Facebook and unprofessional behavior among surgical residents

Have you ever wondered about the behavior of surgical residents on Facebook? I have. A study from the Journal of Surgical Education posted online in June 2014 looked at the issue.

The paper, "An Assessment of Unprofessional Behavior among Surgical Residents on Facebook: A Warning of the Dangers of Social Media," identified 996 surgical residents from 57 surgical residency programs in the Midwest and found that 319 (32%) had Facebook profiles.

Most (73.7%) displayed no unprofessional content, but 45 (14.1%) exhibited possibly unprofessional material. Clearly unprofessional behaviors were noted in 39 (12.2%) resident profiles. The paper said, "binge drinking, sexually suggestive photos, and Health Insurance Portability and Accountability Act (HIPAA) violations were the most commonly found variables."

There were no differences in the rates of unprofessional behavior between male and female residents or by postgraduate year.

I have blogged previously about the ill-defined nature of professionalism, and the papers authors acknowledged that it can be subjective. Some of the behaviors they felt were potentially unprofessional such as photos of residents holding an alcoholic drink, holding a gun while hunting, or making political or religious comments are debatable.

They referenced another paper that found similar rates of unprofessional behavior (16%) on Facebook among applicants to an orthopedic surgery residency program.

A 2005 New England Journal of Medicine case-control study found that practicing physicians disciplined by state medical boards were significantly more likely to have had documentation of unprofessional behavior in medical school as well as lower Medical College Admission Test scores and poorer grades in the first two years of medical school.

Unprofessional behaviors listed in the New England Journal paper were irresponsibility, diminished capacity for self-improvement, immaturity, poor initiative, impaired relationships with students, residents, nurses, or faculty, impaired relationships with patients and families, and unprofessional behavior associated with anxiety, insecurity, or nervousness.

Some of those seem a bit vague. Are diminished capacity for self-improvement and poor initiative really unprofessional behaviors?

Facebook unprofessional behavior and the unprofessional behavior documented in the NEJM paper which pre-dated the widespread use of Facebook may not be comparable.

But I suppose one could say that some of the Facebook behaviors could be categorized as immature or irresponsible.

Until stories about residents being rejected for jobs after training start emerging, there probably wont be a change in the way they use Facebook or other social media.

Or maybe society will change.

In 1987, politician Gary Hart had to withdraw as a candidate for the Democratic Partys presidential nomination because he had an extramarital affair, and just a few years later, the president himself had a dalliance with an intern in the White House and survived.

Who thought marijuana use would ever be legalized?

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Are today’s surgery residents poorly trained What can be done about it

A surgical resident writes

I’m sure you have read several recent studies suggesting that current general surgery residents are poorly trained and unprepared for independent practice at the completion of residency.

My questions for you:

1. In general, do you agree that current general surgery residents are poorly trained and unable to operate independently at the completion of residency?

2. What should we do differently? I personally don’t feel that “more simulation activities”, which many have suggested, is an adequate solution.

Thank you for the excellent questions.

I have been out of the surgical education loop for a few years and no longer have first-hand experience, but the literature does indicate that some surgical residency graduates are not ready to practice by themselves.

In 2013, I blogged about an Annals of Surgery paper reporting as many as one third of subspecialty general surgery fellowship directors felt that about one-third of incoming fellows were deficient in several areas and unable to independently perform a laparoscopic cholecystectomy or 30 minutes of a major case unsupervised.

Click on the table to enlarge it. You can see the responses of the program directors.

This paper was criticized by some because the fellowship directors surveyed were not subspecialtists recognized by the ACGME. The implication was that fellows in these programs might not be representative of all surgical graduates. However, many of them were minimally invasive fellowship programs which continue to be highly sought after.

Does it really matter? Some general surgery graduates apparently can’t operate by themselves.

In 2011, I blogged about a paper that reported 27% of all graduating surgical residents surveyed were not confident performing surgery by themselves. That was approximately the same percentage identified by the fellowship program directors.

Regarding what can be done about the issues of confidence and traing, I agree with you about simulation. You can simulate all you want, but being alone at 2 AM with a patient who is bleeding out cannot be adequately simulated.

