Whats with pre med students shadowing a doctor

Many medical schools are either requiring or highly recommending that applicants show evidence of “shadowing” [following a doctor around] for varying periods of time. This supposedly gives a pre-med student an idea of what doctors do. I guess the schools assume that if someone has shadowed a doctor and still wants to become one, that individual is a better candidate for medical school than someone who hasnt done any shadowing.

A recent incident at a hospital in Syracuse, New York raised some serious concerns about shadowing. An anesthesiologist allowed a college student to endotracheally intubate a patient in the operating room. This was a problem on many levels. Students who are shadowing are not supposed to touch or examine patients. The patient who was intubated likely did not know that an unlicensed college student would be doing a procedure on him. And of course, theres HIPAA.

According to the article, the director of Consumers Unions Safe Patient Project, called the incident an "egregious violation of patient-doctor trust."

Ive had a problem with shadowing for many years, and Im not the first to say so. Dr. Elizabeth Kitsis, director of bioethics education at Albert Einstein College of Medicine in New York, has blogged about the topic.

She told of a male pre-med student who was introduced to patients as a "student doctor" and watched a gynecologist perform pelvic exams. The student himself said he felt a little awkward. One wonders how the unsuspecting patients would have felt had it been known he was a college student thinking about becoming a doctor.

There were many comments pro and con on both Dr. Kitsiss blog and a follow-up piece that appeared on another Einstein blog.

Dr. Kitsis co-authored a paper which found that few studies have looked at shadowing by pre-med students. She called for guidelines and a code of conduct for this activity.

Several questions come to mind.

With all the information available on the Internet, is shadowing really an effective way for college students to decide whether to become physicians or not?

Is there any research comparing career outcomes of pre-med students who shadowed doctors to those who did not?

What about the patients? Do they have any say in this? Are students who shadow introduced as who they really are?

How does a student choose a doctor to shadow? As far as I can tell, there is no quality control for this aspect of shadowing.

Is shadowing mandatory in other fields? Must one shadow before becoming an engineer [civil, railroad, or sanitation], an accountant, a fighter pilot, a shepherd, or an exotic dancer?

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It wasnt like this in my med school

When I was a medical student, we had to practice drawing blood on our lab partners. I remember the first day we did it. One guy fainted as he was having his blood drawn, and another fainted while he was drawing someone elses blood.

Weve made a lot of progress in medical education since then. In 2015, teaching blood drawing, which is going to eventually be taken over by robots anyway, is passé.

Students are suing a Florida sonography school because they were forced to perform transvaginal ultrasounds on each other almost every week. Those who complained were allegedly told to “find another school if they did not wish to be probed” said an article in the Washington Post.

While that seems out of line, it pales in comparison to allegations lodged against a former US Army doctor who ran a company that taught battlefield medicine to soldiers and made more than $10.5 million in the process.

According to Reuters, he gave students alcohol and drugs, including ketamine, a powerful hypnotic used as an anesthetic. Sometimes alcohol and ketamine were given at the same time.

Trainees were told to insert urinary catheters into each other, and two students underwent penile nerve blocks. On another occasion, when students balked at receiving penile blocks, the doctor had the students perform a penile nerve block on him. Its not clear what a penile nerve block has to do with treating wartime casualties.

If thats not troubling enough, he supposedly ran what he called "shock labs," during which he drew blood from trainees, observed them, and gave their blood back to them.

But wait, theres more. The doctor is alleged to have had a few beers with a student and examined, manipulated, and photographed the students uncircumcised penis.

The doctors claim that his methods are standard in Virginia medical schools was refuted by experts quoted in the Reuters piece.

The Virginia Medical Board has suspended the doctors license and will hold a hearing on June 19.

And we thought sticking each other with needles was traumatic.

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More about offshore med schools and residency prospects

Back in April, I blogged about the prospects for graduates of Caribbean medical schools matching in categorical surgical positions and estimated that graduates of two of the more prominent Caribbean schools, St. Georges and Ross, had a 2.5 to 3% chance.

What about some of the other Caribbean schools? Hard data are difficult to obtain since most of the schools do not publish match statistics, and in particular, the number of graduates who dont match in any specialty.

