until residency and, in fact, I know that some physicians never learn to do these things; this is usually by choice as some are just not interested in these “hands-on” activities.

As for spending the night in the hospital, this is another rare experience for a medical student today. Ever since the Libby Zion case in New York, medical educators have gravitated to letting the students go home to get their needed rest. Even the residents have 80 hour work week limitations. These restrictions were unheard of when I was a student or during my residency.

The third and fourth years of medical school were wonderful times but I found my life was changing. My freedom was being taken away, especially on the surgical rotations. My personal needs were forced to take second place to the needs of my patients. I learned that when a patient developed a problem in the middle of the night, physicians must be willing to leave their warm beds, go see the patient and then do what is appropriate to ensure that their patient’s problem was addressed. This responsibility is one of the linchpins that makes the medical profession different from all others.

We “older” physicians sacrificed alot for our careers. Our personal and family responsibilities were always secondary to our patient’s needs. A night’s sleep and an uninterrupted meal were luxuries to be appreciated but never expected. A true surgeon is always on call for his patients and should never expect some “covering” person to be as invested in dealing with all problems that may arise.

The advent of duty hours, mandatory time off, fragmented care with multiple people involved with a particular patient, have not, in my opinion, led to better care. Unfortunately, I don’t see us ever going back to the way we educated the students in the past. Not good.

by Darryl S. Weiman, M.D., J.D.

Professor, Cardiothoracic Surgery, University of Tennessee Health Science Center and Chief of Surgery, VAMC Memphis, TN

MORE ABOUT THE AUTHOR: Darryl Weiman is a featured expert in www.healthcaredive.com on February 17, 2016. 

Surgical Education

Becoming a Physician Requires a Peripheral Brain

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It is very difficult to become a medical doctor. First, you have to go to college and take the necessary prerequisites. These prerequisites include chemistry, physics, organic chemistry, and English. Many medical schools, but not all, require calculus; none of these are “easy A’s”. It is no longer necessary to get an undergraduate degree but most applicants to medical school have graduated. There are programs which allow matriculation into medical school after two years of undergraduate training; these students are usually accepted into an accelerated program right out of high school. Some medical schools will take exceptional students after three years of undergraduate school.

When applying for medical school, most applicants take the Medical College Admission Test (MCAT) which is not easy. It helps determine who will be successful navigating the difficult medical school curriculum. Only about a third of the applicants get into an accredited American medical school.

Medical school itself is also difficult. The first two years are devoted to the basic sciences such as anatomy, physiology, biochemistry, histology, neurosciences, cellular biology, pathology, pathophysiology, pharmacology, medical statistics, genetics, embryology, and some form of Community Medicine. The books for these courses are thick and heavy and a superficial learning will not work. Most of these courses have associated laboratory time which are scheduled but may require extra work at night and during weekends. I spent many nights and weekends with my cadaver and my microscope and was fortunate to pass.

Didactic learning continues during the clinical years and the books associated with the clinical rotations are also massive. Not only are the students taking care of actual patients, they must read and study about the various disease processes. This self-study takes up most of the student’s free time both in the hospital and at home. The point I am trying to make is that the amount of material that must be learned is tremendous and it is increasing every day.

The growth of medical knowledge has been exponential during the time frame of my career. It has been estimated that, today, medical knowledge doubles about every 3.5 years (Peter Densen, MD, “Challenges and Opportunities Facing Medical Education,” Tran Am Clin Climatol Assoc. 2011, 122: 48-58). It has been estimated that by 2020, medical knowledge will double every 73 days (Peter Densen, MD). With the vast amount of medical knowledge necessary to provide competent care, it is not surprising that physicians are looking for new ways to access up to date knowledge. The wise physician knows that he can no longer rely on what he learned in medical school and during his residency as the journals are replete with new information relating to physiology, pathophysiology, pharmacology, genomics, and clinical care pathways.

Computers are now being used as are Electronic Health Records so that templates can be made to advise the physician taking care of a particular patient as to what tests to order, consults to obtain and treatment options. As an aside, IBM has Watson which is being used in a medical setting to provide this knowledge and I am sure there are other companies building their own computers to do this work. I used to think that Watson was not named appropriately since it was Sherlock Holmes who was the really smart one. It took an upper level executive at IBM to inform me that Watson was named after the founder of IBM, not the literary character.

It has become commonplace to see young physicians in training access their hand held devices during rounds so as to have current and credible information relating to their patient’s disease process. This allows them to better answer the questions presented by the attending physician and, in fact, it helps them educate the attendings as to the latest information. I am not so technologically adept and I look forward to this new information coming from the residents as it helps me keep up to date myself.

