Category Archives: Surgical Education

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. 

Surgical Education

Who Pays for Resident Salaries?

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After medical school, the new graduates are required to do further training in residency programs which can last from 3 to 8 years. This training takes place in hospitals around the country and is overseen by the Accreditation Counsel on Graduate Medical Education (ACGME). During this training, the residents spend long hours in the hospitals and clinics where they learn from attending physicians. This added training is essential as the four years of medical school is just not enough to learn all the material and skill sets necessary to safely and independently take care of the multitude of problems that these physicians will face from the patient population.

Unlike medical school where the student is paying a tuition for the education, the resident physicians are paid a salary. They are providing valuable work for the hospitals and clinics as they are taking care of patients and providing coverage day and night, weekends and holidays. This salary is about $50,000 per year. In comparison, a physician assistant salary is about $86,000 per year. Surprisingly, most of a resident’s salary is funded by the United States government. This funding emanated from Congressional hearings which occurred during the formation of Medicare in 1965.

“Educational activities enhance the quality of care in an institution, and it is intended, until the community undertakes to bear such education costs in some other way, that a part of the net cost of such activities (including stipends of trainees, as well as compensation of teachers and other costs) should be borne to an appropriate extent by the hospital insurance program.” (House Report, Number 213, 89th Congress, 1st session 32 (1965) and Senate Report, Number 404, Pt. 1 89th Congress 1 Session 36 (1965))

Under President Lyndon Johnson, the Social Security Act of 1965, established Medicare. A part of Medicare was funding for the residency positions throughout the country. Since there are about 100,000 residents in training, the salary for these residents is about $5 billion. There are other costs associated with educating residents such as malpractice coverage, attending salaries attached to the teaching component of the practice, and the added costs of the clinical tests ordered by the residents who have a tendency to order more than a more senior physician may be inclined to do. Other costs include a Graduate Medical Education office to administer the training programs, accreditation fees, and educational space. Medicare also pays for a portion of these added costs so that, today, about $10 billion is distributed to the various teaching hospitals in the country to cover the costs of this graduate medical education.

Medicare payments for these Direct Graduate Medical Education (DGME) costs go directly to the hospitals that train the residents. Payments to the residents come from the hospitals. In many states, Medicaid also provides some funding for Graduate Medical Education. Veterans Administration Hospitals also provide funding for residents in their hospitals.

Teaching hospitals also receive an Indirect Medical Education (IME) payment from Medicare for the increased medical costs associated with treating more complex patients. This payment is directed for maintaining a standby capacity for such things as burn units and trauma centers; these payments are not for resident training costs.

The United States funding of graduate medical education serves a strong public interest. A knowledgeable, trained, experienced, and skilled physician work force is essential to provide the health care needed for our society.

Prior to the establishment of Medicare, residents would work for the hospital but they were paid very little. They would generally live in the hospital, thus the term “resident.” They would rarely get time off but they would usually be fed and have their uniforms and malpractice insurance premiums paid for by the hospital. The elite residency programs like Johns Hopkins, Massachusetts General, the University of Chicago, and Mayo were highly sought after and, as a result, the salary could be kept low. In a way, the prestige of the training institution led to a de facto tuition payment, in the form of work provided, by those seeking to do the residency.

It may seem like the costs for resident education are high, but the return on investment is significant. With the present duty hour restrictions which limits the resident to just 80 hours in the hospital per week, doing the math reveals that the resident is being paid about $12 per hour. Since residents actually do a significant amount of the patient care in the hospitals and clinics, those facilities with residents can actually take care of many more patients and they are better able to manage patients with highly complex (and expensive) disease processes.

In 1997, Congress put a 100,000 cap on the number of residents it was willing to fund. This cap has been one of the reasons that the United States is facing a physician shortage. Existing medical schools have increased their capacity and new medical schools have been started to help address the projected shortage, but the cap on residency slots may prevent some of these new medical school graduates from getting the residency training they will need to, eventually, go into practice.

