Aarrrggghhh .... July

"Courage - the first of human qualities ... because it guarantees all the others."
~ Winston Churchill

The academic year is coming to an end. There is both happiness and uncertainty in the air. The chief residents are packed up and saying their goodbyes. The newly graduated interns are finding housing and readying themselves for a new venture. It is an exciting time for all involved. At this time of the year, everyone is changing their position in the hierarchy. The rising chiefs have to assume the role of leader and the new interns will be a "doctor" for the first time. Some are up to the task and others, well, take a little bit of coaching. For everyone, July is eventful.

On July 1, there will be a new set of faces here. There will be those who have acquired the skill set needed to assume their new role and there will be others who have not. Some will have the confidence without the skills to back it up; and others will have no confidence but have good skills. In the end, there are very few who are not salvageable. Not everyone was born knowing how to do everything. That guy sitting next to you who acts like he has it all under control is probably just as scared as you are. We are all human and you WILL make mistakes.

Here are a few points that I found helped me put some things into perspective.

When you start getting anxious about a situation, remember start your thought process by taking your own pulse.

Never run to a intense situation (like a code), but walk briskly and come up with a plan of action.

Ask questions if you don't know how. It is not a sign of weakness, it is a sign of strength.

Know your own limitations.

There are probably many more. Good luck to you all on your new adventures. We are all getting ready for a little bit of a roller coaster ride.

“The key to change... is to let go of fear.”

~ Rosanne Cash

All good things have to come to an end ...

“Thinking is easy, acting is difficult, and to put one's thoughts
into action is the most difficult thing in the world.”
~Johann Wolfgang von Goethe

When I was in medical school, one of the key issues that discussed at the time was the increasing need for primary care providers and the over abundance of sub-specialists. There was a push by multiple institutions to increase medical students interest in the primary care areas and a deemphasis of the sub-specialties. Over recent years that prediction was found to be off target. Unfortunately, the opposite was found to be true. One of the causes for the miscalculation was an aging population and a predicted increasing need for care including sub-specialty care. Along with the general population, the orthopaedic workforce is also aging. There are a number of the elders who will be retiring in the near future with no one to fill their position or role. No where in orthopaedics is the particularly true than in my subspecialty, pediatric orthopaedics.

As we go through our medical education and resident training, there are a few individuals who have a lasting impact on those with whom they have interacted. These are the individuals that many years later are still quoted and mimicked. In many instances, these individuals have dedicated their lives to the education of the young physician and the advancement of medical knowledge. Not all of the memories may be good memories, but they have effected you none the less. If you close your eyes and visualize your education, these are the people you see. The more time a person is associated with a program; the more they become a part of that program. They are fixtures at that program, an "institution".

As is the nature of life and careers, they all have to come to an end. Recently, I heard that one of my mentors has cut back his practice. He has not retired, but he has decrease his case volume and stopped performing major procedures. This past week I was reminiscing with some former residents from my program. As you do, we talked about our current practices, how many kids, new relationships, new cities, etc. After we finished with the formal updating of our lives, we reminisced about residency. We laughed about the good and bad. We all had a lot to say about my former mentor. It was very interesting that everyone had very similar stories. While I was still in residency, I remembered having other former residents tell these same stories to me. As we talked about him, I found out that he had cut down his practice. We all had a feeling of sadness about it. It seemed like the end of an era.

When a program loses someone who was influential, part of that program dies. As with many tribes, they depend on the elders to impart wisdom and insight. It is with this wisdom we are able to stay away from mistakes of the past. They remind us of previous successes and failures. Because of their years of experience, they are able to quickly reference the patient catalog and give advise base on previous experience. In their mind, it intuitively "makes sense." It is true their techniques make have fallen behind the current en vogue treatments and/or techniques, but it is their experience that is vital to the education of both medical students, residents, and young attending staff.

In my specialty where 60% of the Pediatric Orthopaedic Society of North America members are over the age of 50, the era is coming to an end in multiple institutions. Unfortunately with the current generation of attendings and residents (GEN X) choosing sexier and more lucrative specialties such as sport medicine and spine surgery, the number of specialists in the other specialties has decreased. For a number of reasons (malpractice, case volume, lower salaries, interest), residents have shied away from some of the other specialties. Pediatrics has be hit particularly hard. We know the mentors and sub-specialty exposure influences resident selection of sub-specialty. With many of the great educators reaching retirement age, who will assume the role?

