Thursday, April 26, 2012

Doctor and Patient: Reinventing Year Three of Medical School

A recent article by Pauline Chen, MD in the New York Times discusses changes in the medical studies curriculum which are meant to ensure that medical students retain their empathy. Unfortunately the process can and will become undermined by a vicious residency training system. I found that it wasn't medical school that made me cynical. It was a general surgical residency where I was working every other night on call, over 120 hours a week. Didn't know there were 120 hours in a week? Well, I didn't either until I did the math. This translates into up at 5 am, at the hospital from 6 am, then overnight until the next evening at 10 pm, then home for a few hours of shut-eye before you repeat. No wonder I quit my surgical residency after only 6 months!

During that time I was distressed at how I was expected, even encouraged, to continue to care for patients despite overwhelming exhaustion. When I collapsed from the stress I was told that this was somehow my problem, and not the result of my grueling schedule. When I went to a therapist, the situation was normalized and I was prescribed Paxil to deal with my depression and anxiety, when I should have been told to leave. The entire medical education system, I soon realized, was set up to get the most amount of labor from the youngest, and financial incentives existed to maintain the status quo. Residents are essentially an itinerant work force: residents are only trainees from between 3 to 7 years and then they move on. Unionization is nonexistent, or discouraged, and most trainees feel that putting up with the crazy hours is the way to pay their dues and the payoff will come later, in the salaries and perks that come with being an attending surgeon.

I genuinely don't think the system will ever change unless there is some pressure from the outside (i.e. federal regulation) to reform it. The doctors and hospitals who currently benefit from the cheap labor of residents in teaching hospitals have no incentive to change it and the residents are powerless to.

While I admire those educators at Harvard who are willing to invest in improving medical school experiences for their third-year students, they really need to take a look at their own backyard first and first examine their residency training programs. Start with Harvard. That was the where the surgery program I quit 10 years ago was. I wonder if it has changed...

Wednesday, April 18, 2012

Frontline: The Real CSI

Frontline: The Real CSI

Last night I watched the most recent installment from PBS and ProPublica about forensic science in the United States. "The Real CSI" focused primarily on fingerprint analysis and bite mark analysis, two forensic methodologies that have been criticized recently by the Federal National Academy of Sciences (NAS) report for a lack of scientific rigor. The show's producers interviewed several prominent judges, and forensic specialists, including pathologist Dr. Cyril Wecht, about the issues of credentialing and on-line diploma mills. Their journalism student even got a quickie credential for $600 from an on line organization called ACFEI. What they forgot to mention were the credentials recently obtained by Steve Eichel, Ph. D., a forensic psychologist, for his cat.

Further missing from the discussion was the existence of a credible non-profit credentialing organizations within the field of medicine: the American Board of Medical Specialties (ABMS) and the Accreditation Council for Graduate Medical Education (ACGME). The former sponsors examinations created by leading experts in the field with published failure rates (about 33% for forensic pathology) and the latter accredits and inspects hospitals including residency and fellowship training programs. In order to become a board-certified forensic pathologist I went through 5 years training at an ACGME-certified residency program, 2 years at an ACGME-certified fellowship program, and I had to sit for 3 tests. The first two (anatomic and clinical pathology), taken together over a two-day period, required me to study for nearly a year. For the final subspecialty test in forensic pathology, I studied for over a month, but by then I was also performing forensic examinations on a daily basis under direct supervision. Both were mind-numbing exercises in minutiae and I am not certain they make me a "better" forensic pathologist, but the amount of work necessary in order to pass does set a baseline for motivation and intelligence, if not competence. Clearly, in my career since then I have seen board-certified forensic pathologists make errors, and I am not immune to errors myself. But it is the egregious errors of un-boarded practitioners that tend to cause the most problems. See: Dr. Steven Hayne in Mississippi and Dr. Charles Smith in Canada.

While it would be reasonable to pass laws that require forensic pathologists to be board-certified by the ABMS in order to testify as experts, it would immediately cause chaos in our courts since there are insufficient numbers of forensic pathologists to cover the needs of the United States. The National Association of Medical Examiners (NAME) estimates that there are approximately 400 board-certified forensic pathologists practicing in the U.S., less than half of what is needed to perform all the forensic autopsies needed. We need to increase the numbers of forensic pathologists by encouraging doctors to go into the field, in the same way we currently encourage doctors to go into primary practice in high-need areas: with outreach in medical school and loan-forgiveness programs for those entering the field.

Furthermore, attorneys need to start challenging experts more about their credentials and qualifications. Attorneys need to know how to find a qualified expert in forensic pathology, and I am hopeful the Frontline series will educate them.