Since the hospitals are making money on the resident’s labor, perhaps they should contribute more to resident salaries. As there are more medical students graduating each year than there are residency slots available to them, perhaps it is time to refigure the graduate medical education funding which could help alleviate the projected physician shortages being projected in the near future. Perhaps, the United States can only afford to fund 100,000 residency slots per year. If so, it is time for the hospitals, the states and the cities to contribute to this essential graduate medical education. Let’s pay our medical school graduates for the work that they do and this pay should better reflect the value they bring to our health care industry.

Becoming a physician is a costly endeavor. A four year public university medical tuition is about $208,000; a private school medical tuition is about $280,000 (Association of American Medical Colleges 2013 data). The four years of medical school would result in lost salary ($57,000 per year for a bachelor degree holding American). Assuming no tuition support, this leaves a typical medical school graduate over $400,000 in debt. Now, with physician pay cuts resulting from an artificial health care market mandated by Obamacare, it will be years before a physician starts seeing a reasonable return on the investment which may allow him to justify the years of study, lost sleep, aggravation from a contentious malpractice environment, and loss of esteem held by an unknowing public. It is not surprising that many of our best students are opting out of a potential career as a physician.

The added pay which our medical and surgical residents deserve should go a long way in helping these young physicians get out from the debt they have accrued in getting their undergraduate and medical education. This pay adjustment may not be enough to keep our best and brightest interested in pursuing a medical career, but it would be a good start.

darrylweiman

 

 

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 Fallacy of Guidelines

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This article originally was posted November 4, 2016 on Huffington Post.

I hate it when someone tries to tell me how I should take care of my patients. However, we are now working with the politics of “evidence-based medicine”. This era is characterized by groups of “experts” who get together and compile guidelines on how best to manage various medical conditions. The fact that our knowledge of patient management is constantly changing is of little concern to these “experts” nor are they of concern to third party payers who insist that the guidelines be followed or they will not pay for the care provided.

Guidelines are generally based on a review of the literature pertaining to a particular condition and the evidence is classified as to its credibility. For example, the most reliable evidence is graded as IA, meaning that it is based on more than one prospective randomized trial without important limitations. Level IB evidence is based on a single controlled randomized trial or non-randomized studies but the trial(s) have limitations such as inconsistent results or flaws in the methods used to derive the conclusions. A Level I classifications means that there is general agreement that the procedure or treatment is beneficial and effective. Examples of methodological flaws would be lack of blinding of the researchers or subjective determinations of the results. Trials which lose a large number of patients to follow up would probably be classified as IB.

Observational studies may be cited in the guidelines but they would not have the weight of reliability as the prospective randomized trials would have. Observational studies are generally cited as IIC, implying that the evidence for the alleged benefit of a treatment may not be clear and there is a difference of opinion about the usefulness of the procedure or treatment.

Guidelines are meant for the “ideal” patient that presents with a certain disease entity. I have never seen such “ideal” patient as they all have individual characteristics which must be taken into account when making a treatment plan. In fact, the publishers of the guidelines make it clear that the recommendations may not apply to all of the patients all of the time, but this is generally ignored by third party payers, the Joint Commission on Accreditation of Hospitals, and the Veterans Administration. If a physician has not followed a guideline, he is assumed to have given substandard care by many plaintiff attorneys.

Here is an example. There is good evidence that the incidence of surgical wound infections is decreased if prophylactic antibiotics are given within one hour prior to the skin incision. There are times when the incision is made a few minutes after the one hour time frame because there may be a delay in getting the patient intubated, and various catheters and lines placed. Clinically, these extra few minutes have no effect on the incidence of wound infections, but the people monitoring this performance measure will classify it as a violation of the guideline.

Now you have to understand that the people hired to monitor these “performance measures” may not be a nurse or physician. They are following rigid written protocols to make their determinations and they are not allowed to use their own judgment. When this type of violation occurs, the surgeon may be deemed to have provided substandard care and may not be paid as much for the procedure even if the results are excellent. This can be aggravating to the health care provider.