The American College of Surgeons created a Transition to Practice Fellowship in 2013. They later change the name from a fellowship to a program. Of course, I blogged about this too. As far as I know, not many hospitals are involved. How many graduating residents have enrolled in this fellowship program is unknown.

Henry Buchwald, a prominent senior surgeon, recently advocated establishing “open surgery” fellowships and wrote, “I submit that it would behoove our training programs to return open surgery schooling to their curricula.” However, he doesn’t explain how this could be done or where one would go to do a fellowship and open surgery.

Life imitates art. In a post last year, I cited the visionary surgeon Leo Gordon who saw it coming in 2002. He predicted the need for a "macrolaparotomy" course, and said it could be run by the newly created "American Board of Open Surgery."

The lack of confidence stems from the gradual increase in supervision of residents over the last 15 to 20 years. In yet another blog post, I pointed out that many of today’s residents rarely if ever operate independently during residency training. To realize you are on your own as a full-fledged surgeon without ever having performed a case by yourself must be frightening.

With all the ACGME regulations, medicolegal concerns, and extensive scrutiny surgeons and trainees are subjected to, I don’t see this problem going away anytime soon.

All you can do as a surgical resident is to try to scrub on as many cases as possible and take care of as many patients as you can. With luck, you may have faculty who have enough confidence in themselves to allow you some autonomy and decision making in the OR and when managing patients pre-and postoperatively.

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OR delays Whos responsible and what can be done

Every two or three years, someone, usually a hospital administrator, decides that delays in operating room turnover time need to be looked into. A committee of 20 or 30 stakeholders (love that term) is appointed and assigns someone the job of measuring the time between cases and identifying reasons for delays. In years when turnover time is not being studied, first case starting delays are on the agenda.

In my nearly 24 years as a surgical department chair, one or the other of these issues was investigated at least 10 times. We were never able to conclusively determine the exact causes of delays or solutions to the problem, and we returned to business as usual.

An article in Anesthesiology News about a paper that looked at causes of operating room delays in over 15,500 cases at a single hospital got my attention.

The number one reason for delays was that the nurses did not have the operating room ready for the patient. Nursing also was responsible for the third most common cause "preop prep (IVs, meds, etc.)."

Surgeons were the reason for the second most common problem, "notes, consent, patient marking not complete." A few more of the top 10 included surgeons running two rooms, surgeon unavailable, and my favorite, "last case ended early." I’m not sure how a case ending early causes a delay in starting the next case. Usually we are blamed for underestimating the length of time we need to do an operation.

Anesthesiologists were cited for only one of the 10 most common reasons for delays—placement of an IV line or regional block.

Not surprisingly, the study was done by anesthesiologists using data they collected.

When I expressed skepticism about this on Twitter, I was accused of implying the research was fraudulent. Not so. Some of my best friends are anesthesiologists. In fact two of my medical school roommates became anesthesiologists. Fraud is not the issue. Its a matter of perspective.

For example when the nurses investigate OR delays, the problem never seems to be nursing.

Im not saying that surgeons dont cause delays. A task force once found that one of my surgeons was late for his first case every time he operated because he had to take his kids to school.

Another surgeon would disappear between cases and was always late for his next one. No one knew where he went. Some thought he may have been calling his broker or perhaps having an affair.

Here’s what the anesthesiologist researchers may have overlooked.

In effort to avoid delays, I would often ask for an anesthesia consult on complicated inpatients booked for surgery a day or two later. On nearly every occasion, the anesthesiologist who saw the patient was not the one assigned to do the case. The consulting anesthesiologist never said a certain lab test was necessary, but in the holding room, the one who was going to put the patient to sleep said it was. A spirited discussion, phone calls, and a delay ensued.

Sometimes a day surgery patient who arrived 2 hours ahead of schedule wasnt interviewed by anesthesia until the scheduled time of the case.

Then there was my patient whose operation was postponed for 6 hours because she had a piece of hard candy in her mouth when she got to OR. The anesthesiologist said it was the equivalent of having a full stomach. Read the full story here.

Can delays be shortened by working together? A 2014 paper in the Journal of Surgical Research by a surgeon and four anesthesiologists found that “various events and organizational factors created an environment that was receptive to change.” The authors were able to decrease their general surgery OR turnaround times from 48.6 minutes to 44.8 minutes, a statistically significant (p < 0.0001) but hardly clinically important difference.

