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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Problems with surgical residents and continuity of care

How are we doing with residency training and continuity of care? Not too well if you believe a recent paper called "Continuity of Care in General Surgery Resident Education" appearing online in the American Journal of Surgery.

A group from Rush University in Chicago looked at the records of 228 patients who underwent commonly performed operations during the year 2012. They found that in only 21/228 (9.2%) of cases had the operating resident seen the patient preoperatively, and in 20/223 (9.0%) had the operating resident seen the patient in postoperative follow-up. In no case, did the operating resident see the same patient both pre- and postoperatively.

The table lists the type of cases and the frequency of resident participation in preoperative care or postoperative follow-up.

This is important because on page 18 of the Residency Review Committee (RRC) for Surgery Program Requirements for Graduate Medical Education in General Surgery, the following is stated:

A resident may be considered the surgeon only when he or she can document a significant role in the following aspects of management: determination or confirmation of the diagnosis, provision of preoperative care, selection, and accomplishment of the appropriate operative procedure, and direction of the postoperative care.

If you interpret this literally, in not one of the 228 cases that were done was the resident who performed the procedure entitled to consider herself the surgeon for purposes of taking credit in the eyes of the RRC.

Continuity of patient care is also part of the professionalism core competency.

This is not the first paper describing this problem, nor is it the first paper to find that no residents followed a single patient all the way through the process.

What is the cause of this problem? Its not the length of the rotations because the shortest rotation for a senior resident was six weeks which should have afforded the residents ample time to have established complete continuity in at least a few cases.

The authors should be commended for their candor in reporting these findings. Had their paper been published 20 or 25 years ago, their program would have been cited by the RRC for a deficiency in continuity of care.

It’s an even bigger concern in community hospital surgical programs where the majority of elective patients come from private practice offices.

Whats the solution? The easiest fix would be to change the RRC requirement. What is the point of having a rule that cant be followed?

The residents are not learning about making the diagnosis, deciding whether to operate, the informed consent discussion, and evaluating the patient after discharge from the hospital.

The real issue is that there is much more to surgery than simply doing the operation.

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