Whether under the Affordable Care Act or under whichever plan the Republicans are considering to replace it, a shift of care must occur to high value, non-hospital, preventative and maintenance care. The goal is to keep the patient out of the hospital where the costs are highest.

As the care of patients shifts away from the hospital setting and more into out-patient clinics and even into the patient’s home, non-MDs become more important in the provision of care. In fact, as the patients and their families take on more of the care themselves, then the “provider” of care takes on a very different meaning from when we relied mostly on physicians. Not surprisingly, the knowledge base of these non-MD providers varies widely. It has been estimated that Americans visit their physician on the average of four times a year. Assuming the visit lasts about 15 minutes, then the total time of direct medical education of the patient is only about an hour a year. Can we really expect the patient to keep up with the latest advances in medical care by doing his own research and learning? I doubt it.

If the patient is going to take on a major role of providing his own health care, it is not surprising that there will be large gaps of medical knowledge among the general population. If it is difficult for physicians to keep up to date, how can we expect nurses, physician assistants, pharmacists, pharmacologists, or patients to do any better?

Through the years, I have ceased to be amazed by how many health care providers fail to keep up with the advances in medical care; they do not go to meetings for continuing education and it is obvious they are not keeping up with the journals. I am also not surprised by how poorly some of these providers take care of their patients. If time is not spent on meaningful study to keep up with the new developments in our field, then there is no way to know how best to take care of the patients.

For someone entering the health care field today, even more so than when I graduated medical school, he must have dedicated time for study; that is the only way to keep up. Although hand held electrical devices—often referred to as “peripheral brains”—will be helpful, they will not be enough. With looming shortages projected for surgeons and some other medical specialties, more clinical time will need to be spent in taking care of the patient load. This will decrease time spent in continuing education, time spent for relaxation, and time spent with families. This does not look good for health care providers. Of more importance, it does not look good for the patients.

by Darryl S. Weiman, M.D., J.D.

Professor, Cardiothoracic Surgery, University of Tennessee Health Science Center and Chief of Surgery, VAMC Memphis, TN

MORE ABOUT THE AUTHOR: Darryl Weiman is a featured expert in www.healthcaredive.com on February 17, 2016. 

In the Courtroom, Surgical Education

Resident Duty Hours

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When I was doing my surgical training at the University of Chicago in the late 70’s and early 80’s, it was common to spend over 100 hours per week in the hospital. The term “resident” was very accurate as we were essentially living in the hospital; we stayed until the work was done. During the great snow of 1979, I lived in the hospital for a month as my car had been plowed over and the wind chill made it dangerous to walk home.

Residency training programs followed the German model. William Osler used that model for Johns Hopkins in 1899, creating the first residency training program in America. Residents learned by doing clinical work, taking on increased responsibilities as they gained experience. They lived in the hospital and, in general, they were not allowed to get married during their training. Other hospitals adopted the model and it became the norm for training physicians. Resident duty hours were to change dramatically in the mid 1980’s based on a tragic case emanating from the New York Presbyterian Hospital in 1984.

Libby Zion, an 18 year old college freshman was admitted to New York Hospital (now New York Presbyterian) with a high fever and “jerking movements.” It was the evening of March 4, 1984. She was agitated but she had periods where she was cooperative with the physicians taking care of her. Since she came in the evening, the physicians who were directly caring for her were residents—doctors in training. Ms. Zion had a history of depression and she was taking an antidepressant called phenelzine. This drug was to play an important role in her clinical course. She also used cocaine, a fact she did not tell the physicians taking care of her. This drug may also have had a role in her clinical course.

The residents made a diagnosis of viral syndrome and they ordered meperidine (Demerol), an opiate, to stop the shaking. They called Dr. Raymond Sherman, the Zion’s family doctor and the attending physician of record and, after hearing the resident’s report, he agreed with the plan. It was about 3 a.m. on March 5.

Later that night, Ms. Zion became more agitated and the first year resident, Dr. Luise Weinstein, evaluated her and ordered restraints and a shot of Haloperidol, another sedating medication. The upper level resident, a second year, had gone across the street to the call rooms to get some sleep. Dr. Weinstein was covering many other patients and did not evaluate Ms. Zion any further.

Although Ms. Zion calmed down after the shot, her vital signs were not checked until 6 a.m. when her temperature was a critical 107 degrees Fahrenheit. Cooling measures were initiated but she suffered a cardiac arrest and died. It is believed that the interaction of the phenelzine and meperidine, led to the development of “serotonin” syndrome, a condition not well known at that time. This syndrome can result in severe muscle rigidity, high fever, and seizures. It can be fatal if not treated in a timely fashion. The role of the cocaine use was not clear.

