OK, Practice Notes readers, this post really requires your contribution.
On Kevin MD's blog, Brian Eule wrote about Match Day (which is today), the third Thursday of March when the nation's graduating medical school students find out to which residency program they have been matched.
Eule writes: "Much of the future of their field will remain unknown, as the country works through health care reform. But for the country’s newest class of doctors, today will give them a little more information as to their futures as doctors."
I'd like to invite you to recall and share your Match Day experience here. What was the process like at your school? How did you feel?
Showing posts with label medical school. Show all posts
Showing posts with label medical school. Show all posts
Thursday, March 18, 2010
Wednesday, November 18, 2009
Gerald O'Malley, DO: Embracing Ambiguity
Today my senior resident, I’ll call him Ricky, wanted to order an ultrasound to rule out testicular torsion. Ricky is a pretty sharp guy and he prefaced his request by saying, “I really don’t think he has a torsion, I think he probably has epididymitis, but I want to make sure he doesn’t have a torsion.”
We talked about the fact that the patient was 27-years-old, sexually promiscuous, and had been seen eight days ago for the exact same complaint (testicular pain) during which he had undergone a scrotal ultrasound. My colleagues that had seen him last week were concerned about testicular torsion, had ordered the ultrasound, ruled out testicular torsion and then sent the patient home with Percocet.
I asked my senior resident, “What does his physical exam show?” Ricky replied that his testicle wasn’t swollen and appeared normal, but was tender to palpation, particularly around the epididymis.
“Come again?” I asked.
My resident sheepishly answered, “His epididymis is tender, the rest of his testicle isn’t, and it really looks like a straight forward case of epididymitis.”
“But you want to get the ultrasound anyway.”
“Well, yeah – how else am I supposed to be sure that it’s not a torsion?”
Variations of this conversation happen every day in my ED (my ED is not so unique that this doesn’t happen everywhere).
Read more
Perfectly neurologically intact kids that fall down get CT scans “just in case” there’s a head bleed; 18-year-old soccer players are admitted to chest pain units “just in case” their two weeks of chest pain might represent an acute cardiac syndrome; otherwise healthy renal colic patients have numerous CT scans “just in case” there is an obstructing stone.
Emergency medicine residents and recently graduated attending physicians have an absolute intolerance of ambiguity.
One time I accepted sign-out from one of my younger colleagues and as we made our way to the twelfth bed of the 18-bed unit (I still like to do bedside sign-out; it tears the residents away from the computer which drives them crazy), I realized that I was being tasked with following up on my fifth chest CT to rule out pulmonary embolus. I asked the assembled group of residents, “What are the odds that five out of the 18 patients in this room all have PEs at the same time? The odds are astronomical!”
My junior colleague pulled me aside and told me that she didn’t appreciate my being critical of her clinical judgment. I replied, “Show me some clinical judgment and I’ll decide if it needs criticism. So far, all I see is a lot of wasteful, time-consuming testing all in the hope of ruling out the worst possible diagnosis. Where is the clinical judgment?”
We are training a generation of residents to not use clinical judgment. We instruct and direct them to not use clinical judgment. We introduce algorithmically driven protocols that exclude the need for disciplined reason and thought. We teach residents to order every test and do everything necessary to exclude a life threat, no matter how irrational, rather than to direct patient management based on what is most likely.
The biggest area at issue in my ED surrounds the use of ultrasound in first trimester vaginal bleeding. At the conclusion of three years of residency (in 1995, thank you), I could count on the fingers of one hand the number of ultrasounds we obtained on first trimester bleeders – and we weren’t stepping over the bodies of young previously ectopically pregnant patients on our way out to the vending machines. Now, pregnant patients with vaginal bleeding routinely get ED ultrasounds “just in case” there is an ectopic pregnancy. The argument always seems to devolve into the “dinosaurs” like myself that trained in the era when the decision to chase the diagnosis was predicated on the ED physician’s suspicion that a ruptured ectopic pregnancy was the most likely scenario versus the “new generation” of ED attendings, all well versed in how to make an ultrasound machine sit up and roll over and that stick a probe on anything that’s not nailed down.
