I have to confess, I had a somewhat visceral response to this paper, and I wondered what the internists?
Gray BM, Vandergrift JL, McCoy RG, Lipner RS, Landon BE. Association between primary care physician diagnostic knowledge and death, hospitalisation and emergency department visits following an outpatient visit at risk for diagnostic error: a retrospective cohort study using medicare claims. BMJ Open. 2021 Apr 1;11(4):e041817. doi: 10.1136/bmjopen-2020-041817. PMID: 33795293.
I like Dr. Pilcher's remark. It gets close to the mark. However, having taught medical students for almost four decades and interacted with residents and clinicians for over fifty years, I've seen the quality of their education erode, the quality of their clinical year experiences erode, and the quality of their training years erode. So, I would add to intelligence the factors of education, training, and experience are critical to assuring "doctors make fewer mistakes". Then there's an understanding of the biases that may affect their clinical decision making without their being cognizant of this.
Mark Gusack, M.D.
MANX Enterprises, Ltd.
"Surgeons are not Pilots" https://www.sciencedirect.com/science/article/abs/pii/S1931720421000167?dgcid=rss_sd_all
Aviation and medicine: https://journals.sagepub.com/doi/full/10.1177/2054270415616548
I've been curious about sepsis/SOFA/Covid and the effects of sepsis alerts.
Our E(H)R (I put the (H) like that because there is no proof, suggestion or even signal that (H) is affected.) displays a "hard stop" (I must stop what I'm doing and process the warning without access to the chart) with ANY abnormality of vitals. It is rarely correct in finding sepsis and has missed a few cases of clear (fatal) sepsis. It does increase the profit margin by automatically warning several $G (charges) worth of tests and interventions.
How do I get this run:
n=1000 consecutive warnings ("n" chosen for no good reason)/t (time interval)
During t, measure:
Warning (+), "sepsis" recorded as a diagnosis within 24 h
Warning (+), "sepsis" not recorded within 24 h
Warning (-), "sepsis" recorded during t
Warning (-), "sepsis" not recorded during t
ICD-10 codes used, eliminating sepsis from procedure unless POA.
I imagine it would take guts to let this be done....but this group is supposed to ask the tough questions.
Because I have been responsible for the education of medical students for a couple of decades, I'm curious why you state that you've seen, "the quality of their education erode, the quality of their clinical year experiences erode."
There is no question that, in comparison to 40 years ago, medical education is quite different. We admit a more diverse cohort of learners who arrive with a wider range of qualifications; the expectations for their performance in medical school are oriented around cognitive and affective outcomes (including skills in communication and health systems science) that are broader and deeper; and the context for which we are preparing them (medicine as it will be practiced 40 years from now when they have become the leaders) is more uncertain.
There is room for improvement in medical education now and there always will be. You most certainly have observed many differences over the years, but I don't find evidence that the "quality" of medical education has eroded at all.
Hugh A. Stoddard, M.Ed., Ph.D.
Assistant Dean for Medical Education Research
Professor of Medicine
Emory University School of Medicine
100 Woodruff Circle, P-378
Atlanta, GA 30322
Phone: (404) 727-8451
There is no question that "burnout" is both common and menacing in medical education. A review of the literature found that, "Factors within the learning and work environment, rather than individual attributes, are the major drivers of burnout." In a nutshell, as trainees become exposed to the milieu of physicians' practice and they experience the panoply of issues in healthcare (many of which are discussed extensively on this listserv), they become disillusioned. 'Medical education' as an institution has little control over the healthcare system or the institutions in which trainees are expected to learn.
As I stated earlier, there are problems that permeate medical education which must be addressed in order to make it "good enough," but the root concern which I believe you and Dr. Gusack are addressing is primarily attributable to the context in which medical training occurs – not in the training itself or the trainees.
(We could also discuss the impact on learners of systematic career uncertainty and the tyranny of using multiple-choice exams as the gatekeepers for the profession, but those are predicaments for another day.)
1. Dyrbye L, Shanafelt T. A narrative review on burnout experienced by medical students and residents. Medical Education. 2016 Jan;50(1):132-49.
I would like to respond to Dr. Stoddard's email from two days ago.
The issue is the volume of medical information and knowledge has expanded dramatically over the past fifty years and is accelerating, whereas the preparation of applicants to medical school has not kept up and, in fact, has dropped off. It is so bad that I'm embarrassed to say where I went to college which, when I went was the academically most rigorous and selective institution in the country. Now? Every course there has take-home tests, everyone gets an A, and the course work is a shadow of what was expected of my class and this is based on direct examination of syllabuses and books as well as interviews with my professors over many class reunions.
Worse, much of this accelerating expansion of knowledge is greatly biased, flawed, and, often, wrong. Therefore, it is critical that medical students have an adequate educational background prior to acceptance and then, continue to get the kind of education that leads to an appropriate attitude and effective approach to assessing the professional literature.
