Monday, March 20, 2017

There are many lessons to be learned from March Madness, but for the sports fan, there is perhaps nothing worse than watching your team lose a close game and not because of the success of an opponent, but because of a referee’s error. Officiating mistakes happen and are usually forgotten, except when they occur at a pivotal moment late in the game, leaving no opportunity for recovery. From a goaltending call that wasn’t made or a travel not called, to a decision on intentional fouls, each team’s fan base will see the exact same slow motion replay and come away with a different truth. It’s not common for NCAA administration to apologize for an error and by then, both teams have gone home and the damage has been done.

In medicine, mistakes are inevitable and while the individual provider aims for perfection, it really is a pipe dream. The complexity of the human body and the way it is attacked by disease, infection and trauma makes for a moving target when it comes to trying to prevent or fix problems. Once upon a time, medical care was mostly diagnosis driven and while doctors could be elegant in deciding what was wrong, they had few tools to treat the things that they found wrong. It’s only been very recently that medical care moved from comfort to cure, but that move has opened the Pandora’s box of error.

There are a variety of errors that are possible in the care of a patient and they mirror what happens on the basketball court. The care provider, whether a doctor in the office, a paramedic in the field or a nurse at the bedside, has to put themselves in the proper positon to collect information, process it and make a diagnostic decision. This is no different than a referee who have to be in position to watch a play, know the rules and make a call. A diagnosis or call is missed if any steps fails.

In medicine, diagnosis needs the information gathering skills of talking to the patient, asking the right questions and performing a physical examination. If the information is misleading, a wrong test might be ordered, driving the diagnosis and treatment in the wrong direction. A patient with indigestion might actually be complaining of pain from the heart and coronary artery disease. If early in the disease process, the patient ignores the symptoms or the care provider misinterprets the symptoms, the opportunity to avert a heart attack might be lost. On the other hand, the indigestion might be gallbladder disease and if that diagnosis is missed, the patient might develop a major abdominal infection. Or just maybe the indigestion is “just” indigestion and heartburn, caused by the reflux of acid into the esophagus. Miss this diagnosis and treatment and chronic reflux can result in Barrett’s esophagus, changes in its lining, that can be a cancer precursor. And these are just the common causes of heartburn; textbooks are filled with plenty more.

The right diagnosis is no guarantee of making the right call when it comes to treatment. While there are guidelines for many situations just like a sports rulebook that lay out the call for most situations. However, it’s hard to know or remember every single nuance, especially when time is of the essence and there are some situations where the rules just don’t apply. There may times at the bedside where decisions have to be made and there are no “best “options. Even if there are, no guarantee exists that picking the right treatment will result in a positive result. A bad outcome does not mean that a mistake was made, and sometimes a mistake happens and doesn’t cause harm.

Mistakes happen in medicine happen but most go unrecognized or unreported; the no harm no foul rule. But medical systems are learning that a near miss is a learning opportunity, to make certain “minor” misses don’t become major disasters. The concept of whistleblowing is encouraged to look for ways to improve and in this way, it becomes the medical equivalent of instant replay. The reporting systems also help sort out what happened when major errors occur and the patient is injured and it often takes a disaster for a system to change.

College basketball may be life and death for some fans and their happiness may depend upon a referee’s call. Some of their mistakes are fixable and can be reversed by instant replay but in many cases, there is only an apology that is issued well after the fans have gone home. Who knew that the same situation exists in medicine. The life, death, happiness paradigm is literally true when it comes to medicine. Mistakes happen and many can be overcome but sometimes all that can be offered is an apology.


Images: NY Post, WCRBtv.com

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the medical draft

Friday, March 10, 2017

The sun sets on the first day of this year’s NFL free agency as rejoicing, and perhaps mourning, breaks out through the country with each team’s fans praying that this…might…be …the…year!  Hope springs eternal for the next season after seminal events in each sport. Whether it is the NCAA signing period bringing high school stars to campus, or the trade deadline in the NBA and NHL where a final push to the playoffs might be a reality. But there is another draft that is happening now that will likely have a much more tangible effect on people’s lives…literally.

The 2017 National Residency Matching Program (NRMP) releases its results beginning March 13 and the lives of thousands of medical students and millions of patients will be forever changed. In the fall of 2016, at the beginning of their fourth and final year of medical school, more than 40,000 soon to be doctors begin the application process for residency training slots and the start of graduate education. Almost 5,000 teaching hospitals offer more than 30,000 training opportunities in every specialty of medicine, from surgery to ophthalmology, psychiatry to family practice, pathology to whatever other type of medicine you can imagine.

The process is relatively simple. The medical students apply to a residency program (usually more than a few), visit and interview at a couple and then on February 22 send their wish list to the “Match”. Residency program directors, and their staff, sift through the applications, medical school grades and interview performance to decide where they rank the soon to be doctors o their draft board and submit their list as well. NRMP computers do the rest, and next week marriages are announced. There will be some rejoicing, some sadness and some mourning. A few students won’t be matched, but like the NFL, there is a supplemental draft since some programs also don’t fill their positions.

But why should the rest of the world care; it’s not like fans fill a stadium every Sunday and have fantasy resident teams based on how well a new doctor cared for a patient in congestive hear failure or assisted on an operation. Aside from the direct care that the residents provide at a teaching hospital, the results of the Match might alter the landscape of a community for a generation to come. Training can last 3 to 7 years or more and during that time, these new doctors start families, put down roots and often tend to stay in the area where they did their training.

The young fourth year medical student that interviewed at your local hospital might be the surgeon who is emergently operating on you in ten years. She might be coaching your basketball team or he might be running for school board. These are the new young professionals who become the fabric not only of the medical community but also of the community as a whole.

Unfortunately, there is a cloud that hangs over this year’s Match. Because foreign medical graduate students also participate in the Match in search of US quality training, there has been concern raised by the NRMP that travel restrictions for some might affect their ability to begin training on the traditional start date in July. From the NRMP press release:

  • …This uncertainty leaves programs the choice of not ranking qualified applicants or risking empty training slots on their program start date. Even if the ban ends after 90 days, there is concern that the consular interviews that are required prior to obtaining visas will be so slow that affected applicants will not be able to start training on time. There also are concerns about whether residents and fellows who are in the U.S. on visas will be able to remain in their training programs. 
  • The consequences of the Executive Order are far reaching for Match applicants, and the upheaval it is causing is extensive. The affected applicants have worked hard for many years to achieve their goal of becoming physicians, and they should not be denied that opportunity because of a blanket policy that does not consider the individual. Similarly, U.S. training programs should be able to select applicants based on their excellent character and qualifications, without regard to nationality. Both applicants and programs benefit from an orderly process for entry into graduate medical education. The Executive Order disrupts that process very considerably.

As NFL free agency winds down and the hype of their draft begins, teams begin reshaping their team to become more competitive in the coming years. The NRMP  allows hospitals and communities to do the same thing when it comes to the quality of medical care available. Perhaps it might be time to appreciate the medical draft that touches health and welfare of thousands of communities in the US. Knowing that your local hospital has filled their training slots in family medicine and surgery should make you feel a little safer for the next thirty years. Wit hall that is at stake, it is surprising that the Match isn’t must watch reality television. I wonder if ESPN might be interested?


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