Libby’s father, a lawyer and journalist who worked for the New York Times, investigated and learned that his daughter had be restrained and was not evaluated by a physician for several hours. He also learned that the attending physician had never come in to evaluate Libby himself. Mr. Zion argued that the lack of sleep of the intern and resident and inadequate supervision by the attending physician contributed to this “medical blunder.” Mr. Zion told his daughter’s story and had several of his colleagues in other newspapers publish this story across the country. He was even able to get the Manhattan district attorney to convene a grand jury in hopes of bringing murder charges against the physicians involved in his daughter’s care.

Besides a criminal action, a malpractice claim was also made. This malpractice case finally made it to trial in 1994. After a civil trial, the jury assigned equal blame to New York Hospital and Ms. Zion for concealing her cocaine use from the physicians taking care of her. The jury found that the two residents and the primary care physician were liable for $375,000 to the Zion family for their pain and suffering. The jury also found that the primary care provider had committed perjury on the witness stand when he denied that he knew that meperidine had been given to Ms. Zion. None of the physicians was found to have committed “wanton” negligence so the malpractice claim was paid by their malpractice carrier. Wanton, or gross negligence, is generally not covered by medical malpractice insurance carriers.

The grand jury did not indict the physicians on criminal charges, but they did write a report that was highly critical of the hospital for having junior level physicians who were tired from long duty hours being the primary care givers for this type of case. The report led to the formation of a state commission, chaired by Bertrand Bell, M.D., a distinguished Professor of Medicine at Albert Einstein College of Medicine. In 1987, after 19 months of testimony, the Bell Commission issued a report which recommended that physicians in training have stricter limits on work hours and stricter rules on resident supervision. The Commission recommended that the residents work no more than 80 hours per week. Dr. Bell later acknowledged that the 80 hour cap was not based on any scientific data but was the result of a conversation he had with a medical colleague. These recommendations were only applicable in the state of New York but several other states followed this example.

It took another 16 years for the Accreditation Council for Graduate Medical Education (ACGME) to make these duty hour restrictions mandatory for all residency training programs. This restriction in duty hours has been an area of contention for students, residents, and attendings ever since. The argument that a well-rested physician is better able to make clinical decisions has never been shown to be true in clinical studies. Any training program which has duty hour violations may be subject to sanctions by the ACGME. The sanctions can be severe and can include loss of accreditation.

Despite nearly two decades of resident duty hour restrictions, the best training model for future physicians is still unknown. Patient polls indicate that the general public favors the restrictions but that should not be surprising since the public is generally naïve in regards to graduate medical education. A recent study of duty hours published in the New England Journal of Medicine, showed that residents with less restrictive hours are better able to use their time off (more “meaningful” time off) and the time off is more likely to be used for study (N Engl J Med. 2016;374:713-727). Residents in the less restrictive arm of the study could actually have some weekends free of any clinical responsibilities; weekends off rarely occur under the restrictive requirements.

The limitation of work hours has led to shift work where patient care information is relayed with “hand-offs” and these “hand-offs” have had the unintended consequence of actually increasing patient errors. This is probably predicated on the underlying belief that the most invested physician is the one originally involved with a particular patient. As the “shift mentality” became embedded, the desire of the physician to manage a critical patient until stable lessened. Shifting responsibility to another physician who does not know the patient nearly as well as the primary provider, to me, is professionally repugnant.

Although the duty hour restrictions only apply to residents in training, my fear is that this “shift mentality” persists when the resident becomes an attending. Patients get sick day and night, weekends and holidays. The best care is provided by the physician who best knows that particular patient. For a surgical patient, it is the surgeon who did the case.

There is nothing to keep the government from limiting duty hours for other health care providers, including attending surgeons and physicians. This model has already been set in the airline industry. If these restrictions become law, a patient may be dependent on a surgeon he does not know and, much worse, does not know the patient.

It is time for the ACGME to revisit its penalties for duty hour violations. If a resident chooses to stay with a sick patient, there should be no penalty levied on the training program or on the resident. This type of behavior should be encouraged. Staying with a sick patient is a hallmark of a good physician.

by Darryl S. Weiman, M.D., J.D.

Professor, Cardiothoracic Surgery, University of Tennessee Health Science Center and Chief of Surgery, VAMC Memphis, TN

MORE ABOUT THE AUTHOR: Darryl Weiman is a featured expert in www.healthcaredive.com on February 17, 2016. 

Surgical Education

Private Practice Versus Academics

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As a young surgeon nears the completion of his training, he will need to make a decision as to the type of practice to join. If he wants to practice surgery, do research and teach, then an academic position may be the best choice. If he just wants to take care of patients, operate, be his own boss, and do very well from a financial standpoint, then private practice is the way to go.