Any criticism of ultrasound application labels me a Luddite. I’ve got nothing against the technology – I think it’s kind of cool, although to me, most ultrasound images look like two polar bears humping in a snowstorm. It’s the overuse and misapplication of the technology that drives me nuts, not just because it wastes time and interferes with patient throughput, but more importantly, because it lets the physician off the hook for having to make the hard decision and it makes us invisible and erodes patient confidence in our competence.
When a patient insists on a CT scan or an ultrasound at the conclusion of my bedside evaluation, I take it personally.
Patient: “I came here to get a CT scan.”
Me: “No, you came here to get an opinion. My opinion is that you don’t need a CT scan.”
Patient: “Well, I’d feel better if you ordered one.”
Me: “Where’s the Maalox?”
When I tell the residents that the presence of an ectopic pregnancy is not a medical emergency, they look at me like I have gills and scales. “For crying out loud, OB/GYN sends them home with methotrexate!” Still disbelief. Ectopic pregnancy is not a medical emergency but ruptured ectopic pregnancy is darn sure a medical emergency and one diagnosis that you can’t afford to miss. Of the half dozen or so ruptured ectopic pregnancies that I have personally examined in my career, none of them were subtle.
“Do you think it’s OK to miss an ectopic pregnancy?” they ask. Of course it is. We do it every day. Even patients that have indeterminate early gestational ultrasounds in the ED go home with “early IUP versus possible ectopic pregnancy” as the diagnosis and “clinical correlation required.” Fat chance of that. The possibility of missing an ectopic pregnancy or a hot appendix or an early pneumonia always exists – that’s what discharge instructions are for.
I practice in Philadelphia – ground zero in the med-mal maelstrom. The medicolegal climate in this city is permanently at DEFCON 1 (expectation of actual imminent attack) but I don’t sweat appendicitis or ectopic pregnancy. I accept the fact that those diseases may be present, but are unlikely in a particular patient and explain to my patient and document the absolute need to return if signs or symptoms change or get worse. I think the vogue term these days is “risk stratification.” I call it “using your clinical judgment and common sense.” My Irish mom calls it “using the brains that God gave you.”
Despite Ricky’s objections, we never ordered the testicular ultrasound. We took a urethral culture, gave him ceftriaxone and azithromycin, advised him to have his sexual partners (all of them) treated, and discharged him. As we watched him walk bow-legged out of the ED, I said to my resident, “I wonder if he had torsion of his appendix testis?”
Ricky turned slowly towards me with his mouth open. “I thought you said he had epididymitis.”
“No, I said that he probably has epididymitis. He sure as heck doesn’t have a testicular torsion. Maybe he has a varicocele. Maybe he’s passing kidney stone. Who knows? Dude, relax. Embrace the ambiguous.”
Gerald O'Malley, DO, is the director of research in the largest, busiest emergency department in Philadelphia and an associate professor of emergency medicine at Thomas Jefferson University Hospital. He’s also the son of a NYC cop, die-hard Yankees fan, and a regular contributor to Practice Notes.
We talked about the fact that the patient was 27-years-old, sexually promiscuous, and had been seen eight days ago for the exact same complaint (testicular pain) during which he had undergone a scrotal ultrasound. My colleagues that had seen him last week were concerned about testicular torsion, had ordered the ultrasound, ruled out testicular torsion and then sent the patient home with Percocet.
I asked my senior resident, “What does his physical exam show?” Ricky replied that his testicle wasn’t swollen and appeared normal, but was tender to palpation, particularly around the epididymis.
“Come again?” I asked.
My resident sheepishly answered, “His epididymis is tender, the rest of his testicle isn’t, and it really looks like a straight forward case of epididymitis.”
“But you want to get the ultrasound anyway.”
“Well, yeah – how else am I supposed to be sure that it’s not a torsion?”
Variations of this conversation happen every day in my ED (my ED is not so unique that this doesn’t happen everywhere).
Read more
Perfectly neurologically intact kids that fall down get CT scans “just in case” there’s a head bleed; 18-year-old soccer players are admitted to chest pain units “just in case” their two weeks of chest pain might represent an acute cardiac syndrome; otherwise healthy renal colic patients have numerous CT scans “just in case” there is an obstructing stone.