Let me hear your experiences with OR delays.

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What can be done about letters of recommendation

Many surgical educators feel that letters of recommendation are not particularly helpful in evaluating applicants or predicting eventual resident performance.

Among the issues are lack of uniformity of content, excessive use of superlatives, reliability—if the writer is not known to the recipient—and more.

Even if the writers are well-known academic surgeons, the degree of their personal knowledge of the applicants is not always clear.

During an extensive Twitter discussion over the weekend, someone mentioned that in an attempt to deal with this problem, emergency medicine had developed a standardized letter of recommendation.

A recent paper from the EM Standardized Letter of Recommendation Task Force shows that there is still work to be done. From the abstract:

For the question on "global assessment," students were scored in the top 10% in 234 of 583 of applications (40.1%), and 485 of 583 (83.2%) of the applicants were ranked above the level of their peers. Similarly, >95% of all applicants were ranked in the top third compared to peers, for all but one section under "qualifications for emergency medicine."

Ive written before that deans letters are more like public relations press releases than accurate assessments of a students performance. You will rarely find negative comments in them. But another recent paper by a group of psychiatrists found that The presence of any negative comments in the deans letter yielded significant correlations with future problems. Further, those applicants with future major problems had significantly more negative comments in the deans letter than did those with future minor problems. Other factors such as USMLE scores, failed courses, letters of recommendation, and interviewer ratings and comments did not predict future problems.

These problems are not new. A 1983 New England Journal opinion piece about recommendation letters entitled "Fantasy Land" is remarkable for its validity even today. Here are a few choice quotes.

Its a land where everyone is "a pleasure to work with," has "excellent initiative," is "enthusiastic and conscientious," and possesses and "above-average fund of knowledge."

No one is ever poor, fair, or average; they are all "very good" or "excellent."

The author, Dr. Richard B. Friedman, said letters of recommendation were useless and advocated doing away with them.

A brief JAMA essay by Dr. Henry Schneiderman in 1988 called for more openness in describing students but acknowledged that negative comments were often "the kiss of death."

He proposed a new system of categorizing medical student performance. Here are just a few examples.



@AmirGharferi suggested this:

"Dr.G, do you feel comfortable writing me a strong letter?"
"No."
"Ok, Ill find someone who is."

That works if the student is aware enough to ask, and the faculty member is honest enough to say no. In my experience, even the most marginal of students can find someone—in addition to the dean, of course—to write a good letter.

I am no longer involved in the process of selecting residents. I have no suggestions.

What is your solution to this problem?

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Chance can turn a surgeon into a killer

Risk-adjusted 30- to 90-day outcome data for selected types of operations done by specific surgeons and hospitals are now being publicly posted online by Englands National Health Service.

According to the site, "Any hospital or consultant [attending surgeon in the UK] identified as an outlier will be investigated and action taken to improve data quality and/or patient care."

After cardiac surgery outcomes data were made public in New York, some interesting unexpected consequences were noted.

Surgeons and hospitals resorted to "gaming the system" by declining to operate on patients who were high-risk and tinkering with patient charts to make those they did operate on seem sicker. This can be done by scouring the charts for all co-morbidities and making sure none are overlooked when they are coded. An article from New York Magazine explains it in more detail.

Interpreting outcomes data can be tricky.

In a post three years ago about a report that nine Maryland hospitals had higher-than-average complication rates, I pointed out that whenever you have averages, some hospitals are going to be worse than average unless all hospitals perform exactly the same way or, like medical students, are all above average.

A much more sophisticated way of looking at this subject appeared in a fascinating 2010 BBC News piece by Michael Blastland, who is the Nate Silver of England [or maybe Nate Silver is the Michael Blastland of the US], called "Can chance make you a killer?"

Blastland set up a statistical chance calculator for a hypothetical set of 100 hospitals or 100 surgeons performing 100 operations each. The model assumes that every patient has the same chance of dying and that every surgeon is equally competent. The standard is that a mortality rate 60% worse than the norm set by the government for any hospital or surgeon is not acceptable.

