Why don't we get to discuss money in medical school?

“The object of education is to prepare the young to educate themselves throughout their lives.”
~Robert M. Hutchins

Long ago, I remember sitting in an interview for medical school and the interviewer asked me, "what do I want to do?" A typical question that most applicants get. I had already decided on orthopaedic surgery as a specialty, but I still had the idealistic views that I could make a difference. My answer was like so many others who said in some way, shape, or form that they wanted to help the "world." This idealistic views do change as time goes by and we realize that this is a business and that money makes the world go around. In medical school, especially at an academic powerhouse, no one ever talks about the financial side of medicine. It is money that fuels the machine and without it the machine does not run. So, why is it that there is such a lack of training on the business end of medicine?

I began to write this post about a month ago and Howard J Luks, MD posted before I could complete the thought. He raises the same question that I have. When is it that we talk about business? (which really means talking about money)

No question that our students are well trained in the science of medicine. Unfortunately, very few students prove to be well trained in the business of medicine. Many students are even embarrassed to ask questions pertaining to the business of medicine because they are afraid they will betray their idealistic or altruistic beliefs that made them commit to a career in medicine in the first place. What do I mean? A student who recently rotated with me felt she could not discuss the business aspects of a career in medicine with her professors or colleagues in fear that she will appear to be cold or unfeeling. I had a student rotating on my service recently who wanted to go into Cardiothoracic surgery because it was "really cool." He had no idea how much their reimbursement has been cut. He had no idea that their case load has diminished dramatically over the years and he had no idea that true cardiac centers were performing some "pretty cool" new cardiac procedures. Some women are afraid of a career in ortho because they are petite. Some think that a pediatrician makes 300-400k per year.

I must say that I feel we owe the students much more than a book based education about the science of medicine. They need to know about what a career in medicine entails. They need to know about some of the hardships we are experiencing now and some that we are afraid may materialize. They need to know about EMRs, P4P, reimbursement changes, and the people/organizations behind the push to change the way that medicine will be practiced in the near future. LEAPFROG, PROMETHEUS, CMS, Payors, PBMs, EMRs, PHRs etc should be terms the students should be comfortable with. Otherwise they will plod through their residency, learn little more about the biz of medicine than they already do and then they will be thrust into a practice environment they have no idea how to navigate through.

WEB SITE LINK

The other week I was sneaking some brownies in the general surgery conference room and all 30 of the medical students where present (okay that was an exaggeration, there were only about 5, but it seemed like 30). I asked them if they wanted a lecture on something. I was in between cases and would be glad to teach a little. Of course they said no, but I forced myself on them anyway. I asked what their plans were etc.. Some how we got on the topic of coding. I informed them by CMS guidelines the medical student note means nothing. For billing purposes, we can not "link" to their note and bill. They seemed astonished.

For about 20 minutes or so I went on about ICD-9 , E&M, and CPT codes. We discussed billing, overhead, and collections. We discussed what it means to "par" with insurance. I spoke to them about the differences in incomes between military, academic, employed, and private practice. I think I over loaded them. But, I think it was a conversation that they needed to have.

As Dr. Luks points out, many of those in medical school today do not get the training in business; yet, when they graduate medical school, they are asked to run a business. I hear so many medical students speak of the "salary" they will have when they are done. Unfortunately, in todays world, it is becoming more of an "eat what you kill" type of world. There is really no "salary" anymore. So, should the business side of medicine be taught? I would scream YES. The question then is when do we teach it? The information in medical school is already more than one can manage. Residency time (total hours) is decreasing yet the complexity is increasing. Where do we find the time? I wish I had the answer.

“You are the embodiment of the information you choose to accept and act upon. To change your circumstances you need to change your thinking and subsequent actions.”

~Adlin Sinclair

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Please visit this site. Thank you all.



Someonetc

Tying the attendings hands ...