Perhaps we can look at the following:
When I was in medical school, we were expected to read the professional literature critically and not accept the statistical 'proof' presented by the author(s) until we had evaluated it. At that time, not all of us had taken a course in statistics but many had. The rest got a crash course during our discussions. Starting in the late 1980's I began to see a trend so I began to ask every single student in each class I taught about their background in mathematics. Here is what I found:
From 1980 when I started my residency through my recent retirement, I have had hundreds of 'friendly' disagreements and not so 'friendly' confrontations with my fellow physicians regarding simple logic as applied to well established facts. This started out as a sporadic event occurring, perhaps, once per month and usually involving the same fellow residents or staff members at the hospital I trained at. These were people who tended to stick to their rusty guns because they certainly were not going to be swayed by a pathology resident. By the time I retired, I found myself biting my tongue constantly to avoid confrontations over younger clinician's lack of ability to solve even simple problems. They had difficulty developing a systematic assessment of initial findings and applying simple logic to formulating a plan of action.
In one case, it had to do with the staging of colon carcinoma according to AJCC standards. We were doing it wrong in our tumor board when I arrived at the facility. It took 18 months to 'educate' the tumor board members most of which were many years younger than me. After we were finally properly stagging our patients, I met with each member separately and found that those in my age group had a good understanding of logic and were relieved when my position was finally accepted (so, why didn't they speak up?). None of the young gun slingers had taken a course in logic or philosophy, and none had taken more than the bare minimum in math courses at college; usually simple introductory courses in calculus and trigonometry. No statistics. They just could not understand how I got from a to b to c!
DIVERSITY VERSUS PREPAREDNESS:
I agree that medical schools are admitting a more diverse cohort of learners who arrive with a wider range of qualifications. And this is not a bad thing. My class of 1980 at GWU was experimental in this area and way ahead of its time. However, the school did not drop its standards of education for our class. Many expected us to fail; some due to outright bigotry. No such thing happened. Turns out our diverse class was no less intelligent than those classes full of straight A students with high MCATS. Did some of those chosen for diversity suffer? Yes. But both the student body and professors helped those less prepared, and they all did well during their clinical years. If anything, those who came in with an educational disadvantage rose to the challenge and went on to be highly successful clinicians.
Now, standards are being systematically abandoned both in college and medical schools in favor of diversity so as to be 'socially' just and to not hurt anyone's feelings. This isn't being socially just. It's setting up disadvantaged people to failure which is a new form of bigotry. And, what about the patient's feelings especially those who are socially disadvantaged in our society? Not being as well prepared in college leads to not being able to benefit fully from a medical school education prior to entering residency training and not being held to high academic standards in medical school aggravates this trend.
TIMELESSNESS OF WHAT NEEDS TO BE TAUGHT:
Regardless of what course healthcare takes in the next forty years, there are certain timeless issues that will affect future students. In particular, we need to go back to making sure the three R's are well taught throughout the life of those applying to medical school so that, when they arrive, they are ready to absorb the enormous and growing volume of information and knowledge. These include but are not limited to:
I have the honor to be, respectfully,
Dr. Gusack raises some very important points. Logic and problem solving taught in philosophy, math, and physical sciences (physics, chemistry) should have more emphasis than they do in pre-med curricula. I learned how to think, reason through an argument and justify it through all of the essays and long answer tests in undergrad – I took very few multiple choice tests outside of science/math courses.
One concern I have is around what standardized tests and grades indicate about preparation. I believe there is a solid body of evidence that performance on standardized tests correlate better with affluence and opportunity than with intelligence. We've all met the med student or resident who can spout encyclopedic knowledge of the Krebs cycle or has every formula from the Aa gradient to Winter's formula memorized but couldn't diagnose the simplest of conditions.
There is an inherent structural disposition in US medicine just like every other major industry that disadvantages people of color. I'm only the first chapter in to Medical Apartheid by Harriet Washington but am already ashamed, as a white straight male physician, of how little I knew about the history of my beloved profession in the US. And I was struck by Robin DiAngelo's presentation at the OSU President and Provost Lecture where she asked, "What sort of cultural competency must you demonstrate to do your job?" I don't claim to be "woke" – but I now have an inkling of knowing what I don't know which is the first step to correcting any deficiency, just as knowing about cognitive biases helps us avoid them.
My Answer to DiAngelo's question was "None"- I have to prove nothing to be a doctor and take care of people of color, immigrants, the impoverished. As noted, much of the medical "knowledge" that is being generated at an accelerated pace is flawed and biased. But it is partially biased because we have not acknowledged medicine has engendered, even protected a biased system.
What this has to do with the EHR I have long since lost track of.
Joe Grubenhoff, MD, MSCS (he/him/his) | Associate Professor of Pediatrics
Section of Emergency Medicine | University of Colorado
Medical Director – Diagnostic Safety Program
Children's Hospital Colorado
13123 East 16th Avenue, Box 251 | Anschutz Medical Campus | Aurora, CO 80045 | Phone: (303) 724-2581 | Fax: (720) 777-7317
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