Another example deals with the choice of peri-operative antibiotics. We are currently faced with a crisis involving a very virulent form of bacteria called Staphylococcus aureus which is resistant to many antibiotics. We are allowed to use Vancomycin, an effective antibiotic to Staphylococcus aureus, but only if the patient fits certain criteria. The reason we are not allowed to use the drug for all patients is to try and limit the selection of bacterial strains which may be resistant to this drug; this would, theoretically, make treating future infections even more difficult. We are allowed to use the drug in patients who have been hospitalized within one year prior to the planned operation.

In cardiac surgery, most of our patients fit this latter requirement as they have been previously hospitalized to evaluate them for cardiac disease. However, the people who monitor the use of peri-operative antibiotics will consider the provider to be in violation of the measure if there is no documentation as to why the drug was used. In other words, the physician must write that Vancomycin was used because the patient had been hospitalized within the previous year. The provider must write what is inherently obvious in the medical records.

You can see why surgeons and other physicians are frustrated. We are forced to do more documentation which, we believe, does nothing to improve the care being provided to the patients while at the same time, if we do not do this documentation, it may be published that we are not good physicians! I know of no other profession which faces such scrutiny. There are no good options except to try to comply the best we can knowing that every year the third party payers will do their best to pay us less no matter what we do. Plus, what may be deemed the “standard of care” today, may not be the “standard of care” tomorrow.

When I was a resident in surgery in the early 80’s, it was considered wrong to give a blood transfusion without a compelling reason to a patient with renal failure as this would hurt the patient’s chance of having a successful kidney transplant in the future. We now know that patients who get transfusions are less likely to reject a transplanted kidney. Our knowledge and practice changed as a result of solid clinical research. If we forego clinical research in deference to “guidelines”, then advances in medicine are going to slow down and stop. Clearly, this will not be good for health care in America, or the world for that matter, as the United States has always been a leader in making advances in clinical care.

I like to tell my residents and the medical students that guidelines are just that; they are not the law. There is no one better able to take care of an individual patient than the physician taking care of that patient on a very personal level. After all, the patient’s individual characteristics may be such that he does not fit into the guidelines.

For now, the physician who does not follow the guidelines may be denied pay for his work or worse, his name may be published in a database accessible to the public and press where he may be deemed as a less than satisfactory practitioner. This cannot be in our public’s best interest.

darrylweiman

 

 

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

Simulation in Surgery

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Simulation: the imitative representation of the functioning of one system or process by means of the functioning of another—Webster’s Collegiate Dictionary, seventh edition.

For the last several years, a group of “seasoned” cardiothoracic surgeons from around the country gather in Chapel Hill, North Carolina, where they are joined by many young surgeons who are starting their residency in the specialty. The meeting is three days of intensive training using simulation models to replicate surgical situations the residents will be confronting during their surgical training. Getting familiar with the instruments, scopes, dissection techniques, heart lung machine, valve replacements, and small vessel suturing are some of the basic skills learned.

The “boot camp”, sponsored by the Thoracic Surgery Directors Association, is a rare opportunity for the residents to get individualized training with some of the most experienced surgeons in the field.

Historically, surgical training involved the resident getting graded levels of responsibility for doing procedures in the operating room (OR) and at the bedside. The training also involved pre and post-operative care but technical skills, cognitive knowledge, and clinical acumen were usually dependent on real patients in the operating room. The residents work one on one with an “attending” surgeon who will supervise as the resident does parts of the procedure.

Jonathan Nesbitt, M.D., director of the Cardiac Simulation Program at Vanderbilt University and one of the teachers at the Chapel Hill program, says “[b]y immediately imparting these skills early in training, we significantly compress the learning curve to allow [the residents] to work effectively and safely in the clinical realm.” Not only do the residents get to learn the basic technical skills required in the specialty, they get to experience realistic models of surgical catastrophes so they can learn what to do before a real patient’s life is on the line.