Here is what one recent commenter on that April post had to say:

My girlfriend studied at University of Medicine and Health Sciences (UMHS)-St.Kitts in the Caribbean. She is a very hard worker and studied well. All of my savings are gone and extra bank loans add up. No match, no residency, and no more hope. Applied for medical lab tech and waiting. In my opinion, IMG is not an option, try local medical schools and if not try something else.

The UMHS website says 59 of its graduates matched in a specialty in 2014, 2 in preliminary surgery and 2 in general surgery, presumably categorical. The number of graduates of UMHS is not listed although the school apparently has three graduations per year reflecting its three different starting dates for students per year.

Another school, Medical University of the Americas on the island of Nevis, had about 90 matched graduates for 2014, 2 of whom obtained positions in surgery—both preliminary.

An additional commenter on my April post, who turned out to be the owner of a different Caribbean school, said this:

Caribbean medical school is best platform and nice and informative….. Successful communication is key in every successful business…. Understanding your subject and having good knowledge on your blog topic is always essential for a successful blog… Thanks for this post…..

Normally I would have blocked this comment as spam, but before I did so, I googled his school, the American Global University School of Medicine, located in the Central American country of Belize. The International Medical Education Directory lists its total enrollment as 100 students. The schools website does not provide any details about match results for its graduates or much of anything else, such as names of faculty or specific hospitals where students do clinical rotations in the US.

I found some other interesting links—too many to list here—about the school, its officials, and its standing in Belize. You would be wise to google it too, or you can see some links in my comment to the schools owner on my April post.

If you have any interest in attending this or any other school not accredited by the Liaison Committee on Medical Education (LCME), you should do a thorough Internet search before going ahead with an application. Do not send money unless you are certain that the school is legitimate and that most of its graduates are obtaining residency positions.

Keep in mind that the number of residency slots available for international graduates will decline even further over the next few years because several new US medical schools will be producing graduates, and many established schools have expanded their classes.

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Review courses and board exams

Four years ago, I wrote a post called "Hints for new residents." Among my 15 tips was this: "Read, read, read. This isnt like school. You cant cram for your boards. You can’t learn 4 or 5 years’ worth of material in a one-week review course. You have to learn it as you go along."

Just published online in the journal Surgery is a paper entitled "Review courses for the American Board of Surgery certifying examination do not provide an advantage" by four officials from the board.

They surveyed new surgeons who took the certifying (oral) exam, 1067 for the first time and 329 who had previously failed the test, during the time period from October 2012 through June 2013. The overall response rate was 90%.

The pass rate for first-time takers was significantly better than that of repeaters, 82.1% and 72.6% respectively, p < 0.001; 77.9% of all examinees took a review course—76.1% were first-time takers compared to 84.6% of those repeating the exam, p = 0.002.

From the paper: "The overall CE [certifying exam] pass rate did not differ between those who did and those who did not participate in a review course (82.7% vs. 78.9%; p = 0.22)."

The results were controlled for sex, US or international med school graduate, written board exam scale scores, average written board scores over the last five years for the candidates program, and size and type of program.

The review courses were also analyzed, and the authors found that attending any one of the specific courses failed to predict passing the certifying examination. The only significant predictor of passing the certifying exam was the scale score of the candidate on the written examination.

The authors concluded: "On the basis of this survey, there was no evidence that participating in a board review course provided a benefit to passing the CE of the ABS."

The work was presented at a meeting, and the transcribed discussion was also published. The assigned discussant, Dr. Michael Nussbaum, said, "As a long-term program director, I really strongly believe that preparation for the CE is a 5-year process, not something that can be taught in a short course or crammed for."

I am pleased that the board and the discussant agree with what I said four years ago.

However, it is not clear from this paper that review courses are of no value when preparing for the written board examination. The paper said the score on the written examination correlates with passage of the oral examination. If a review course a helps candidates pass the written exam, then indirectly, a course might have a positive effect on the outcome of the oral exam.

Another problem with the paper is its failure to separate prep courses for the written and oral exams. One would not expect a course directed at the written exam, which is more of a multiple choice test about remembering facts, to help with the oral exam, which focuses on a candidate’s judgment and maturity in managing hypothetical patients.