“Wisdom is knowing what to do next, skill is knowing how to do it, and virtue is doing it.”
~David Starr Jordan

The 80 hour work week restriction has gotten a lot of attention over the past 5 years. Many believe that these are the only changes that have significantly affected resident and medical student education. Over the past 20 years there have been a number of things that have change the way physicians practice. As much as the 80 hour work week was a shock to the training system, there have been small changes in requirements for billing, resident supervision, and reimbursement, that have probably affected resident education in a more subtle way.

In the early 90's, many academic medical centers were evaluated by CMS and levied huge fees on a number of academic medical centers. From these evaluations, a number of new guidelines were set for billable encounters in teaching situations. The changes have require more of an attending presence in clinical and surgical procedures. Although this did not directly change resident education, it changed the attendings participation in patient care. The days of (billed) resident run clinics went away. The days of (billed) surgical procedures without attending presence are gone. These changes are good for patient care, but changed resident education. It increases the duration of the learning curve. There is no room for allowing the young surgeon to figure out how to get through the cases. I call this the "futz factor." Young surgeons need to "futz" to figure out what works best for them. With attendings present, they tend to become impatient with "futzing" and take over the case. Most young surgeons need to do, observation is not as helpful unless you have the experience on which to build. This change the resident attending interactions and cause many attendings to become more hands on.

Along with increased requirements for billing came a decreases in physician reimbursements. Decreases in reimbursements caused an increasing need for surgeons to become more clinically active. Department chairmans began to see the departments overall income decreasing. Systems to encourage increase clinical production (incentives) were set up. Now, you income became more like true private practice. The mentality of "you eat what you kill" began to creep into the mentality of new attendings. The days of seeing few patients, doing a couple of cases and getting a large salary are gone. With less overall (clinical) income, salaries became effected. It has caused attendings be like Snoop said, "with my mind on my money and my money on my mind."

The question may be posed, "why would this change resident teaching?" You would assume that more attending presence there should be better education. You would assume that more cases and more out-patient and in-patient experience would be better for resident education. Unfortunately, I don't see this as being the case. What I see is more patient being seen in clinic and less time for teaching. What I see is more cases being done with a limited amount of time, requiring more attending participation and less time to "futz". What I see in an increasing number of different procedures and increasing complexity of these procedures with less time to learn them. I see residents being over extended because of the increasing demand to produce clinically. I see the use of PA's and other physician extenders taking away residents ability to learn some of the basic skills, such as casting. With money being the driving factor, education suffers. Teaching does not pay, therefore education suffers.

So, as much as I harp on the "new generation" and on the 80 hour work week, I also think that our ability to educate well has also been affected. I think that we are not educating as well. Our ability to spend time educating our future surgeons has changed. We will have to develop new techniques for educating them. I fear things will get worse before they get better. I worry that we may be graduating future surgeons who are less prepared than in the past. Is this better for patient care?

“Real education must ultimately be limited to men who insist on knowing, the rest is mere sheep-herding.”
~Ezra Pound

Practice makes perfect ... or something like that

“The surest way to corrupt a youth is to instruct him to hold in higher esteem those who think alike than those who think differently”

~Friedrich Nietzsche

Over the past 10 years, I have had the opportunity to work with residents from different backgrounds, undergraduate majors, and orthopaedic programs. I have worked in 5 different academic settings. I state these facts because my upcoming view is not based on a view of one way of educating (i.e. the Harvard or Duke Way), but based on an understanding of the differences in both teaching and learning styles, academic and clinical settings, and generational changes. In my anecdotal point of view, residents in today's residency setting are technically delayed. The technical skills that I observed in residents 5 years ago don't seem to appear in the residents until about 6 months or so later. Some people reading this may feel that it is a slam. It is not; it is just my observation. When I ask myself why has there been such a change across the board, the only significant change has been the institution of the 80 hour work week.

One of the main reasons I like teaching is because I like to watch the intellectual growth of young surgeons. I enjoy seeing their development from novice surgeon afraid of cutting too deep, to a confident graduating chief. It is almost like raising your kids. "Oh, look he is using the cob like a big boy, now. He makes me so proud." Recently I have begun to notice that some of the skills that I had, I guess, taken for granted are not being developed. Basic skills that many learned in their internship in the past are being learned as second year residents. I wonder if we are failing our residents by not providing them with the tools they need to practice on their own. Are we setting them up for failure?