You are assigned one hospital. Using a slider, you may choose an operative mortality rate anywhere from 1% to 15%. After you do this a number of times and recalculate for each mortality rate, you will notice that the number of unacceptably performing hospitals or surgeons changes randomly for each percent mortality and your hospital may appear in the underperforming group strictly by chance alone.

The whole concept is explained in more detail on the site. I encourage you to try it for yourself. The link is here.

So it may be difficult for the NHS to separate the true outliers from the unlucky surgeons who happened to fall outside the established norms.

What do you think about this?

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Can cholecystectomies safely be done at night

A new study from surgeons at UCLA found that laparoscopic cholecystectomies done at night for acute cholecystitis have a significantly higher rate of conversion to open than those done during daylight hours.

Nighttime cholecystectomies were converted 11% of the time vs. only 6% for daytime operations, p = 0.008, but there was no difference in the rates of complications or hospital lengths of stay.

The study, published online in the American Journal of Surgery, was a retrospective review of 1140 acute cholecystitis patients, 223 of whom underwent surgery at night.

The authors advocate delaying surgery until it can be done in the daytime, but this conclusion needs to be examined.

Although the percentage of gangrenous gallbladders was similar in both groups, it wasnt clear from the data how many patients were semi-elective and how many were true emergencies.

Operative procedure durations were 110.5 minutes for nighttime and 92.4 minutes for daytime cases, and 1.5 and 2.0 days elapsed respectively before the patients were taken to the operating room, both p < 0.0001. The hospital lengths of stay were similar at 3.7 days for the night group and 3.8 days for the day patients. The causes for these lengthy operations, delays in operating, and long hospital stays were not explained in the manuscript.

The authors acknowledged that patient follow-up was no better than 50%.

Unreported confounders such as variations in the level of skill of the surgeons or whether or not a resident did the procedure could have influenced the results.

Another recently published study from the University of Texas Health Science Center in Houston found that although there was a slight but significant increase in complication rates [mostly retained stones and superficial wound infections] for patients having cholecystectomies at night, conversion rates of day and night surgery were similar.

Durations of operations averaged about 80 minutes [a more realistic figure than those in the UCLA study] in both groups. Hospital lengths of stay were significantly shorter [2 days vs. 3 days] for the nighttime patients. The authors acknowledged that a limitation of their study was that severity of gallbladder disease was difficult to accurately assess.

The decision about timing of cholecystectomy for acute cholecystitis depends on the availability of operating rooms, the severity of illness, the presence of comorbidities such as diabetes, and the surgeons schedule and other responsibilities.

Most surgeons agree that the sooner patients with acute cholecystitis undergo surgery, the more quickly they will recover and get back to normal activities.

In my own practice as a solo community hospital surgicalist taking care of emergency cases only, any patient with acute cholecystitis who I was consulted on before 6 or 7 pm had surgery that same night if an OR was available. If not, they always had the operation within 24 hours. The length of stay (LOS) averaged under 48 hours and the median LOS was 1 day.

Because one of the two hospitals involved in the UCLA study is a major trauma center in Los Angeles, the papers findings may not apply to other institutions where nighttime OR availability may be better.

Based on these papers, surgeons and patients should not be wary of undertaking cholecystectomies during evening hours.

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The ultimate resident evaluation

It comes as no shock to me, and probably many other current and former program directors, that a recent study showed faculty overall performance evaluations of residents do not correlate with their scores on the yearly American Board of Surgery in Training Examination.

According to the JAMA Surgery paper, faculty evaluations encompassed technical skill and the six core competencies—medical knowledge, patient care, interpersonal and communication skills, professionalism, practice-based learning and improvement, and system-based practice.

The paper analyzed data for 150 residents at different levels of training over 4 years and also found that even faculty evaluations of the category medical knowledge couldn’t predict who would get a good or a bad score on the test.

It’s great to know that at the authors’ institution, the average annual evaluation scores ranged from just over 75 to 100 with means and medians both slightly above 92—like Garrison Keillor’s mythical Lake Wobegon, “where all the women are strong, all the men are good looking, and all the children are above average.”

Medical knowledge can be measured, but the other parameters are so subjective that they border on meaningless. They remind me of the infamous “smiley face” numerical pain scale that means different things to different patients.