Under a true private practice model, the physician is his own boss. He can work as hard as he wants and take care of as many patients as comes his way; the goal is to make a good living, hopefully in a location of his choosing. The downside of this practice model is that time away, either a vacation or a continuing education activity can be nerve racking. Lost time is lost income.

The overhead is very high in a private practice so some may choose to become an employee of a hospital or health care group. In this model, the physician will have a salary based on work done. In either of these private practice models, the physician will need some business knowledge to generate referrals. Marketing one’s skills and knowledge will be critical for success.

Physicians going into an academic practice, usually with a teaching hospital affiliated with a university or medical school, should have an interest in teaching and research. The employing hospital or university will expect teaching and research activity and some of the salary will be tied to these areas. The physician will still be expected to provide patient care and the salary will be related to the generated income, but a guaranteed salary goes a long way to relieving the anxiety of meeting overheads and making a living.

The University surgeons, those with an academic practice, focus on the complex and unusual. It is appropriate for complex patients to come to a university setting where the health care infrastructure is robust. Residents are in the hospital at all times and sudden changes in a patient’s condition can be evaluated by a physician quickly. These residents will keep the attending physician informed so that appropriate care can be initiated in a timely fashion. Residents, as a first line of care, are worth their weight in gold for the academic attendings. This is especially true in the middle of the night when the attending surgeon may not have to go in and evaluate the patient himself.

Some say that academic surgeons are the surgeons of last resort. Because of their goal to advance medical knowledge, they are inclined to take on the tougher cases. They also have resident surgeons to help in the operating room; this extra pair of experienced hands can be useful in difficult cases and is less expensive than calling in another surgeon to help. In general, you will not read about university surgeons in the newspapers. Well, that’s not exactly true as some do like to make headlines. Academic surgeons do research, teach future generations of health care providers, and take care of patients—all patients, whether they can pay or not.

Unfortunately, the last few decades has seen less financial support going to university centers from their state and local governments and less from federal funding and philanthropy for research. As a result, the academic model has changed; physicians are expected to generate more of their income from clinical care. The fact that third party payers are giving lower reimbursements has made this new model even more difficult.

Duty hour restrictions on the residents have resulted in an increased faculty involvement in patient care. Since there is only 24 hours in a day, time spent for research and teaching has decreased. It is not surprising that clinicians are spending less time doing research, either clinical or in the lab. The PhD’s who can focus totally on research, are finding it more difficult to get the help they need from the MD’s who are the ones able to bring the research findings to the clinical arena. After all, the PhD’s are not licensed or trained to take care of patients!

We are heading into a doctor shortage as our population has increased and our residency slots have remained capped. Salaries which are crucial to attract an academic physician have fallen, but the need to attract this type of clinician had increased. It is a challenge to find someone who is willing to do primarily clinical work in an academic setting. After all, if the job is mainly clinical, then you might as well do it for more money in a private setting.

Having trained at the University of Chicago which is focused on making academic physicians, it is not surprising that I chose the academic route.

As an academic cardiothoracic surgeon. I do cardiac surgery mostly; coronary revascularizations, cardiac valve operations, and I have been involved with cardiac transplantation. I also do operations on the pulmonary system; lung resections for cancer, lung volume reduction for patients with chronic obstructive pulmonary disease, and clean outs (decortications) for lung infections. The trachea, esophagus, chest wall, diaphragm, and great vessels are also areas of interest.

Academic surgeons love what they do! The pay is good; by that I mean fair. They will never be considered in the same financial class as the private practitioners but that’s ok. By training future surgeons, their knowledge and experience will live on for years. By advancing medical knowledge, they are helping enumerable future patients most of whom they will never meet. This is a legacy worth pursuing.

As to the future of medicine, I am not so optimistic. The goals used to be to improve and prolong life. But now that costs of medical care are so high, they have become a factor in the equation. Ethicists and politicians are now involved in deciding when the costs of care outweigh the perceived benefit. All I can do is shake my head and hope that physicians can be strong and principled enough to continue to do what they believe is right for the patients.

Doctors are human. Not all of their outcomes are perfect as they are not. Sometimes they are heroes, but things have a tendency to be messy. The pressure of being a surgeon can be intense but the job satisfaction is second to none. I hope that future generations will be willing to work hard to learn to do what I do. It is an honorable calling.

by Darryl S. Weiman, M.D., J.D.

Professor, Cardiothoracic Surgery, University of Tennessee Health Science Center and Chief of Surgery, VAMC Memphis, TN

MORE ABOUT THE AUTHOR: Darryl Weiman is a featured expert in www.healthcaredive.com on February 17, 2016.