When the 80 hour work week was initially proposed, many surgical programs and grey-haired, "old school" surgeons said this will never work. I believed and still believe that the change was necessary. I also believe that once all of the data comes out that there will be changes in the duration of residencies (increase in time), the operative logs will be used for hospital credentials (no enough cases in residency = no privileges), and increases in the requirements for initial hospital monitoring of new surgeons and board certification. This is what I see in my crystal ball; although, it is sometimes cloudy.

There has been a recent study that have noted a decrease in cases logged.

Weatherby and fellow researchers used ACGME case logs to study PGY2 and PGY3 students' operative experience gained in a two-person orthopedic residency program in 2002-2003 (before the 80-hour week) and in 2003-2004, after the longer week took effect. Researchers also gave junior residents logs in which to record subjective caseload information, Weatherby said.

In 2003-2004, PGY2 and PGY3 residents performed 759 operations, or 195 (21%) fewer than in the previous year, Weatherby reported. Cases per rotation averaged 79.5 in 2002-2003, compared to 63.3 the next year, showing a 20.44% decrease (P=.009).

"The trend is obvious," he said. "It is obvious that it is national, too."

Residents missed 9% to 13% of total surgical case volume between November 2003 and January 2004, with each resident missing an average 10.8% of cases, totaling 254 cases over 64 post-call days, Weatherby said.

"Our study shows that residents who have begun training after the 80-hour work week will do significantly fewer procedures, particularly at the PGY 2 and 3 level," Weatherby said. "This may result in a decreased level of skill acquired during training or it may shift the majority of operative experience to the PGY4 and 5 years, prolonging the learning curve."

Weatherby called for more research and more assessment of how the new hour regulations affect surgical training. He also voiced concern about residents having fewer opportunities to learn surgical procedures in a reasonable amount of time.

"We must ask ourselves if we will at some point, in fact, build up the skill of orthopedic surgery," he said. "This also supports the theory that operative experience is deferred ... throughout the year, thus prolonging the learning curve."

Weatherby B, Rudd R, Ervin TB, et al. The effect of resident work hour regulations on orthopaedic surgical education. #121. Presented at the American Academy of Orthopaedic Surgeons 73rd Annual Meeting. March 22-26, 2006. Chicago.

I ask myself, how do we accommodate for the decreased numbers? Years ago, many surgeons would practice at home. They would learn how to drill and sew outside of work. They always worked on their technical skills. In the current generation, I have not seen the desire to work outside of “work” to learn how to perform their craft. Technical skill can not be read, it must be practiced. My residents and medical students are well read. They can quote literature, know how to gather information, and put on a heck of a power point show; but operative skill "not so much." The chiefs feel the need to operate because they what to gather the skills before graduating (and they are avoiding clinic) and the juniors operate less because of floor, clinic, and ER responsibilities. Then the cycle continues the next year because the rising junior becomes a chief and needs the operative experience.

I can hear people now saying, "Well just let them operate and get PA's and NP's to manage the floors and clinic." That is not the answer either. One of the most important skills for a surgeon is making good clinical decisions. Decisions like when to operate and when not to operate; which patients are good candidates and which ones are bad candidates; and what your outcomes are realistic expectations from procedures. That experience comes from follow-up. As they say, there is nothing like follow-up to ruin your good outcomes. We haven't even addressed billing, coding, and the other business aspects of a practice that are barely taught in residency.

As I look forward, I wonder if we are failing them by not providing them with ways to develop technical skills without actually operating on a patient. I know that there are simulators that are being used to help address these deficits (arthroscopy simulators), but are they being utilized appropriately? How can we accommodate for a decrease in case volume without increasing residency time? Maybe some of you have ideas. For now, I am still trying to keep from getting frustrated.

“Learn from yesterday, live for today, hope for tomorrow. The important thing is not to stop questioning.”
~Albert Einstein

This was nice ... I thought I would share it.