Emergency medicine residents and recently graduated attending physicians have an absolute intolerance of ambiguity.
One time I accepted sign-out from one of my younger colleagues and as we made our way to the twelfth bed of the 18-bed unit (I still like to do bedside sign-out; it tears the residents away from the computer which drives them crazy), I realized that I was being tasked with following up on my fifth chest CT to rule out pulmonary embolus. I asked the assembled group of residents, “What are the odds that five out of the 18 patients in this room all have PEs at the same time? The odds are astronomical!”
My junior colleague pulled me aside and told me that she didn’t appreciate my being critical of her clinical judgment. I replied, “Show me some clinical judgment and I’ll decide if it needs criticism. So far, all I see is a lot of wasteful, time-consuming testing all in the hope of ruling out the worst possible diagnosis. Where is the clinical judgment?”
We are training a generation of residents to not use clinical judgment. We instruct and direct them to not use clinical judgment. We introduce algorithmically driven protocols that exclude the need for disciplined reason and thought. We teach residents to order every test and do everything necessary to exclude a life threat, no matter how irrational, rather than to direct patient management based on what is most likely.
The biggest area at issue in my ED surrounds the use of ultrasound in first trimester vaginal bleeding. At the conclusion of three years of residency (in 1995, thank you), I could count on the fingers of one hand the number of ultrasounds we obtained on first trimester bleeders – and we weren’t stepping over the bodies of young previously ectopically pregnant patients on our way out to the vending machines. Now, pregnant patients with vaginal bleeding routinely get ED ultrasounds “just in case” there is an ectopic pregnancy. The argument always seems to devolve into the “dinosaurs” like myself that trained in the era when the decision to chase the diagnosis was predicated on the ED physician’s suspicion that a ruptured ectopic pregnancy was the most likely scenario versus the “new generation” of ED attendings, all well versed in how to make an ultrasound machine sit up and roll over and that stick a probe on anything that’s not nailed down.
Any criticism of ultrasound application labels me a Luddite. I’ve got nothing against the technology – I think it’s kind of cool, although to me, most ultrasound images look like two polar bears humping in a snowstorm. It’s the overuse and misapplication of the technology that drives me nuts, not just because it wastes time and interferes with patient throughput, but more importantly, because it lets the physician off the hook for having to make the hard decision and it makes us invisible and erodes patient confidence in our competence.
When a patient insists on a CT scan or an ultrasound at the conclusion of my bedside evaluation, I take it personally.
Patient: “I came here to get a CT scan.”
Me: “No, you came here to get an opinion. My opinion is that you don’t need a CT scan.”
Patient: “Well, I’d feel better if you ordered one.”
Me: “Where’s the Maalox?”
When I tell the residents that the presence of an ectopic pregnancy is not a medical emergency, they look at me like I have gills and scales. “For crying out loud, OB/GYN sends them home with methotrexate!” Still disbelief. Ectopic pregnancy is not a medical emergency but ruptured ectopic pregnancy is darn sure a medical emergency and one diagnosis that you can’t afford to miss. Of the half dozen or so ruptured ectopic pregnancies that I have personally examined in my career, none of them were subtle.
“Do you think it’s OK to miss an ectopic pregnancy?” they ask. Of course it is. We do it every day. Even patients that have indeterminate early gestational ultrasounds in the ED go home with “early IUP versus possible ectopic pregnancy” as the diagnosis and “clinical correlation required.” Fat chance of that. The possibility of missing an ectopic pregnancy or a hot appendix or an early pneumonia always exists – that’s what discharge instructions are for.
I practice in Philadelphia – ground zero in the med-mal maelstrom. The medicolegal climate in this city is permanently at DEFCON 1 (expectation of actual imminent attack) but I don’t sweat appendicitis or ectopic pregnancy. I accept the fact that those diseases may be present, but are unlikely in a particular patient and explain to my patient and document the absolute need to return if signs or symptoms change or get worse. I think the vogue term these days is “risk stratification.” I call it “using your clinical judgment and common sense.” My Irish mom calls it “using the brains that God gave you.”
