Tuesday, December 5, 2017

Chronic shortage of training sites worries medical schools

The Association of American Medical Colleges (AAMC) says many of its members are worried about a shortage of training sites for students and residents.

The AAMC’s 2016 Medical School Enrollment Survey found that 80% of schools were concerned about the number of available clinical training sites. There were also issues with the numbers of primary care and specialty preceptors.

The graphic below shows that these problems are not new, but in general seem to be worsening. [Click on the figure to enlarge it.]

The situation is exacerbated by increasing competition for clinical sites from osteopathic schools, offshore medical schools, and nurse practitioner and physician assistant schools.

Tuesday, November 21, 2017

The case against live tweeting

“Live tweeting” of conference presentations continues to be popular. The practice is defined as posting one or more tweets attempting to tell the Twitter audience what the presenter has to say. It is touted as a great way to convey information to those who are unable to attend the conference.

I’m not a fan of live tweeting, and here’s why.

The live tweets are also supposedly used as a substitute for notetaking. I have blogged about some of the studies showing retention of information is better when notes are taken on paper.

Many of the tweets are incomplete and/or incomprehensible because the description of them has to fit within 280 characters—at most two or maybe three sentences.

Good speakers will use short bullet points and verbally explain what they mean. This can be difficult to accomplish in a tweet.

Papers presented at meetings have not been peer-reviewed. [Okay, I understand that peer review is not perfect, but it is the current gold standard for evaluating published medical literature.] Some people may not know this, but program committees can only judge what is in an abstract—which can be misleading. The submitted abstract is usually worded to attract the attention of those deciding which papers will be accepted. When the paper is presented at the meeting, it sometimes only faintly resembles what was contained in the submitted abstract.

People who rely on live tweets for medical news assume the live tweeter understands what has been presented and is able to coherently communicate it. I worry that snippets of misinformation may be widely disseminated.

What about impressions. Some organizations brag about their combined meeting tweets having 240 million impressions. That doesn’t mean 75% of citizens in the US have seen a tweet. Impressions are simply an index of how many twitter accounts could possibly have seen a tweet. Most tweets are not at all. I have almost 18,000 Twitter followers. I average about 2000 impressions per tweet. Most of my tweets get fewer than 10% engagementsdefined as as clicking on a link, expanding detail, likes, and retweets.

Photographs of PowerPoint slides tend to be from bad angles and are often blurry. Here are some examples. Identifying information has been removed to protect the guilty.




The prosecution rests.

Friday, November 17, 2017

Residents, duty hours, and respect

The following is an email I received.

I, a surgical resident, would like to ask for help navigating conversations about resident duty hours. You had a very strongly worded post on the subject. My intent is not to contradict your perspective, but perhaps get and give some insight on this question. First, I wish to show you the conversation with a surgeon "fossil" as I experience it:

Fossil: "In my day we worked __ many hours and operated all night and never slept or ate and were glad of it. It made me the surgeon I am today. You will never have this privilege."

Me: "Wow, I agree. You had it much harder." Meanwhile, I am thinking:

Monday, November 13, 2017

Useless general surgical interventions that should no longer be done

England’s National Health Service (NHS) could save €153 million [$178 million USD] per year by scrapping 71 low-value general surgery practices says a recently published paper in the British Journal of Surgery.

The authors, from Imperial College London, extensively reviewed the literature and Choosing Wisely recommendations from a number of countries.

I agree with many of the 71 including performing a cholecystectomy during the first admission for a patient with symptomatic gallstones instead of waiting for another admission (saving more than €54 million) and not repairing minimally symptomatic inguinal hernias, which they estimate would save over €32 million.

The Telegraph reported, “The team also discovered that robotic surgery has ‘little or no advantage’ when compared with traditional keyhole operations and said it must be ‘considered a candidate for disinvestment.’” This probably wouldn’t fly here in the US, because—like guns—too many robots are already in the hands of users.

Friday, November 3, 2017

What does Jersey City have that New York City doesn’t? Two hospitals with Leapfrog Group “A” safety grades

Leapfrog just released its semi-annual hospital safety grades. Incongruities identified in my previous blog posts [here and here] appeared again.

New York City had no A grade hospitals, only four got Bs, and nationally known hospitals such as New York Presbyterian (Columbia and Cornell), New York University, and Mount Sinai received C grades.

Residents of New York City are in luck because several A-rated hospitals are located just across the Hudson River. Four of them—Jersey City’s CarePoint Health-Christ Hospital, Jersey City Medical Center, CarePoint Health-Bayonne Medical Center, and CarePoint Health-Hoboken University Medical Center—aren’t exactly household names, but they scored better on safety than their New York neighbors.


CarePoint has figured out how to achieve a top rating but can’t compare to the numbers of California Kaiser Foundation Hospitals scoring well on multiple Leapfrog evaluations. The current rankings show 19 of 26 Kaiser hospitals in California were A rated.

Friday, October 20, 2017

The lost sheep: They’re MDs but can’t find residency positions

I haven’t written about offshore medical schools since this post back in January, but yesterday I received communications from two graduates of those schools which moved me. Both are edited for length and clarity.

This was an email. I read your article on Physician’s Weekly about unmatched MDs. I am a bit down and looking for advice. I graduated from a Caribbean Med school. I have failed attempts and many gaps. Academically I dug myself into a deep dark hole, but my desire to practice medicine kept me going. I recently took Step 3 and just received my scored (failed by 2 points). I do not know anyone in medicine that can help me get a residency. I know I will be a great physician. I am just a horrible test taker.

I didn't apply for the match since I was told that I needed to pass Step 3 to even try to match which would still be almost impossible even with a good score. I know many people who have not matched and have just given up on it. I have so much debt and no way of paying for it. What do you suggest I do? A friend thinks I should just take it again and apply, but I no longer have the funds especially since my chances are so low. I wish there was something more for me.

Any words of advice would be really appreciated.


Monday, October 16, 2017

Is an autonomous robot better than a human surgeon?

That was the headline on the website BGR [“a leading online destination for news and commentary focused on the mobile and consumer electronics markets”].

Engineers working with the Smart Tissue Autonomous Robot (STAR) claim it can cut skin and tissue with more precision than a surgeon.

A paper they presented last month at the International Conference on Intelligent Robots and Systems featured a video supposedly proving the point.

STAR works “by visually tracking both its intended cutting path and its cutting tool and constantly adjusting its plan to accommodate movement.” The intended cutting path must be marked by a human beforehand. So, it is not really autonomous; rather it is semi-autonomous.

The video can be seen in its entirety here or you can watch two excerpts below. The first is the robot using cautery to make a straight 5 cm skin incision which is compared to an unidentified surgeon cutting a similar incision. Watch approximately 15 seconds of this clip.



As you can see, the surgeon strays from the intended path about halfway through the process. But note that the surgeon is not holding the cautery the way most surgeons would use it. The proper way to hold the instrument is as if it were a pencil. No human could possibly cut a straight line holding the instrument as far away from the tip as the video depicts.

A second video shows the STAR excising a geometrically shaped pretend tumor.


Note: Although the video is being shown at 4X speed, it is still painfully slow. It is not clear what would happen if the robot encountered a blood vessel that bled despite the use of cautery, which by the way is not the instrument of choice for excising many tumors.

What we have here is a nice example of a “straw man” which is comparing a new technique against a phony one to make the new one look better.

Another website, IEEE Spectrum, went with this headline:

The headline should have read:


[Type straw man or artificial intelligence in the search field to your right on my blog site for more posts about these two topics.]