The authors noted that only 29% of candidates for the boards in took review courses in 1990, and the courses are expensive.

Should the nearly 80% of candidates who took courses 2 years ago not have done so? Unfortunately, this paper does not conclusively answer the question.

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Is the surgeon still captain of the ship

A Kentucky appeals court ruled that a surgeon was not responsible for a burn caused by an instrument that had been removed from an autoclave and placed on an anesthetized patients abdomen.

According to an article in Outpatient Surgery, the surgeon was not in the room when the injury occurred and only discovered it when he was about to begin the procedure.

An insufflator valve had been sterilized and was apparently still hot when an unknown hospital staff member put it down on the patients exposed skin. [An insufflator is a machine that is used to pump CO2 through tubing into the abdomen for laparoscopic surgery.] When the doctor saw the mild second-degree burn, he asked what happened, but "but no one in the OR claimed any knowledge or responsibility."

The hospital had settled the suit on behalf of its staff, but the surgeon, who as a private practitioner had his own malpractice insurance, held out. The original lower court ruling dismissing the suit against him had been based on the plaintiffs lawyers failure to prove that the surgeon was responsible for the actions of the hospital staff.

In December 2012, I wrote a post stating my opinion that activities such as counting the sponges during an operation were not the responsibility of the surgeon. Many who commented on the post were highly indignant that I could suggest such a thing.

I wrote another post last year on the subject in response to another surgeons blog entitled "Everythings my fault: How a surgeon says Im sorry." I felt that many things that happened to patients were beyond the control of the surgeon. Most of the comments agreed with me.

I keep hearing that medical care has become a team sport. If thats true, then the surgeon, like everyone else, is simply a member of the team. People on teams have different roles and must execute properly for the team to succeed.

One of the most interesting things about the case in question was that none of the OR team members had any idea how that hot insufflator valve found its way to the patients abdomen.

One thing we know for sure, at least in Kentucky, is that a surgeon is not legally responsible for everything that happens to a patient in the operating room, particularly when he is not even present.

Is this decision the first nail in the coffin of the "captain of the ship" doctrine?

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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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Another Caribbean med school graduate needs advice

I did not attend St. Georges, Ross, or Saba. I chose my school because it has a premed program which leads to an MD program. My USMLE Scores on Step 1 and Step 2 CK are above 230.

I did not apply for the 2015 match because I did not have my step 2 CK results until November. It would have been too late. I could have rushed my step 2 but I wanted to get a good score and be a solid applicant. Also I would not have been able to complete my surgical electives in time to get letters of recommendation. At some point, I will be doing research at [a very well-known medical school]. I felt that for these reasons this would make me a better applicant the next year.

Since graduating I have been trying to find a medical related job (scribe) but have had no success. I have reached out to many institutions regarding research opportunities but have come up dry. I may be able to secure a volunteer research position by next month. Do you have any suggestions for me? I knew I would hate being out of the medical field for this long but this was my best bet. Does this gap hurt my chances?

I am concerned that despite your excellent USMLE scores, taking a year off from clinical medicine may cause your application to be rejected immediately. I do not know if a 9 week research elective, even at a premier med school, would be enough to offset your lack of clinical experience over the entire year. Acting as a scribe would not be considered clinical experience.

Another issue is what is the record of your school regarding matching graduates into surgical programs? Since you didn’t tell me your school’s name, I cannot give you any insight into that situation. Even if I did know the school’s name, it may not have published its match results.

To answer your specific questions:

How many gen surg programs should I apply to? I was thinking ~100. That seems reasonable. You should be able to gauge your chances better after you see if you receive any offers for interviews from the 100 programs.

During a gen surg interview, should I be open about my backup specialty? I would advise you to say that you would take a preliminary spot in general surgery if you didn’t match in a categorical position. Admitting that you would do internal medicine is often seen as a lack of commitment to surgery.

Most hospitals I am looking to apply are IMG friendly. Which means the surgery and medicine programs are both IMG friendly. Would it be a bad idea to apply to different specialties at the same hospital? I think it would be a bad idea. I suggest you wait and see if you get interviews from the general surgery programs. If you don’t, then there would be no problem applying to internal medicine at the same place. I doubt very much that the two services would talk about any specific applicants. Most surgery programs get hundreds of applications and those applicants who are not offered interviews are not remembered.