I received this in an email today. I thought I would pass it along to all of my friends in the blogsphere. Enjoy.

TWO FRIENDS WERE WALKING
THROUGH THE DESERT.
DURING SOME POINT OF THE
JOURNEY, THEY HAD AN
ARGUMENT; AND ONE FRIEND
SLAPPED THE OTHER ONE
IN THE FACE.
THE ONE WHO GOT SLAPPED
WAS HURT, BUT WITHOUT
SAYING ANYTHING,
WROTE IN THE SAND:

TODAY MY BEST FRIEND
SLAPPED ME IN THE FACE.

THEY KEPT ON WALKING,
UNTIL THEY FOUND AN OASIS,
WHERE THEY DECIDED
TO TAKE A BATH

THE ONE WHO HAD BEEN
SLAPPED GOT STUCK IN THE
MIRE ! AND STARTED DROWNING,
BUT THE FRIEND SAVED HIM.

AFTER HE RECOVERED FROM
THE NEAR DROWNING,
H E WROTE ON A STONE:

"TODAY MY BEST FRIEND
SAVED MY LIFE ".

THE FRIEND WHO HAD SLAPPED
AND SAVED HIS BEST FRIEND
ASKED HIM, "AFTER I HURT YOU,
YOU WROTE IN THE SAND AND NOW,
YOU WRITE ON A STONE, WHY?"

THE FRIEND REPLIED
"WHEN SOMEONE HURTS US
WE SHOULD WRITE IT DOWN
IN SAND, WHERE WINDS OF
FORGIVENESS CAN ERASE IT AWAY.
BUT, WHEN SOMEONE DOES
SOMETHING GOOD FOR US,
WE MUST ENGRAVE IT IN STONE
WHERE NO WIND
CAN EVER ERASE IT."

LEARN TO WRITE
YOUR HURTS IN
THE SAND AND TO
CARVE YOUR
BENEFITS IN STONE.

THEY SAY IT TAKES A
MINUTE TO FIND A SPECIAL
PERSON,
AN HOUR TO
APPRECIATE THEM, A DAY
TO LOVE THEM, BUT THEN
AN ENTIRE LIFE
TO FORGET THEM.

TAKE THE TIME TO LIVE!

DO NOT VALUE THE THINGS
YOU HAVE IN YOUR LIFE, BUT VALUE
WHO YOU HAVE IN YOUR LIFE!
AND IF I HAPPEN TO GET IT BACK,
THEN I KNOW MY PLACE IN YOUR LIFE

"Be kinder than necessary, for everyone you meet is fighting some kind of battle."
...AMEN TO THAT

Okay ... I am a big kid

Alright, I know I am a big kid, but I use to love the Transformers. I use to watch them everyday after school. One of my residents showed me this, so I had to share. First, you need to see when Optimus Prime died.



What would happen if they brought him back? This is hilarious.

It was hot ... they stopped the race ... but I finished

"Don't wait until everything is just right. It will never be perfect. There will always be challenges, obstacles and less than perfect conditions. So what. Get started now. With each step you take, you will grow stronger and stronger, more and more skilled, more and more self-confident and more and more successful."

~Mark Victor Hansen

I didn't decide to go to medical school until the second semester of my junior year in college. I knew it would take a lot of preparation and would be a long road. For many who decide to go to medical school, we realized we would have to sacrifice. It would be long road; but in the end, we would accomplish our ultimate goal. Whether it be to save lives, to save the world, or to have a stable income, our goals helped dive us forward into medical school understanding that we would lose countless hours of sleep, time with family, and about a decade of the most productive time of our lives. For many, the pure thought of competition is what drives us to succeed.

On Saturday, I was at the Chicago Marathon expo picking up my bib, chip, and T-shirt. there were people of all ages and sizes. All with a common goal, the Chicago marathon. Whether their primary goal was for a specific time and others for the spirit of completing, they were all there for the purpose of completing the 26.2 mile Everest. A video played on one of the screen showing the marathon from the previous year. It showed the winners sprint to the finish. Then, at the end of the video, the runners didn't have that thin marathoner build. They came in all shapes and sizes. They crossed the finish line at 5 or 6 hours, everyone so proud of completing their primary goal. I almost teared.

