How the ACGME and ABA are infantilizing resident training

Not long ago, my patient in a complex thoracic case developed progressive bradycardia followed by a malignant-looking multifocal atrial arrhythmia that didn’t generate any blood pressure.

“Get out some epinephrine!” I said to my resident, who was standing closer than I was to the drug cart. The resident quickly drew up a milligram of epi, but then paused. I could almost see the thought bubble overhead: “Should I print out a label? Put a tamper-proof cap on the syringe?”

The resident – perhaps spurred on by the look in my eyes – made the right call, pushing epi immediately into the IV line and not stopping first to clean the injection port with alcohol for 15 seconds. The patient responded right away with return of sinus rhythm and a blood pressure consistent with life.

This brief but intense drama led me to ponder (not for the first time) whether the protocols and rules that infuse our days are improving safety or leading to paralysis when decisions must be made. Sometimes you have to act as you think best, accepting the possibility that your action may be vulnerable to criticism.

Even if you follow the protocol today, tomorrow it may change. Wearing masks all the time at the start of the COVID pandemic was considered a bad idea – until it wasn’t. On average, 20% of the recommendations in clinical practice guidelines don’t survive intact through even one review – on the next updated version, they’re downgraded, reversed, or omitted.

Today’s resident education process isn’t helping residents face the inevitable ambiguity of medical decision-making. No wonder residents get rattled when they find that one attending does things far differently from another. The ACGME and ABA are turning residency training into an infantilizing experience. Residents are used to studying to the test, and on the test there’s only one right answer.

Anesthesiology trivial pursuit

I don’t envy residents today. When I peer over their heads in the OR to see what they’re looking at on the computer screen, it’s often a multiple-choice question in preparation for the ABA basic exam, which looms over their first two years like an executioner’s axe. Never once has the question had any relevance to the patient or the case. The question itself seems to be part of an anxiety-ridden trivia game, geared toward testing the ability to prep for the test, not the gain of medical knowledge with any connection to patient care.

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I originally wrote this column just before Thanksgiving one year, and then updated it in 2012 after the tragic massacre of the Newtown first-graders. Now COVID-19 — and all the losses and grief that 2020 has brought — makes it only too relevant once again. For families who have lost a child, each holiday brings fresh grief, hurdles to face, and mourning for celebrations that will never happen.

The glittering commercialism and noisy cheer of any American holiday can be stressful for most of us. But for the parent who’s lost a child during the past year, facing the first of many holidays with an empty place at the table can make already unbearable grief so much worse.

No one in modern America expects a child to die.  Children only die in nineteenth century novels and third-world countries, or so we’d like to think.

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This article, with advice for residents about the future of anesthesiology, was published first in the October 2020 issue of Anesthesiology News

You may be weary of being told that our profession is facing a time of unprecedented threat – from third-party payers, from the government, from non-physician practitioners. You’ve heard it so often that your brain is tuning it out. Is the threat level exaggerated for dramatic effect? Is it better just to go on with your day and not think about it at all?

That would be a mistake. The real question is:  How should we deal with the upcoming “market adjustment” that almost certainly will result in lower anesthesiologist compensation? In the face of gloomy reality checks, how can we promote pride in our profession and recruit the best medical students? How can we continue research that will reduce risk and improve outcomes? How do we avoid becoming irrelevant or extinct, like Kodak, Xerox, Sears, and now Hertz? It’s time to face the future.

The threats are real

Unfortunately, the “unprecedented threat” claim is all too real. Department chairs everywhere  worry that they will not be able to maintain the compensation rates that anesthesiologists have enjoyed up to now. Why?

The Medicare Trust Fund is expected to become insolvent as soon as 2024. The chair of the Medicare Payment Advisory Commission (MedPAC), Michael Chernew, PhD, recently commented, “We are very dedicated to finding payment models to promote efficient delivery of care.” No one could possibly think this will mean anything other than lower payments to physicians.

Scope-of-practice expansion is gaining ground. On March 30, CMS issued an array of “temporary” waivers and new rules, waiving the requirement that a nurse anesthetist must work under the supervision of a physician. How likely are these new rules to be reversed under a new administration, whether Republican or Democratic? Whether or not you live in an “opt-out” state may not matter in the near future.

Hospitals were in trouble even before the COVID-19 pandemic. Many have gone bankrupt; others are merging with larger health systems. At present, around 80% of hospitals subsidize their anesthesiology departments to the tune of millions of dollars each year. Realistically, can these subsidies continue? Probably not. Will hospital administrators seriously consider cheaper staffing models for delivering anesthesia care? Probably yes.

Make yourself indispensable

First, it would be wise to assume that a downward “market adjustment” to anesthesiologist compensation is coming. Plan for it now. Stop yourself from spending to the full extent of your income, and put away all you can in a tax-deferred retirement account.

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I live and work in Los Angeles, one of the plastic surgery capitals of the world. Quite a few of my patients have “had a little work done” — the blandly euphemistic term you’ll hear for plastic surgery makeovers of all kinds. That’s fine. Plastic surgeons have children to feed too.

