From: fulk@cs.rochester.edu (Mark Fulk)
Newsgroups: sci.med
Subject: Re: Questions for MDs
Date: 31 Jul 92 15:51:36 GMT
Organization: Computer Science Department University of Rochester

In article <15903@pitt.UUCP> km@cs.pitt.edu (Ken Mitchum) writes:
>In article <55403@mentor.cc.purdue.edu> hrubin@pop.stat.purdue.edu (Herman Rubin) writes:
>>In article <15851@pitt.UUCP> km@cs.pitt.edu (Ken Mitchum) writes:
>>But in any case, the amount of training should be totally irrelevant.
>>We should not be at all interested in time served as a student or an
>>apprentice or whatever.  It is the knowledge and ability which is what
>>should be considered.
>
>Herman, again, you are talking about a subject of which you know
>absolutely nothing. The knowledge a medical student has when then
>MD is granted at the end of medical school is very minimal. The
>real learning comes in internship and residency (and possibly
>fellowship) and you learn medicine only one way: by seeing and
>caring for patients. 

I think Herman still thinks medical knowledge is entirely like other kinds
of academic knowledge: consciously available information used in reasoning.
He seems to have missed the point that much of it is perceptual and manual,
and needs to be available without much thought.

>You can criticize and say that all the doctors should see patients
>when they've had a full night's sleep, but the real world is
>different: unless you have a very genteel practice, you are always
>going to have to see and treat patients at inoportune times and
>in the middle of the night.

Yes, but it is unusual to have to see patients after many days of short
sleep, except in wartime.  It is much easier to get up to speed at 3am
one night in a row than three or four (here I speak from experience:
Coast Guard).

>The risk from this is minimal, as interns and residents do not
>function alone, and they are seldom all trashed at the same time.

I'm not sure of the degree of the risk, and doubt that it has ever
been measured.  The risk is definitely real.

In 1988, during the Lilac 10k held every spring here in Rochester, NY,
a runner (Douglas Zefting, an experienced runner in very good shape)
collapsed with heat exhaustion.  The temperature was over 90 F, the
humidity very high.  Zefting was taken to Highland Hospital, where he
died of heat stroke that evening.  Now, of course, one cannot know for
certain what his condition would have been in the best of circumstances.

However, he was not treated for heat exhaustion for several hours; no
attempt was made to reduce his body temperature.  It seems that the
staff at Highland had classified him as a head trauma patient (he had
a lump from his fall).  When asked about this, the residents said that
they had been on since the previous night, and had no idea how hot it
was outside or that there was a race on.  It had been quite cool when
they showed up for work.  Bear in mind, the race started at 10 am, and
Highland Hospital is two blocks north of the route of the race, which
draws thousands of runners and results in blocking the main road to
the hospital.

(This is a classic Murphy's law case:
The race should have started much earlier.
There should have been more medical help at the race.
The hospital should have been informed, and the ER staff alerted.
The people who brought Doug to the ER should have made sure someone
knew what was going on.
The residents should have paid more attention.

NOW:

The race starts at 8:00.
There are numerous medical tents and ambulances at the race.
The hospitals are carefully informed in advance (two are nearby,
Strong and Highland).
The release form for the race is pushing a page in length.)

At about that time, the parents of a deceased NYC woman were pushing for
a law limiting resident's hours.  She was apparently the victim of an ER
fuck-up at Mount Sinai.  Rather than sue, the parents successfully lobbied
Albany for new rules on training time.

>TIME is also important because there are some diseases you only see
>rarely, and if training is abbreviated, you won't run into them. There
>are several diseases that I have only seen once, and if my training
>had been abbreviated, I would have missed them. 

Absolutely.  Incidentally, I think this is an argument for shortening weeks
and lengthening training.  After all, the unusual case will still be around
in the morning, most of the time.  Train even longer, see even more.  In
order to make this really feasible, though, I think we ought to reduce
medical school costs drastically, so doctors aren't confronted with that
vast debt at the end of training.

Is seeing it once really enough?
-- 
Mark A. Fulk			University of Rochester
Computer Science Department	fulk@cs.rochester.edu