On Sunday, we all walked to our positions. I stood next to a man and we talked. The marathon bound us. The national anthem was sung. At the end, we all clapped. The starter sounds and the crowed moves forward. Everyone was smiling. That wouldn't
last for long. I was already sweating. Step, Step ... Breathe.

For me, medical school wasn't that hard. That is not to say I had an easy time with it, but the material itself was not that hard. It was just a lot of information. Some people in medical school buckle under the pressure. They study too much or too little. They don't pace themselves through the mentally trying time of medical school. You must understand your strengths and weaknesses. It is not a sprint. Mental stamina was required for survival.

Step, Step, .... Breathe. At the forth mile, I asked myself, Why? It is the same question that I ask every race. In a marathon, the question usually comes up somewhere between mile 16 and 22. This race it was at mile 4. I knew it was a going to be difficult and I adjusted my pace as well as water intake. I had a plan. You always need a plan. This was not the time to take risks. I knew this would not be a record setting pace. I just wanted to survive.

Residency was different problem. It was particularly demanding. There was both mental and physical fatigue. At times, you had to sprint; other times, the pace slowed and you were able to take in the scenery and enjoy your time.

Step, step .... breathe. At the half way point, I was in the shade. My legs felt good. I was still well hydrated. I decided to quicken my pace to my usual marathon pace. That lasted for 2 miles until the shade ended. I came to the realization that to finish was an accomplishment. I slowed my pace again and decided to enjoy the spectators. I high five'd the little kids and asked the crowed for more cowbell. At one point, I was running with a man from New Zealand. It was his first marathon. It was winter in New Zealand. So, this weather was rather brutal on him. We ran and talked about rugby. Then we somehow got split up.

Because of the harsh circumstances of the residency environment, I developed very close bonds with those in my residency and others from my internship. Had we not been in residency together, we may have never become friends. We all were very different. These differences ranged from our political views to religion to personal style, but the common bond of out harsh environment cemented relationships that survive to this day.

Step, Step .... Breathe. At mile 18, there were only 8 miles to go, but the heat was draining every ounce of mental fortitude out of me. I noticed that the general mood had changed. It was hot, there was no breeze, and no shade. The general flow of the runners went from a brisk pace at the beginning to almost a walk. I looked on as runner after runner looked for medical attention. It was more like a war zone than a race. There were IV bags hanging in the medical tents. I kept hearing the sirens of passing ambulances. Spectators attended to the fallen runners who did not make it to the aid stations. People showered the runners with the from their house. Spectators brought water from their own homes to help.

When I completed residency, I thought I was finished. I would get a job and everything would be right in the world. I would be like the normal people. I would be like the "humans" who had regular lives. I would take weekends like regular people. The competing would be done and I would sail off into the sunset completing all of my goals.

Step, Step ... Breathe. I passed the mile 25 marker. It was hot. A man shouted, "the race has been cancelled." I thought my hearing must be going. So, I kept running like Forest Gump. People continued to cheer on the runners. The finish line was different from what I remembered. This time I actually saw all of the people cheering the runners on. I heard people shouting, "Keep running ... You can do it ... Your almost there." I crossed the finish line again. It was more gratifying than before because the obstacles were greater.

Goals change as time goes on. My major academic goals accomplished, but I continue to be driven to find new adventures. As much as I like to challenge my mind, I also like to push my body to extremes. I have realized that normal is a dial on the washing machine. Normal for me is driving to the next goal or destination. It is what keeps me alive, what keeps me from getting stale.

I met up with my family at the meeting place. My kids were dirty from playing in the dirt. My daughter hands me a flower and gives me a hug. My son jumps in my arms. "I love you dad," my daughter says. We check out from the hotel and drive back home. In the car, we were already making plans for the next marathon. Step, Step .... Breathe.