Some examples. Earlier this year, I wrote about the difficulty defining professionalism. Using a numerical scale, how can you rate one resident as more professional than another?

And I always had trouble ranking one resident over another in system-based practice. It might be better to rate system-based practice on a binary scale; that is, can a resident define the term or not?

Big business is having trouble evaluating employees too. The evaluation process at General Electric was examined by Quartz. At GE, the annual review is not effective for managing people or improving performance. “It leads to a tendency…to focus excessively on process over outcomes” and is “an exercise in paperwork and bureaucracy instead of an agent of change.”

Note that the JAMA Surgery study accumulated 1131 evals. Even if that was only virtual paperwork, it’s much work for little value, but at least there was a lot of data to show a site visitor from the Residency Review Committee.

A New Yorker article noted that consulting firm Deloitte’s evaluation process involves consensus meetings ending with managers marking on a 5-point scale how strongly they agree with two statements: “Given what I know of this person’s performance, and if it were my money, I would award this person the highest possible compensation increase and bonus;” and “Given what I know of this person’s performance, I would always want him or her on my team.” And they must answer yes or no to two more: “This person is at risk for low performance,” and “This person is ready for promotion today.”

Maybe we should adopt a modification of Deloitte’s system for our resident evaluations. Faculty must respond yes or no to this statement: “I would let this resident operate on me.” If the answer is “no,” why should we let that resident operate on anyone?

This post originally appeared on Physicians Weekly.

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An intraoperative leak test should not be done or should it

Here is an abstract recently published ahead of print in the American Journal of Surgery. Please read it because a one-question test follows.

Introduction: Staple line leak after sleeve gastrectomy (SG) is a rare but dreaded complication with a reported incidence of 0-8%. Many surgeons routinely test the staple line with an intraoperative leak test, but there is little evidence to validate this practice. In fact, there is a theoretical concern that the leak test may weaken the staple line and increase the risk of a postop leak.

Methods: Retrospective review of all SG performed over a 7-year period. Cases were grouped by whether an intraoperative leak test (IOLT) was performed, and compared for the incidence of postop staple line leaks. The ability of the IOLT for identifying a staple line defect and for predicting a postoperative leak was analyzed.

Results: 542 SG were performed between 2007-2014. 13 patients (2.4%) developed a postop staple line leak. The majority of patients (N=494, 91%) received an IOLT, including all 13 patients (100%) who developed a subsequent clinical leak. There were no (0%) positive IOLTs and no additional interventions were performed based on the IOLT. The IOLT sensitivity and positive predictive value were both 0%. There was a trend, although not significant, to increased leak rates when a routine IOLT was performed versus no routine IOLT (2.6% vs. 0%, p=0.6).

Conclusions: The performance of routine IOLT after sleeve gastrectomy provided no actionable information, and was negative in all patients who developed a postoperative leak. The routine use of an IOLT did not reduce the incidence of postop leak, and in fact was associated with a higher leak rate after SG.

Do you agree with the authors that the routine use of the IOLT was associated with a higher leak rate after sleeve gastrectomy?

I dont, and heres why.

As I tend to do whenever I criticize a paper, I begin with a confession that I have written a lot of marginal papers in my time. Its one of the reasons I maintain my anonymity.

A "trend" has no scientific validity. A comparison is either statistically significant or it is not. Many scientists and statisticians have rightfully criticized our blind faith in p values, but they remain a standard way of comparing research results. That discussion is for another time. Let’s face it—p values will be around for a long time.

The claim that there was a trend toward an increased leak rate with IOLT was based on a difference of 2.6% among 542 subjects. Even if one believed in trends, the p value of 0.6 clearly indicates that there is no difference between the two percentages. Many authors get away with stating that trends exist when p values are 0.051 or 0.06. Thats still debatable, but at least close to the magic p of < 0.05.

I was never a big fan of intraoperative leak testing and agree with the authors finding that postoperative leaks can occur when the IOLT was negative. As they mention in their discussion, leaks often present long after the date of the operation and may be caused by ischemia, cautery injury, or other factors not readily identifiable by an IOLT.