Despite Ricky’s objections, we never ordered the testicular ultrasound. We took a urethral culture, gave him ceftriaxone and azithromycin, advised him to have his sexual partners (all of them) treated, and discharged him. As we watched him walk bow-legged out of the ED, I said to my resident, “I wonder if he had torsion of his appendix testis?”
Ricky turned slowly towards me with his mouth open. “I thought you said he had epididymitis.”
“No, I said that he probably has epididymitis. He sure as heck doesn’t have a testicular torsion. Maybe he has a varicocele. Maybe he’s passing kidney stone. Who knows? Dude, relax. Embrace the ambiguous.”
Gerald O'Malley, DO, is the director of research in the largest, busiest emergency department in Philadelphia and an associate professor of emergency medicine at Thomas Jefferson University Hospital. He’s also the son of a NYC cop, die-hard Yankees fan, and a regular contributor to Practice Notes.
Wednesday, November 11, 2009
Gerald O'Malley, DO: What is important to teach
Tonight I worked a shift with an exceptional medical student from a fine school who had never heard of Ignaz Semmelweiz.
My student didn’t recognize his name, but more importantly, this talented and engaging medical student had never heard the tragic story of the great physician who deduced the etiology of puerperal fever (physicians performing autopsies and then delivering babies without washing their hands), who was ridiculed when he proposed that physicians were the fomites responsible for peripartum infection and death, who lost his mind, most likely due to tertiary syphilis (an occupational hazard of 19th century gynecologists), and who died in a mental institution after a savage beating at the hands of other inmates.
Read more
Similarly, this particular student had never heard of Werner Forssman, the German physician who won the Nobel Prize in medicine by demonstrating the feasibility of introducing a catheter into the right atrium of the heart via a peripheral vein — an experiment he performed initially on himself.
Why is the history of medicine not taught in medical schools? How can modern day medical students appreciate their place in the continuum of medicine and their place in history and their responsibilities to past and future generations of physicians unless they learn the great and noble and honorable and not-so-honorable accomplishments of the men and women that have made their marks on our world’s history?
What about the history of medicine through fiction? Sir Arthur Conan Doyle was a physician (many people believe that Dr. Watson was his literary alter-ego). In addition to the adventures of Sherlock Holmes, Conan Doyle wrote numerous short stories about being a physician in 19th century London. Reading Conan Doyle’s “Round the Red Lamp,” one realizes the shared experience of despair at the bedside of a dying patient. Helpless to do anything to stop the inevitable, the great and awful responsibility we have as physicians reaches down through the ages from gaslight to halogen bulbs.
Last year I gave as a graduation present to each of the residents in my department a copy of William Carlos Williams’ “The Doctor Stories” in the hopes that they might see something of themselves in these beautiful stories of doctors and patients from the mid 20th century.
The student that I worked with tonight was born in 1982, which was my sophomore year in college. She grew up in a world that has never not known AIDS. I instruct my residents to consider what it must have been like to practice medicine in the age of polio and rampant tuberculosis and yellow fever, and how the physicians of that age were intimately familiar with those diseases.
Then I ask them to consider the future, when HIV has been conquered and the physician of the next century is dealing with whatever new pathogenic horror has developed. The physician of the future might ponder what it must have been like to practice in the age of AIDS, and I remind them of the awesome responsibility that they have each agreed to.
Gerald O'Malley, DO, is the director of research in the largest, busiest emergency department in Philadelphia and an associate professor of emergency medicine at Thomas Jefferson University Hospital. He’s also the son of a NYC cop, die-hard Yankees fan, and a regular contributor to Practice Notes.
My student didn’t recognize his name, but more importantly, this talented and engaging medical student had never heard the tragic story of the great physician who deduced the etiology of puerperal fever (physicians performing autopsies and then delivering babies without washing their hands), who was ridiculed when he proposed that physicians were the fomites responsible for peripartum infection and death, who lost his mind, most likely due to tertiary syphilis (an occupational hazard of 19th century gynecologists), and who died in a mental institution after a savage beating at the hands of other inmates.
Read more
Similarly, this particular student had never heard of Werner Forssman, the German physician who won the Nobel Prize in medicine by demonstrating the feasibility of introducing a catheter into the right atrium of the heart via a peripheral vein — an experiment he performed initially on himself.
