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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Effects of acupuncture on pain and inflammation in pediatric appendicitis

A paper [full text here] from The Journal of Alternative and Complementary Medicine says that "acupuncture may be a feasible and effective treatment modality for decreasing subjective pain and inflammation" in pediatric patients with appendicitis.

They studied six adolescents with appendicitis and administered acupuncture for pain control prior to surgery. Pain was assessed using three analog scales, and inflammation was measured using serial white blood cell (WBC) counts and C-reactive protein levels (CRP). CRP is a nonspecific indicator of inflammation in the body.

Figure 2 from the paper summarizes the results.

You can see that after 20 minutes of acupuncture, all three pain scores and WBCs declined. However, CRP continued to rise. Conspicuously absent from the figure and the text of the paper are any statistical analyses. This is due to the lack of a significant difference in any of these values because of the limited number of subjects studied.

The authors were undeterred and concluded "Although CRP as a general marker of inflammation stayed roughly the same on sequential blood draws, the median WBC showed a modest and noticeable drop. The implication of this finding is that the effectiveness of acupuncture may have a biophysiological basis." Look at the figure and decide for yourself if the WBC drop is really more noticeable than the CRP rise.

While the authors did mention some limitations of the study including the lack of statistics, they didnt discuss impediments to using acupuncture in patients who present to an emergency department. Whether patients were given antibiotics before or during the acupuncture session was not stated.

Even if the technique actually works [which is certainly not proven by this paper], how practical would it be to have an acupuncturist on call? Would she take in-house call? If not, how long would it take for her to get to the hospital? Would insurance pay for acupuncture? Would the acupuncturist be subject to work hours limitations?

The authors are not proposing acupuncture as a definitive treatment for appendicitis. So what is the clinical value of reducing inflammation? An even better way to reduce inflammation [and pain] is to remove the diseased appendix.

I know how difficult it is to publish papers and continue to do all the clinical and administrative work of an academic physician. As I have said on several occasions, many of my published papers were simply not very good.

But acupuncture to decrease inflammation in appendicitis patients? I doubt youll be seeing an on-call acupuncturist any time soon.

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What is an acceptable rate of VTE prophylaxis

According to the paper “Hospital Performance for Pharmacologic Venous Thromboembolism Prophylaxis and Rate of Venous Thromboembolism: A Cohort Study” that appeared online in JAMA Internal Medicine last month, a rate of 70% for all eligible patients is good enough.

The retrospective study looked at rates of prophylaxis for VTE at 35 Michigan hospitals.

Of the 20,794 eligible patients included in the analysis, 1,658 either died or were transferred to higher or lower levels of care leaving 19,136 evaluable patients, 226 (1.2%) of whom suffered a VTE during either the hospitalization or the 90-day follow-up period.

Based on rates of prophylaxis administered, the hospitals were divided into three groups with 85.8% of patients receiving adequate prophylaxis in high-performance hospitals, 72.6% in moderate-performance hospitals, and 55.5% in low-performance hospitals.

From the results section of the paper: "Compared with patients at hospitals in the highest-performance tertile, the hazard of VTE in patients at hospitals in moderate-performance (hazard ratio, 1.10; 95% CI, 0.74-1.62) and low-performance (hazard ratio, 0.96, 95% CI, 0.63-1.45) tertiles did not differ after adjusting for potential confounders."

The authors concluded that "Efforts to increase rates of pharmacologic VTE prophylaxis in hospitalized medical patients may not substantively reduce this adverse outcome."

Heres the problem. They defined adequate rates as patients receiving pharmacologic prophylaxis during 80% or more of hospital-days such as "1 of 1 dose for daily regimens, 2 of 2 doses for twice daily regimens, or 2 of 3 doses for 3 times daily regimens.”

This means that patients could be classified as receiving appropriate prophylaxis but miss nearly half of their doses. For example, a patient in hospital for 5 days who got 2 of 3 doses for 4 days and missed all 3 on one day would be classified as having received appropriate prophylaxis. Why do the authors give full credit for delivering such low quality care? Why is missing any doses acceptable?

Does missing doses matter?

"Yes," at least in surgical patients, says this JAMA Surgery paper "Correlation of Missed Doses of Enoxaparin with Increased Incidence of Deep Vein Thrombosis in Trauma and General Surgery Patients."

Missing more than one dose of enoxaparin increased DVT risk significantly, and the more doses that were missed, the more DVTs occurred.

Of the 202 patients studied, 119 (58.9%) missed at least one dose of prophylactic enoxaparin. The overall incidence of DVT was 15.8%, but 23.5% of the patients who missed at least one dose developed a DVT compared to 4.8% of patients whose prophylaxis was never interrupted. Patients were aggressively screened for DVT accounting for a higher incidence than most centers report.

Missing 2-4 doses increased the odds ratio of suffering a DVT to 8.49, missing 5 to 8 doses raised it to 10.13, and the odds ratio rose to 14.73 if 9-17 doses were missed.

Among all 35 hospitals in the internal medicine paper, the rate of DVT prophylaxis for eligible patients was only 70%. The authors of that paper seem to think that is not worth improving. Wouldnt 100% compliance be a better goal?

What do you think?

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Pain is not the 5th vital sign

No, contrary to what you may  have heard, pain is not the 5th vital sign. Its not a sign at all.

Vital signs are the following: heart rate; blood pressure; respiratory rate; temperature.

What do those four signs have in common?

They can be measured.

A sign is defined as something that can be measured. On the other hand, pain is subjective. It can be felt by a patient. Despite efforts to quantify it with numbers and scales using smiley and frown faces, it is highly subjective. Pain is a symptom. Pain is not a vital sign, nor is it a disease.

How did pain come to be known as the 5th vital sign?

The concept originated in the VA hospital system in the late 1990s and became a Joint Commission standard in 2001 because pain was allegedly being undertreated. Hospitals were forced to emphasize the assessment of pain for all patients on every shift with the (mistaken) idea that all pain must be closely monitored and treated .

This is based on the (mistaken) idea that pain medication is capable of rendering patients completely pain free. This has now become an expectation of many patients who are incredulous and disappointed when that expectation is not met.

Talk about unintended consequences. The emphasis on pain, pain, pain has resulted in the following.

Diseases have been discovered that have no signs with pain as the only symptom.

Pain management clinics have sprung up all over the place.

People are dying. In 2010, 16,665 people died from opioid-related overdoses, a four-fold increase from 1999 when only 4,030 such deaths occurred. And the number of opioid prescriptions written has doubled from 109 million in 1998 to 219 million in 2011.

Meanwhile in the 10 years from 2000 to 2010, the population of the US increased by less than 10% from 281 million to 308 million.

Doctors are caught in the middle. If we dont alleviate pain, we are criticized. If we believe what patients tell us—that they are having uncontrolled severe pain—and we prescribe opioids, we can be sanctioned by a state medical board or even arrested and tried.

Some states now have websites where a doctor can search to see if a patient has been "doctor shopping." I once saw a patient with abdominal pain in an emergency room. After looking up her history on the prescription drug website, I noted that she had received 240 Vicodin tablets from various doctors in the four weeks preceding her visit.

Thats a lot of Vicodin, not to mention a toxic amount of acetaminophen if she had taken them all herself during that month.

What is the solution to this problem?

I dont know, but as long as pain is touted as the fifth vital sign, I do not see it getting any better.

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