Because the authors didnt find a single leak by doing the IOLT in 494 cases, they suggest that an IOLT is not necessary. But what if they had found one leak and fixed it. Would that have changed their conclusion?

I wonder if everyone at their institution has stopped doing IOLTs.

PS: Don’t just read the abstract; read the whole paper.

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So Many Scams So Little Time! by Marc Charles

So Many Scams -- So Little Time!

12:04 PM
Owls Head Maine

 

Question from a subscriber: 

Im frustrated.  Ive spent a small fortune on every conceivable home business opportunity and online money making deal. 90% of them are a joke! Most Internet marketers are nothing more than shills and hucksters. I value your opinion and insight...and every time youve recommended something its been valuable. Is anything legitimate these days?


Dear Friend:


Wow.....I enjoyed your email! If you apply this attitude to business youll make a fortune!

But first I need to defend my fellow hucksters and business opportunity salesmen.

Im serious.

Yes......there are cons, shills, crooks and everything in between in the world today. I could devote a dozen books to all of the crooks Ive met in my life and in business.

Ironically, it was one such con artist where I had the most fun in business. I was young entrepreneur but I couldnt believe how resourceful this guy was. In one business venture this guy started offering handguns as premiums! And it worked! The stupid phone rang off the hook for two weeks straight.

Anyway, the problem is not finding legitimate business opportunities or money making ventures.

You could STOP ordering books, courses, tapes, DVDs, special reports, newsletters, conferences, eBooks, webinars and everything in between today, and you would have all of the information you need to run a profitable business and make money.

Im not kidding.

You need to stop looking for "the secret" formula. The "secret" formula does not exist. There is NOTHING new under the sun.

What you need to acquire is wisdom and understanding.

95% of what you buy from someone else will not impart wisdom and understanding. This is a BIG lesson to learn.

I encourage people to look for the "essence" of a business opportunity or money making venture.

The "essence" is what you really need to make a business go.

And ironically...."essence" is the one thing which is not available when you buy or start a business.

Now...this doesnt mean people cant or wont help you.

This blog is a good example. Im not charging a nickel for this wisdom. Im also willing to help almost anyone who has PROVEN they have a passion to learn.

But when you order information products, books, courses and the rest......look for the "essence".

When you understand the "essence" of a business or money making formula, and YOU APPLY this understanding...you will gain wisdom.

Its a big deal.....and this is 100% true and accurate.

I hope that helps!!

I look forward to hearing from you.

Regards,

Marc Charles
Fellow Huckster

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Used Car Dealerships Done Right by Marc Charles

10:06 AM

Greetings:

Im reposting a question I received recently about my views on used car dealerships.

I thought you would enjoy this....

Feel free to post your comments!

Marc




Question: Im thinking about starting a used car dealership. Ive researched 23 comparable used car dealerships in my state over a three year period. Ive also been involved in the industry at several levels - but never as a owner principle. Im not over extending myself with debt and inventory...in other words Im starting really small. My question is in this economy, which I think is a depression, am I nuts?
A.V. Scottsdale AR


Answer Marc Charles:

Most of the people and entrepreneurs I meet with rarely do the research and due diligence youve done. Im serious. Most people are in too much of a hurry to start a business, and most people bite off more then they can chew.

But, as Ive mentioned in my newsletters, columns and The Liberty Street Letter, a nieghborhood used car dealership can be a very wise choice, especially in a depression.

New car dealerships are dropping like flies, downsizing, and just trying to survive until the next bull market arrives. The next bull market in new cars may be ten years down the road..or longer.

Whats more, most new car dealers are expanding their used car inventory....in a big way, because thats what people want (and can afford).

A small neighborhood used car lot with an Internet division, could do extremely well.

Obviously if you can offer reasonably priced services like financing, repair, sound system installation, interior repair and upgrades (like carpet and seats).....you should do extremely well.

On top of that, youll be competing with the huge auto mall superstores (with dedicated Internet divisions and wholesale auction access)....but who cares! Most of these guys will be ghost towns if the depression persists...which I think it will.

And by the way, you can run commercials just like they do on YouTube...FREE!

So...no I dont think youre crazy. In fact, please keep me posted. I put you on my list for buying a car!


Marc Charles

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