I look back at my own education and remember how much I was influenced by my faculty. Both in my fellowship and residency, it was the wisdom of my elders which particularly influenced me. As I look to the future, I hope these voids will be filled. This is an unknown. In the end, all I can do is hope and pray that this is only a cycle and we are on the bottom end of that cycle. If not, may be at the beginning of an ice age.

“Wise men speak because they have something to say;
Fools speak because they have to say something.”
~Plato

Are we there yet?

“You have your way. I have my way. As for the right way, the correct way, and the only way, it does not exist.”
~Friedrich Nietzsche

Education is a wonderful thing. I learn something new everyday. Everyone from my patients, students, residents, nurses, and even the cleaning ladies, teaches me something. I truly believe that when I stop learning or wanting to learn, I should retire. While I love to learn, I also have the same passion for teaching. This is a double edged sword. The more you teach; the more you must know; the more you know; the more you realize you know nothing. This is a vicious cycle. How can you teach when you don't know?

Teaching in the medical field is tiresome. Sometimes I just want to do things myself, because it is easier and I don't have to think so hard or try to keep bad things from happening. I do realize that I have to allow the residents to grow and have to give the medical students some sort of education because they are paying for it. The whole process is taxing. Leading a service with medical students and residents is like being the lead car taking a caravan of cars through downtown Detroit. When you are leading, you have to drive slower than you usually do. If you see a stoplight turning yellow, you'd better slow down because not everyone will make it through the stop light. You'd better rethink passing that car because not everyone will be able to pass. Signal early so that everyone will know when you are turning. Don't forget about those potholes. For everyone in the caravan, it is stressful; but for the lead car, you have to anticipate what the needs are for the other drivers as well as try to predict how they will react.

It is my favorite time of the year, the end of the educational year, April-June. Everyone has a sense of confidence about them. From the medical students to the chief residents, everyone is spreading their wings and ready for the next level. It is when I have to lead less. My chiefs are leading the service without much need for our input; the mid levels are showing that they have advanced in both their knowledge and surgical skill; the juniors are making fewer errors and gaining confidence; and the medical students, well they just are nowhere to be found (just jokes). My least favorite time of the year comes right after this, July-September. It is like groundhog's day all over again. I feel like I am repeating myself. "I swear we just lectured on that." Or "I do it like I always do." I do realize that they don't necessarily know how I do it and others may do the same procedure differently. It can be a little frustrating. Usually I am whining, "Why can't we just do it like we did last time." It is probably more dramatic because it was so good a month or two before. We go from freshly paved highways to unpaved roads.

In my view, this is what keeps me on my toes and keeps me learning. The changes in residents and differences in experience help to enrich my experience. Yes, it is painful when I have to re-explain when and when not to brace scoliosis; or when I have to go over the different types of in-toeing for the millionth time. At the same time, those same residents and medical students question what I do and why I do it. It forces me to constantly re-evaluate what I do and why I do things the way I do. As much as many resident and medical students complain about attending pimping, all those questions you ask are like reverse pimping. Sometimes I want to shout out like a parent, "Just because that's the way I do it." As much I (attendings) am there to help in their (medical student and resident) education, they prevent me from getting stale and set in my ways. It makes almost everyday interesting; every case a little different; and every patient special. To those who are graduating, thank you and lead well; and to those who are entering, welcome and watch for the break lights.

“For everything you have missed, you have gained something else, and for everything you gain, you lose something else.”
~Ralph Waldo Emerson

My thoughts go out to you and your families....

To the family members of the University Michigan Transplant team who were lost in the tragic plane crash,

my thoughts are with you and your loved ones during this difficult time of loss.

RIP
Dr. David Ashburn
Dr. Martinus "Martin" Spoor
Richard Chenault II
Richard Lapensee

How do we educate residents with todays restrictions .... (part III)

“It is a miracle that curiosity survives formal education.”

~Albert Einstein

So the next question is how do we, educators, teach our audience, the learners, our craft with in the restrictions of different governing bodies, while appropriately meeting the specific needs of the current generation?

As we look at the need of the current generation, we can see that there is an emphasis on the individual yet they want to be mentored. They are in touch with the newest technology and may require different ways of communicating. You may be required to give them instant feedback. Heck, we have cell phone and the text messaging. I want to know now. Why didn't you pick you your phone? I think we, educators, must keep in mind that everyone’s time is important. The learners do not need to learn all of the information in one sitting. People learn and think best when well rested and fed. This progression to a kinder gentler medical training is a change in philosophy. It will make less bitter people.

