Archive for the ‘Medical Education’ Category

“Each man or woman is ill in his or her own way,” Dr. Abraham Verghese told the audience at the opening session of ANESTHESIOLOGY 2019, the annual meeting of the American Society of Anesthesiologists. In his address, titled “Humanistic Care in a Technological Age,” Dr. Verghese said, “What patients want is recognition from us that their illness is at least somewhat unique.”

Though we in anesthesiology have only limited time to see patients before the start of surgery, Dr. Verghese reassured listeners that this time has profound and immense value. He pointed out that there is “heightened drama around each patient” in the preoperative setting. “Everything you do matters so much,” he said. What patients look for are signs of good intentions and competence, and the key elements are simple: “the tone of voice, warmth, putting a hand on the patient.”

Dr. Verghese, a professor of internal medicine at Stanford University and the acclaimed author of novels including the best-selling Cutting for Stone, believes that patient dissatisfaction and physician burnout are the inevitable consequences of today’s data-driven healthcare system, where physicians seldom connect with patients on a personal level or perform a thoughtful, unhurried physical examination. “Our residents average 60 percent of their time on the medical record,” he said.

“It’s the ‘4000 clicks’ problem,” Dr. Verghese said, citing a study in which emergency room physicians averaged 4000 mouse clicks over a 10-hour shift, and spent 43 percent of their time on data entry but only 28 percent in direct patient contact.

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The Hahnemann Disaster

Though the news at first stayed local in Philadelphia and the northeast, it’s gaining traction nationwide. ZDoggMD is on it. Bernie Sanders held a rally.

What happened? The venerable Hahnemann University Hospital, the main teaching hospital for Drexel University College of Medicine in Philadelphia, is bankrupt and will soon close its doors after more than 170 years as a safety-net hospital serving inner city patients.

Why should we care? After all, there are other teaching hospitals in the immediate area with capacity to absorb the patients, and they had several months’ warning to prepare.

We should care for many reasons, but I’ll start with the plight of the 570 residents and fellows who are being displaced from their jobs. Getting a residency position in the first place is a perilous process – there aren’t enough spots for all the graduating medical students who want them. Only 79% of the more than 38,000 applicants in 2019 snagged a first-year or internship position in a residency program.

So the Hahnemann residents – the “Orphans from HUH”, as they’ve started to call themselves – are scrambling on their own to find new jobs at a time when most residents are thankfully settling in to the new academic year. There’s no organized program to help them.

Even for the residents who’ve already found new positions, there are other boulders in the road. To begin with, they haven’t been released yet. They can’t start their new jobs and the Medicare funding for their positions is still tied up in bankruptcy court.

They’re still at work, wandering around a nearly empty Hahnemann with only a handful of patients left. The ER isn’t admitting any new patients and will shut down completely on August 16. The labor-and-delivery ward has closed. The new interns aren’t gaining any real experience and will be lagging behind their peers wherever they go.

“Doctors have been writing notes to update plans of care and people have come in as part of the liquidation to take away their computers,” a third-year internal medicine resident named Tom Sibert, MD, told Medscape reporter Marcia Frelick last week.

Tom Sibert? Any relation? Why yes; he’s my son. You can understand, I’m sure, why I went into full-blown mama lion fury when the Hahnemann situation blew up, and why I was beside myself with worry until he locked in an acceptance to an excellent program where he’ll finish his training.

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Once again, it’s Physician Anesthesiologists Week, and it’s a great time to celebrate our specialty’s many successes and accomplishments.

But we’re wasting an opportunity if we don’t also take this week to consider the state of the specialty today, and what it could or should mean to be a physician anesthesiologist 20 or 30 years from now.

There is no question that a seismic shift is underway in healthcare. Look at how many private anesthesiology groups have been bought out by—or lost contracts to—large groups and corporations; look at how many hospitals have gone bankrupt or been absorbed into large integrated health systems. Mergers like CVS with Aetna are likely to redefine care delivery networks. Where does a physician anesthesiologist fit into this new world?

An even better question to ask is this: Is your group or practice running pretty much as it did 20 years ago? If so, then my guess is that you are in for a rude awakening sometime soon. One of two scenarios may be in play:  either your leadership is running out the clock until retirement and in no mood to change, or your leadership hasn’t yet been able to convince your group that it can no longer practice in the same expensive, antiquated model. As one academic chair said ruefully, at a recent meeting, “They’re like frogs being slowly boiled. They just don’t feel what’s happening.”

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Avoiding #metoo in medicine

Let me say first that any woman who has ever been harassed or assaulted should NEVER be made to feel that it is her fault. It is always the perpetrator’s fault. Men can be boors, or worse, and testosterone can be toxic.

I went to Princeton University at a time when the ratio of men to women was 8:1, graduated from medical school in the 1980s, and raised two daughters. I’ve had ample reason and plenty of time to think about strategies to deal with harassment, parry a verbal thrust, and maneuver out of a potentially humiliating or harmful situation.

We’re lucky in medicine that we have intellectual qualifications — board scores, professional degrees — that are our primary entryway into medical school and residency programs. We’re not being judged PRIMARILY on our looks. Yet many social media comments recently have underscored the fact that some women in medicine have endured ridicule, harassment, and even assault in the course of their careers. It makes sense to explore any tactic that can help other women avoid similar painful encounters.

Here are some tips — learned through long experience. My hope is that they might help younger women in medicine feel less like potential victims, and more like strategists in a behavioral chess game.

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The Practical Art of POCUS

The longer you practice a profession, the easier it is not to bother to learn the next new thing. We may think we’re doing just fine without that new drug, or that new piece of expensive equipment. We’ve seen how the new drug sometimes turns out to have more side effects than benefits, and how the equipment may gather dust in the corner because no one really needed it in the first place.

That isn’t going to happen with point-of-care ultrasound, or “POCUS”, I’m willing to bet. As I learned at a weekend conference on POCUS, jointly hosted by the anesthesiology departments at UCLA and Loma Linda University, the practical applications for bedside patient care are multiplying, and the technology is improving all the time. Ultrasound isn’t just for cardiologists and radiologists any more.

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