Why is the history of medicine not taught in medical schools? How can modern day medical students appreciate their place in the continuum of medicine and their place in history and their responsibilities to past and future generations of physicians unless they learn the great and noble and honorable and not-so-honorable accomplishments of the men and women that have made their marks on our world’s history?
What about the history of medicine through fiction? Sir Arthur Conan Doyle was a physician (many people believe that Dr. Watson was his literary alter-ego). In addition to the adventures of Sherlock Holmes, Conan Doyle wrote numerous short stories about being a physician in 19th century London. Reading Conan Doyle’s “Round the Red Lamp,” one realizes the shared experience of despair at the bedside of a dying patient. Helpless to do anything to stop the inevitable, the great and awful responsibility we have as physicians reaches down through the ages from gaslight to halogen bulbs.
Last year I gave as a graduation present to each of the residents in my department a copy of William Carlos Williams’ “The Doctor Stories” in the hopes that they might see something of themselves in these beautiful stories of doctors and patients from the mid 20th century.
The student that I worked with tonight was born in 1982, which was my sophomore year in college. She grew up in a world that has never not known AIDS. I instruct my residents to consider what it must have been like to practice medicine in the age of polio and rampant tuberculosis and yellow fever, and how the physicians of that age were intimately familiar with those diseases.
Then I ask them to consider the future, when HIV has been conquered and the physician of the next century is dealing with whatever new pathogenic horror has developed. The physician of the future might ponder what it must have been like to practice in the age of AIDS, and I remind them of the awesome responsibility that they have each agreed to.
Gerald O'Malley, DO, is the director of research in the largest, busiest emergency department in Philadelphia and an associate professor of emergency medicine at Thomas Jefferson University Hospital. He’s also the son of a NYC cop, die-hard Yankees fan, and a regular contributor to Practice Notes.
Wednesday, September 9, 2009
A dose of reality for med students
A group of University of Washington medical students spent their summer getting a glimpse of some of the healthcare system's ills – and learning what many physicians already know: the reimbursement system needs to be fixed.
According to The New York Times story: “The students learned not only to deliver babies and suture wounds, but also to order unnecessary tests as protection against law suits, to hector specialists into seeing Medicaid patients, to match patients with prescriptions on Wal-Mart’s $4 list.”
Read more
The rising second-year students, who spend a month providing care in rural and underserved areas in the Northwest, saw firsthand some of the ills of the profession, like doctors only spending five minutes with each patient and burn out on 13-hour nonstop days.
They were dispatched to perhaps some of the areas most in need, dealing with some of the harshest realities of the system, but my guess is these issues and sentiments are shared to varying degrees across the country. Perhaps unsurprisingly, some students said they didn’t want to pursue primary care, and many said they saw the dire need for healthcare reform.
“I often wondered what we were actually doing to help people,” one student told the NYTimes.
Lest this be a downer post, I'll end by reminding you (and letting any doubting med students know) of one of the top 10 reasons to be happy you're a doctor: You make a difference. Despite the specter of denials, malpractice, and overwork, you still have a job that provides a genuine service to the public, with tangible results and healthier patients.
According to The New York Times story: “The students learned not only to deliver babies and suture wounds, but also to order unnecessary tests as protection against law suits, to hector specialists into seeing Medicaid patients, to match patients with prescriptions on Wal-Mart’s $4 list.”
Read more
The rising second-year students, who spend a month providing care in rural and underserved areas in the Northwest, saw firsthand some of the ills of the profession, like doctors only spending five minutes with each patient and burn out on 13-hour nonstop days.
They were dispatched to perhaps some of the areas most in need, dealing with some of the harshest realities of the system, but my guess is these issues and sentiments are shared to varying degrees across the country. Perhaps unsurprisingly, some students said they didn’t want to pursue primary care, and many said they saw the dire need for healthcare reform.
“I often wondered what we were actually doing to help people,” one student told the NYTimes.
Lest this be a downer post, I'll end by reminding you (and letting any doubting med students know) of one of the top 10 reasons to be happy you're a doctor: You make a difference. Despite the specter of denials, malpractice, and overwork, you still have a job that provides a genuine service to the public, with tangible results and healthier patients.
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