The learners, on the other hand, must understand that they will be required to be active participants in their own education. Because less will be learned directly from the educator, the learner must be facile with the other learning media. Learners must seek out knowledge. There is not enough time to do passive learning; the learner must seek out the opportunities to gain clinical skill. This is something in the past that was provided by shear volume; now, it must be sought out and learn through alternative means. Unlike many things that can be learned by reading, those who are in clinical specialties must learn from patients. Patients and their diseases do not always follow the rules. The more patients you see, the better understanding of the possible variations in presentation. This can not be learned by computer simulation or by reading in a text book. There is no algorithm will incorporate every clinical scenario. So, the patients must be seen and evaluated. With all of the new technology, one of the key skill set of the physician is slowly being lost, the physical examination.

There are some significant changes coming in the future that will effect resident education. Many current residents and medical students harp on the 80 work week and the low pay. There are the arguments that say that the hospitals and universities get 100+ thousand dollars for each resident and the resident should get more money or have to work less hours. I say, be careful what you wish for. Let's go into some basic changes that will effect resident education directly and indirectly.

NEED TO INCREASE PHYSICIAN NUMBER

Although there are some that believe that,

There has been a systematic attempt to limit the number of spots in medical schools. With a limited supply of training institutions, there was insufficient supply to meet demand.

There have been some significant changes over the past few years to actually increase the number of physicians. Here is a little history.

In 1992, the Council on Graduate Medical Education (COGME) issued a series of reports expressing concern with potential surpluses of physicians and recommending an increase in the percent of physicians trained and practicing as generalists. These concerns led the Council to develop a recommendation that 110 percent of the number of U.S. medical graduates in 1993 should enter residency training each year (or about 19,750 physicians) and that half of these physicians should be generalists. This recommendation became known as the “110/50-50” goal for the physician workforce in the U.S.

Recently put out in the COGME's 16th report, they assessed the future supply, demand, and need for physicians in the United States (U.S.) through 2020 for both generalist and non-generalist physicians will exceed what we are currently producing.

Summarizing some of their findings:

1. Under current production and practice patterns, the supply of practicing physicians in the U.S. is expected to rise from 781,200 full-time equivalent (FTE) physicians3 in 2000 to 971,800 in 2020, a 24 percent incease.

2. At the same time, for a number of reasons and under a number of scenarios and models, the demand for physicians is likely to grow even more rapidly over this period than the supply.

3. The need for services, reflecting primarily the use of services under universal insurance and increased utilization review processes, is also expected to increase over the period.

4. The models and alternative scenarios used to make the predictions included a number of factors that could have a major impact on supply, demand, and need and, consequently, on a potential gap in the physician supply. Many of these factors are likely to add to the shortage of physicians.
> Changing lifestyles for the newest generation of physicians, with the possibility that new physicians will work fewer hours than their predecessors;
>Continuation of the rate of increase in the use of physician services by those over 45, which has been increasing for the past 20 years, and increased use of services by the baby-boom generation compared to prior generations
> Expected increases in the Nation’s wealth that would contribute to continued increases in the use of medical services.

Other factors could also lead to larger shortages and are not included in the baseline projections or alternative scenarios. These include the following:

> A potential increase in non-patient care activities by physicians, including research and administrative activities;
> A potential change in practice patterns for physicians over 50, including a reduction in hours worked before retirement and earlier retirement patterns;
> Possible increases in departures from practice due to liability concerns of physicians;
> Decreases in hours worked by physicians in training;
> Possible decreases in immigration of graduates of foreign medical schools;
> Possible increases in the number of physicians limiting the number of patients on their panel (sometimes referred to as “boutique medicine”);
> Advances in genetic testing that could lead to increases in the use of services as individuals learn they are at risk for certain illnesses or conditions; and
> Additional medical advances likely to keep individuals with chronic illnesses alive longer without curing their illnesses.

THE MEDICAL SCHOOL RESPONSE

In response to the findings of COGME, medical schools have started the process of increasing the class sizes to help with predicted future needs. This is in contrast to the past where there was a decrease in both medical school classes, as well as a push towards the primary care specialties. With the current findings, there will be a need across the board. There is less of a push for those primary specialties. In June of 2006, AAMC came out with a Statement on the Physician Workforce. They recommended:

1. Enrollment in LCME-accredited medical schools should be increased by 30% from the 2002 level over the next decade. This expansion should be accomplished by increased enrollment in existing schools as well as by establishing new medical schools.