"Courage is the discovery that you may not win, and trying when you know you can lose."
~Tom Krause

A failure to communicate ....

“To effectively communicate, we must realize that we are all different in the way we perceive the world and use this understanding as a guide to our communication with others.”
~Anthony Robbins

So the other day, I had an anesthesiologist decide a patient I had scheduled was too unstable for transport to the OR and the procedure should be done in the ICU with the ICU team providing sedation. Now, it had been 3 days since the initial injury and the patient had been stable and transported for several studies without event. For some reason, this person thought the the patient was too "unstable." So, I went to the family and discussed the recommendations. I spoke with the ICU attending about it. The ICU attending the proceeded to ask me questions about why it couldn't be done in the OR, yada yada yada. I informed him it was not my decision. He then spoke with this anesthesiologist. In the end, anesthesia came and provided sedation and everything was fine. Days later, another case, same anesthesiologist, I hear that the anesthesiologist is trying to do the same thing. This time it was dealt with without confrontation or actual communication. This person just avoided me and passed it off to someone else. Hmmm, I thought that was strange. The avoidance of communication makes it all better.

Last week, we help out with a procedure with a patient in a halo. My team had explained to me that the patient needed a PEG tube and the person doing it said that the front had to come off. He spoke with my brace person, my chief resident, and the nurse in the OR. I heard the needs, but the kid is in a Halo for a reason. We can only do so much as far as providing space for the PEG tube. They informed me that he was adamant that he needed the whole front of the abdomen free. They actually said he was a bit of an A_ _, but that is hearsay because I did not witness it. So, at the time of placement of the PEG tube, we were all there. I was watching the neck and supervising the adjustments to the Halo. You know he did not say one thing to me. Hmmm, go figure. Yesterday, I was walking down the hall and I see the same physician. As you do, I looked up, we made eye contact, and I say, "morning, how are you?" He keeps walking and says nothing. Now, I was pretty sure that he wouldn't say anything because he never does. But, I keep trying. (With hands up in the air screaming to the sky) We are all on the same team.

Today, I am going to a faculty meeting. I am getting off of the elevator. The door opens, and a team (I assume surgical) is standing 1 foot from the door. I try to get out as the team rushed to get in and a medical student, in his short coat, bumps me. Not a little bump, a full shoulder to shoulder hit. I say, "excuse me." Again, nothing in return. Now, I thought, "OK, I am not in my white coat, but come on this is common courtesy. We don't live in New York City." (No slight to my NYC fans) This got me thinking. Do we create these people believe that they are better than the next person because they may have a little more knowledge? Why is it that in medicine we lose our ability to effectively communicate to one another? Does it have to do with the inherent hierarchy of the medical field or does it have to do with the god complex that some people develop? Why can't we just be civil? Ok, that was way too many questions. Just some thoughts I wanted to put out there to see if anyone else has any answers.

“The single biggest problem in communication is the illusion that it has taken place.”

~George Bernard Shaw

Medical Blogging grand rounds .... 4.02

I have to say this was rather cleverly done. I wish I was this smart. Please take a look at Musings of a Distractible Mind. Dr. Rob is the host of grand rounds 4.02. It is cleaver and fun to read.

I love movies ....

I love movies. I love quoting movies. Do you ever have a movie that every time it is on you end up watching it? I have several. Mr. and Mrs. Smith, may be it is because it is always on cable and those two have some chemistry. Another is Silence of the Lambs, because Hannibal is such an evil character. But, one of my favorites is Aliens. Yeah, Aliens. Why? It is not for all the action, or Sigourney Weaver or the special effects. The reason why I love this film is Bill Paxton. He has the best set of comedic lines for a supporting character in a non-comedic that I can remember. I think his character is hilarious. I have even found a blog post about W.W.B.D (What Would Bill Do?). So, I thought I would share the awesome youtube tribute. ENJOY!

It is out .... SurgExperiences 105

SurgExperiences

SurgExperiences 105 was posted yesterday by Rlbates on her site Suture for a Living. It was excellently done. It is worth a look. Please take the time to look through all of the great surgical blogs across the world.