Some readers may have other opinions. I hope they will comment.

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Dr Topols bad day

Dr. Eric Topol is a cardiologist, author, editor-in-chief of Medscape, and genomics professor. In 2009, he was named one of the 12 Rock Stars of Science by none other than GQ magazine.

But even rock stars occasionally have a bad day. After blogging for almost 5 years, I sometimes have trouble thinking of things to write about. This apparently happened to Dr. Topol the other day. He published a Medscape article with an accompanying video about how doctors are being squeezed by many outside forces that require them to do things they dont want to do.

It was kind of a rambling discourse in which he suggested that doctors should offload the responsibility to do these "more mundane aspects of care" to the patients. He thinks this would make medicine more exciting "the way it used to be."

Dr. Topol offered this cartoon to illustrate the outside forces that are squeezing doctors.

Genomics is a focus of Dr. Topols research, but I dont think a lot of doctors are concerned that they lack knowledge about it.

His post created a lot of controversy prompting Medscape to take down all of the comments.

With great foresight, one physician, Dr. Kristin Held, preserved her comment with a screenshot which I have thoughtfully provided for you below.

What do you think she really wanted to say with the start of her second paragraph? Could it have been "How about growing a _ _ _ _ of _ _ _ _s?

Like Dr. Held, I have no idea which of the "mundane aspects of this new world" Dr. Topol had in mind to offload on the patients. Of the 16 forces squeezing doctors that he illustrated, I dont see many of them being taken over by patients. They already control patient satisfaction and whats written on Yelp. Maybe they can cover the lack of genomic knowledge too.

Its sad that an influential doctor like Topol is so lost in the woods. However, the bright side is that gave me something to write about.

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What about activity restrictions after surgery

Although, uncommon, bleeding after surgery is the most common potential post-operative complication. To minimize the chances of this occurring, patients are advised to be as minimally active after surgery as possible. This includes activity restrictions such as:
No bending or heavy lifting
No rigorous exercise or exertion
Do not make important plans in the days immediately following your surgery

The above instructions appear on the website of a medical school department. The operation in question is

A. Cholecystectomy
B. Partial mastectomy
C. Inguinal hernia repair
D. All of the above
E. None of the above

Answer: E. None of the above. While all three of the operations mentioned could have been the subject of these activity restrictions, they were taken from a dermatology services description of the aftercare of Mohs surgery, which is a way of exercising skin cancers—not exactly major surgery.

This topic was suggested to me by a Twitter follower.



I told him that as far as I knew, there is no evidence basis for any of the activity restrictions we tell patients.

When I was a resident in the early 1970s, we kept patients who underwent inguinal herniorrhaphy in bed for no fewer than five days, and nephrectomy patients were bedbound for a week.

For the former, the theory was that early activity might disrupt the repair—implying that many repairs were tenuous in those days. Regarding nephrectomy, the prevailing wisdom was that the tie or ties on the renal vein could be dislodged by increased pressure in the inferior vena cava from something as trivial as a Valsalva maneuver. Following this logic, we should have prevented nephrectomy patients from coughing or having bowel movements too.

Since then, progress has been made. Hernia patients are discharged on the day of surgery, and nephrectomies are not kept in bed.

What is the definition of "heavy lifting"? It is usually described as lifting more than 10 lbs. Where did that come from? Other than 10 being a nice round number, I cant think of another reason.

A far-from-exhaustive literature search revealed no evidence-based studies and nothing at all pertaining to general surgery.

A 2008 opinion paper suggested that cardiac surgery patients who have excessive limitations on their activities might suffer excessive anxiety and depression leading to poor outcomes. They recommended that patients be given "personalized activity guidelines developed by an exercise specialist to help them resume their presurgical lives."

Activity restrictions after gynecologic surgery are also not evidence-based. A review from the University of Utah found no studies relating postoperative activity and surgical success. A previous survey had found "Depending on the surgery, 88-99% of surgeons restricted lifting for mean of 5–7 weeks (range 1–26 weeks and up to forever [?] after vaginal hysterectomy with vaginal repairs)."