2. The aggregate number of graduate medical education (GME) positions should be expanded to accommodate the additional graduates from accredited medical schools.

3. The AAMC should assist medical schools with expanding enrollment in a cost effective manner; assuring appropriate medical education for traditional and non-traditional students; and increasing the number and preparedness of applicants.

4. The AAMC should continue to advocate for and promote efforts to increase enrollment and graduation of racial and ethnic minorities from medical school; and promote the education and training of leaders in medical education and health care from racial and ethnic minorities.

5. The AAMC should examine options for development of: (1) a formal, voluntary process for assessing medical schools outside the U.S.; and (2) a mechanism for overseeing the clinical training experiences in the U.S. of medical students enrolled in foreign medical education programs.

6. The AAMC should undertake a study of the geographic distribution of physicians and develop recommendations to address mal-distribution in the U.S.

7. National Health Service Corps (NHSC) awards should be increased by at least 1,500 per year to help meet the need for physicians caring for under-served populations and to help address rising mdical student indebtedness.

8. Studies of the relationship between physician preparation (i.e., medical education and residency training) and the quality and outcomes of care should be conducted and supported by public and private funding.

RESIDENCY FUNDING

Residents are mostly funded by Centers for Medicare and Medicaid Services (CMS) and this is for taking care of Medicare patients. That funding is split into 2 parts: DGME and IME. The DGME (Direct Graduate Medical Education payment) is the direct cost of the resident (salary, benefits, malpractice, etc). The IME (Indirect Medical Education) is the indirect cost of medical education (teaching, supplies, cost of personnel for each residency and GME, and the increased cost of training institutions because of trainees). The dollar amounts vary based on an algorithm, but the gist is that the DGME is about ~$70-90,000 and the IME is ~$30,000. In the near future, like next year, the IME is being decrease by about 1/2. Another change that will affect residencies is that if a resident goes to a course for education, the government will not pay for those days, unless they were vacation days. If a resident is in an outpatient setting, unless approved by CMS, the hospital or facility will have to cover the residents salary for that given time. Every hour of a resident’s day has to be accounted for and reported to the government. If there is a question, that time will have to be covered by the institution. Many would have you believe that the hospital make a mint of of the residents. They get money from the government and then they are able to bill for facility fees and attendings bill for their work. There are actually some articles that are coming out to dispute this.

Along with the CMS guidelines the numbers of medical graduates will be increasing but the residency "cap" has not. Therefore the number of residencies paid for by CMS will not change. There have been some policies to change this, but they are not currently in place. Hospitals have responded to the lack of governmental GME funding by funding residency positions themselves.

Why do I say be careful what you wish for? I can see in the future requiring tuition for residency. When the government pulls most or all of the funding, this may be happening.

TIME

Time is going to be an issue. With many of the newer generation wanting a "life", they are going to spent less time learning in the hospital. We have run into this problem with trying to fit in a curriculum that is considered a necessity by the RRC. When do you find time to have didactics? In today’s world, the didactics must be taught between the hours of 630 am and 6pm, Monday through Friday, no weekends, no holidays. This makes things tough in the surgical specialties. Yes, we can hire PA's and NP's to cover floor work; and yes, the attendings can start the cases by themselves (I actually prefer this because I get to operate). The problem is that this is education time too. In the surgical specialties, noon conferences don't work. That means it must be at the beginning or the end of the day.

Hospitals are being crushed by decreases in reimbursements so they are pushing to get more done with less. More cases are done in less time. Start the cases early and on time so that they can get more done before the end of the day shift. They don't want to pay overtime. Many hospitals want to push the OR time back to 7am. Hospitals administrators know that residents slow down many attending surgeons and would rather not have them operate to decrease OR time. So how are we going to prevent monetary problems from effecting the education of our needed practitioners?

WHAT'S THE ANSWER?

In the end, this question I wanted to solve has only brought more questions. I will continue to reevaluate my on education styles. I hope to keep this generations eyes open. I want them to look not only at how they are affected, but at how their choices and actions affect those who will follow them. As an educator, my ultimate goal is to put out a good product (physician/surgeon) in the end. The means of doing that may vary but hopefully the outcomes will be the same.

"In youth we learn; in age we understand.”

~Mari Von Ebner-Eschenbach