The rise in simulation in surgical training is being driven by several factors. Minimally invasive surgical techniques make it difficult for the attending to first assist in such a way as to keep the trainee out of trouble. Only one person can drive the robot or the scope. Reductions in duty hours, mandated by law, cuts down on the actual OR time a resident may have to learn what to do and how best to do it. And, of course, the ethicists are now making it more difficult to justify allowing inexperienced physicians to learn on actual patients.

Under the stresses brought on by the Affordable Care Act, many surgeons have become employees of hospitals or medical groups. This model has forced the surgeons into a productivity model based on fees generated for services rendered. The employer looks to the surgeon to generate income and the surgical education component of the practice is suffering. The surgery residents, generally slower than the attendings, are getting to do fewer cases so the attending can generate more income.

As third party payers are moving to pay based on quality models, attending surgeons may be even more inclined to do the operations themselves instead of helping a surgical trainee. One of my attendings in the surgical training program I went through believed that the best surgeon in the room should do the operation. Since he was always the best surgeon in the room, the resident could do no more than first assist. First assisting was frowned upon by us residents, but we did it the best we could so as to learn from this superb surgeon. However, there is no substitute from being the primary surgeon.

Although the simulators are good for teaching the basic skills, they have not reached the level needed to teach the skills that must be acquired when things go terribly wrong or when the dissections are difficult from aberrant anatomy or intense scarring.

In a patient with previous surgery, the scarring can be so dense that the blood vessels may not be seen until they are cut. The sudden fear felt by a surgeon who is confronted by hemorrhage that is so brisk as to be audible can lead to a complete inability to cope with the situation and may lead to the death of the patient. The same feeling of horror can occur with unintentional injuries to other structures like the common bile duct, ureter, heart, and brain. How to handle these potential disasters is hard to teach on the simulators.

Simulators are costly and the restrictions of the 80 hour work-week make it difficult for residents to find the time to use them. Dedicated simulation time, such as that provided in Chapel Hill, is very valuable.

Some facilities have built simulation centers that are recreating whole operating rooms, delivery suites, intensive care units, and endoscopy suites. The University of Tennessee where I work is finishing a new building devoted totally to simulation. I would expect that these large facilities can be used to train health care providers from other areas who will come in for specific training.

It is hard to prove that skills learned from simulation training will lead to improved care for patients but I think it does based on what I see from the residents I worked with at Chapel Hill. Small sample sizes and the ability to detect small changes in skill sets make training assessments difficult. However, since practice makes perfect and since there are not enough patients to go around, I believe the role for simulation in surgery will only increase in importance.

Another benefit of simulation is to learn how to deal with possible catastrophes before confronting them with a real patient. Brilliant saves rarely occur the first time a problem is seen; saves do occur in subsequent cases.

Teaching residents to act in a professional manner is usually done by surgical mentors who serve as role models. This training could be enhanced by using actors in vignettes presented in videos which can be viewed by the residents—a form of simulation.

Outcomes research and cost comparisons need to be done but simulation is here to stay. There are cognitive skills and communication skills which are also very important in surgery and there is a role for simulation in these areas which will need to be developed—sort of like the “mock trials” that law students have to go thru. For now, we are concentrating on technical skill enhancement.

Although surgical simulation does not replace the skill sets learned from actually operating on patients, the models do allow for repetitive practice of the basic technical skills needed by the surgeon without having to rely on actual patients. The attending surgeon is more inclined to let the resident do more if the basic skills are being demonstrated on a daily basis.

I think the time spent on simulators should not count towards the statutory mandated 80 hour work week restriction. I would consider it as time spent studying and unrelated to actual patient care. The time spent on patient care in the hospital setting is critical for surgical training and should not be further diminished.

It is said that surgeons do four things unique to patient care. These are (1) control hemorrhage; (2) drain pus; (3) restore normal (functional?) anatomy, and (4) train future surgeons. By participating in the boot camp at Chapel Hill, I am helping with #4. I enjoy doing it very much.

darrylweimanby 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.