In 2011, an expert panel said patients undergoing laparoscopic supracervical hysterectomy should avoid lifting more than 10 kg, bicycle riding, and vacuum cleaning [?] for two weeks.

At the other extreme is the story of Ryan Callahan, a forward for the Tampa Bay Lightning of the National Hockey League. Last May, he began practicing three days after a laparoscopic appendectomy and played in a playoff game two days later.

To put it mildly, the topic of postoperative activity restrictions is long overdue for prospective study.

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Should I go to med school

A young man writes

I am thinking about pursuing medicine as a career. However, it is not something that I am entirely sure of because of the changing healthcare landscape.

Suppose I enter medical school at age 26. Four years later I have my MD. Five or six years later I will be done with a surgery residency and two years after that with my fellowship. I will 37-38 years of age with kids, a wife, and most likely a home. My kids will be around 9-11 years of age. In addition, I will be near $250K in debt from medical school because of interest accumulated throughout my residency and fellowship. This is of course not including retirement, car, house, investment, and kids’ college savings.

My friends tell me not to think about it, but if I don’t, I can end up in a position that I don’t want to be in. Even if I pay off my debt at age 50, I still have all those other things to address. And even if I do, when will I enjoy my money? What is perhaps most important though, is the time component. I am essentially giving up my entire life to a profession that will not allow me to transfer laterally to other professions if I choose to. I can be pursuing my other interests in the time that I would be becoming a surgeon such as business or engineering.

Lastly, I grew up in poverty and have no financial assets. It will take me years to accumulate wealth. And once I do (at around age 60), that wealth will be passed down to my children.

Did I miss something? What are your thoughts? 

While rereading and editing your email, I realized you did miss something. Whats missing is enthusiasm for becoming a doctor. You listed several reasons not to go to med school, but nothing about why you want to do it. If you don’t truly love the idea, you will be very unhappy.

I think you need to reassess your future.

For those who want more information, I have written a couple of posts about questions related to this one [links here and here.] The comments on the more recent post are worth reading..

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So you got into medical school… Now what

"So you got into medical school… Now what?" is a book written by Dr. Daniel R. Paull, a recent med school graduate. His aim was to inform newly matriculating medical students about what to expect and how to survive. For the most part, he succeeds.

The first four chapters are a bit on the dry side because Dr. Paull tries to simplify such complex things as how to live with anxiety in the first two years of medical school. He also spends a bit too much time on how to study. I agree with him that studying in medical school differs from studying in college, and that sticking to a schedule is a sensible way to organize time. However, I think that most people will figure out what works best for them on their own.

The book picks up steam starting with Chapter 5 on how to prepare for USMLE Step 1. I get a lot of questions about USMLE, and with no recent experience, I sometimes find them difficult to answer. Dr. Paull takes care of that quite nicely.

The remaining chapters offer plenty of practical advice on transitioning to the clinical years, clerkships and how to arrange them, studying for the two parts of USMLE Step 2, the fourth year of medical school, and finally how to arrange and succeed in the all-important residency interview process.

Regarding clerkships, Dr. Paull wisely recommends that students ask their residents and attendings for feedback during the rotation instead of waiting until the end to find out that their performance was not up to par. He gives some specifics like asking for feedback about H&Ps and presentations and how to improve on them.

The pros and cons of away rotations are discussed in some detail and should help any student who is conflicted about whether to do one or not.

He explains how the National Resident Matching Program works and offers some hints about ranking programs which echo similar comments I have made on this blog.

The book is in trade paperback format and inexpensive at a list price of $19.95. Its also available in a Kindle edition.

My only other criticism of the book is that Dr. Paull relies a little too much on an alarm clock about to go off or going off as a way to introduce a challenge he is trying to help students deal with.

Why should we believe anything Dr. Paull says? Well, he has a bachelor of science degree in physics from New York University, graduated from the University of Miami School of Medicine, and is currently an orthopedic resident at the University of Toledo in Ohio. In case you hadnt heard, orthopedic residencies are highly competitive.

Also, I have read the book myself and think most med students will find value in it.

Disclosure: I received a complimentary copy of the book from the author.

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