The problem is this: many of my patients want to convince everyone that their “look” is entirely natural. They don’t want to admit that they’ve had a tummy tuck, an eyelid lift, or breast implants. One patient tried to tell me that the perfectly matched scars behind her ears were the result of a car accident, not a face lift. In front of family members, patients will even deny having dentures. That’s understandable, but unwise from a medical point of view.

The fact is that plastic surgery has implications for future medical care. Your anesthesiologist needs to know about it, and your surgeon does too. It may be cosmetic, but it’s still a bigger deal than getting your eyebrows waxed.

Here’s why we need to know the cosmetic secrets our patients may NOT want to tell us.

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If you’re a parent who is still on the fence, trying to decide whether or not to vaccinate your children, I’m going to try to be kind and helpful. Here is a link to a video by a physician and father, Dr. Zubin Damania, with facts that may address some of your fears.

If you’re firmly pro-disease and anti-vaccine, however, I am baffled at your irrationality and frankly enraged by it. I am speaking from the intensely personal point of view of a physician and mother who knows what it’s like to attend the funeral and watch the coffin of her own child being lowered into the ground.

My daughter Alexandra is dead. There is no vaccine that could have saved her. The only thing that could make that enduring grief any worse would be the knowledge that there was a vaccine, and she didn’t get it because of me.

The only bright side to the recent outbreak of measles in the northwestern U.S. is the fact that some parents are finally deciding to protect their children with vaccination, as the New York Times reported on February 16.

I’m old enough to remember the terror that my parents went through every summer as polio epidemics swept the country, and the miracle of standing in line to take the sugar cube with the first oral vaccine in 1961. I have two dear friends who are paraplegic as the result of childhood polio, and you don’t want to have the anti-vaccine conversation with them, I promise you.

Our duty — all of us, as human beings in a civilized society — is to make sure that we and our children are immune to measles, chickenpox, whooping cough, and other infectious diseases so we can protect those who can’t be vaccinated due to real medical problems. We are the herd that has to take responsibility for herd immunity.

Every single one of us has a duty to the cause of public health to be vaccinated ourselves, and a duty to our children to make sure that they are vaccinated on schedule. Yes, I understand that in rare cases the flu vaccine can result in Guillain-Barre syndrome, but I still get the shot every year. It’s my duty to protect my patients, my husband, my children, and my grandchildren from being exposed to the flu, which could happen in the early stage before I might even realize that I was getting sick.

It’s particularly mind-bending to see that some parents think diseases like measles and chickenpox are benign. For every 1000 children who catch measles, one to three will develop encephalitis. Of those, 10 to 15 percent will die, and many more will have permanent neurologic damage. Chickenpox too can lead to encephalitis, and the blisters can get infected and cause full-blown sepsis or pneumonia.

The death of Olivia Dahl

Have you read any of Roald Dahl’s books to your children, and watched Charlie and the Chocolate Factory or James and the Giant Peach with them? Did you know that his seven-year-old daughter Olivia died of measles encephalitis in 1962, before the MMR vaccine was available? Here is what Mr. Dahl wrote:

“As the illness took its usual course, I can remember reading to her often in bed and not feeling particularly alarmed about it. Then one morning, when she was well on the road to recovery, I was sitting on her bed showing her how to fashion little animals out of colored pipe-cleaners, and when it came to her turn to make one herself, I noticed that her fingers and her mind were not working together and she couldn’t do anything.

‘Are you feeling all right?’ I asked her.

‘I feel all sleepy’, she said.

In an hour, she was unconscious. In twelve hours, she was dead.”

For the rest of his life, Mr. Dahl pleaded with parents to vaccinate their children. Even today, there is little that can be done to save a child who develops measles encephalitis. What we can do is prevent it by vaccinating.

I would never wish for any parent, no matter how irresponsible and irrational the pro-disease advocates are, to suffer the relentless and indescribable grief of their child’s death. In centuries past, parents frequently lost more than one child, but the fact that children’s deaths were common didn’t lessen the pain. If you don’t believe me, read this:

There’s a narrow ridge in the graveyard
Would scarce stay a child in his race,
But to me and my thought it is wider
Than the star-sown vague of Space.

Your logic, my friend, is perfect,
Your moral most drearily true;
But, since the earth clashed on her coffin,
I keep hearing that, and not you.

Console if you will, I can bear it;
’T is a well-meant alms of breath;
But not all the preaching since Adam
Has made Death other than Death.

It is pagan; but wait till you feel it,—
That jar of our earth, that dull shock
When the ploughshare of deeper passion
Tears down to our primitive rock.

Communion in spirit! Forgive me,
But I, who am earthly and weak,
Would give all my incomes from dream-land
For a touch of her hand on my cheek.

That little shoe in the corner,
So worn and wrinkled and brown,
With its emptiness confutes you,
And argues your wisdom down.

That poem, “After the Burial“, was written by American poet James Russell Lowell, who suffered the loss of three of his four children in the mid-nineteenth century. He hit the mark. So did Ben Jonson, writing about the death of his first daughter in 1593.

I will never write as eloquently as they have. So here’s the bottom line. Get a grip. Vaccinate your kids.