On the subject of resident pay, I feel like its a bit shallow to not delve into the financial burdens new residents are under right now. Correct me if I'm wrong, but we are seeing unprecedented rises in inflation, student debt, and cost of housing in cities (where most residents are forced to live)
I guess I'm biased, but I just feel like it's not a good look to reinforce the party line on the side of a literal monopoly thats trying to suppress a rebellion amongst their debt slaves.
As a 73 yo Retired FM(Geriatrics&Obesity Med), I trained where I had to be OnCALL q3days!! Not easy. Esp after 8th ICU Admit pt in24h. We were taught well. No yelling or humiliation like in Med School. BUT I think that many find themselves married,with children, and do deserve to have enough. I can’t imagine being under a 250K debt load. Who are we helping? Hospitals need to give adequate Benefits. If they need to prolong their servitude to fulfill the mandate, so be it - with Pay!
And include mandatory Counseling and/or Coaching from those that know how and WHAT medicine is all about. Making mistakes we all do - BUT Shame means we are worthless and unloveable. Suicide rates should be no worse than other similar professions!! We always had several 3-5 day Staff retreats/yr to work some of this out. We are not nuts but the Stress can be profound!! Keep up good stuff!!
ps. Don’t forget Gabe Mirkin MD and John Ioannidis MD. Two strong Foundations!!
I enjoyed your recent podcast dealing with conservative versus progressive decision making in medicine. In the second segment, you discussed the recent study in the NEJM in which P values were not assigned. Dr. Mandrola felt that this was an advance, Dr. Foy was less sanguine. I lean more towards Dr. Foy's point of view. I think it's very interesting that the New England Journal has published papers recently that eliminate P values. This is the most prominent example, although a masking analysis that they published from 11/2022 indicating that it was beneficial to retain masking in schools, although showed an absolute benefit, there was no discussion of P values to indicate which strategy may have been superior statistically or the increase may have been random. Dr. Mandrola heralded this approach, but I am much more of a skeptic. I'm inclined to believe that the New England Journal is switching over to this method not because they've seen the light regarding the dubious statistical benefit of a P value in medicine, it's because they are becoming increasingly more willing to align with the powers that be, and they need the wiggle room when a study doesn't have the proper P value to tout its results.
Industry and government will love this! No P value, no problem. They can push more dubious products to market, or mandate crazy behaviors simply because they say they believe they are right. In the real world it is valuable in that one can apply the results intelligently to good effect. In an individual with a very high bleeding risk defer. In a healthy youngish guy - early.
By the way as a Cardiac intensivist who saw a lot of consultations in the Neuro ICU, that question regarding anticoagulation timing came up daily.
I must say I am aghast that as one of his teachers in residency, Dr. Foy doesn't worship the ground I walk on! As a former program director in Cardiology, my opinion is that the educational experience of trainees has been so watered down, I worry that they may not have enough clinical experience by the time they graduate.
Regarding guidelines, I think the very first line in every guideline should be: "Patient autonomy should always be respected, regardless of the guidelines." Perhaps the second line should be: "Always provide informed consent, which means providing risks and benefits in absolute terms, including for primary prevention when relevant." The absolute risks and benefits should be provided in the guidelines, based on high quality evidence, because I suspect many doctors don't have a clue what they are. As for ELAN, I'm unclear whether the wide CI's were due to a moderate sample size (it didn't seem highly underpowered), due to a large amount of variability, or both. If large variability played a role, wouldn't the logical next step be to analyze outcomes by relevant patient characteristics? Maybe I'm missing something....
You guys should consider getting a resident on the podcast and continuing that convo. I think there is some great potential talking points about the state of med ed. Residency is not broken, but it is passively becoming less and less about learning as patient complexity, documentation, and volume increases. Grateful for the podcast, thanks for your efforts!
Kind of shocking to me how blase our hosts are about residency. If residency was a choice, I think that case would be much stronger. That is to say, if you graduated medical school and could work as a clinical physician and attain licensure without any further training, through a free market of jobs, and residency was a choice for those who wanted to specialize and improve their training, then it would make sense. This isn't crazy at all; a new physician graduate is better trained than an APP but is unable to be legally employed in a similar capacity. And frankly, if you graduate from medical school with an MD and can't actually work in the capacity for which you've trained, you've been defrauded. The only thing needed to practice should be to pass the exams and attain an MD; if this isn't the case, then it is possible that someone can attain a doctoral degree in medicine but not be a doctor in any meaningful sense.
Given that residency is mandatory, certainly practicing in a supervised capacity is not the same as being an attending, but a resident or fellow should easily be paid as much as a PA.
It's also much harder to get a residency even than when our hosts would have been searching, with several thousand perfectly qualified unmatched grads and growing and the slots not expanding to match demand.
In Australia, where I studied, all domestic medical school graduates are guaranteed employment as an intern, and can continue working thereafter and apply for a specialty at their leisure, or not apply and perhaps become a GP. They also get paid substantially more than we do, and they work a 40 hour work week like a normal person, maybe stretching up to 60 in high-demand circumstances. They think our system is insane. I agree.
The fact that young single people with money can make it work in the short term and reap the benefits in the long term does not mean that the system is not abusive. And the obvious fact that many people work harder for less money under worse conditions does not mean that we as physicians should keep our mouths shut until we are the worse off. We're supposed to be leaders.
Excellent talk. It is so difficult to do little, even when it is in the patient's best interest; when big pharma and big business profit from when you do more.
I’m a vascular neurologist and a huge fan of Sensible Medicine. Would like to provide the stroke doc perspective on the ELAN trial, which you wonderful cardiologists openly stated you did not grasp on the recent pod.
The question of when to start anticoagulation in patients with afib after ischemic stroke might be the most pressing unknown that I face in my day to day practice. There IS enormous equipoise on this question, and it is a decision that stroke doctors have to make every day. One of my fellowship mentors talked about “spinning the wheel of anticoagulation” to decide on what day after stroke to commence AC. The tension between the risks of recurrent ischemic stroke—known to be most prevalent in the first days after an index event—and hemorrhagic transformation of the existing stroke weighs heavily on us. Over time, based on observational studies (and probably on a general bias towards doing more things more quickly—we medical conservatives are certainly in the minority in medicine), the trend has been towards earlier initiation. But many of us in the field worry about whether, in following this trend, we are really doing the right thing for our patients, or whether we are being seduced by misleading, biased, non-randomized data. So for me, this trial provides assurance that I am probably not hurting people by starting AC early. Like you, I appreciate the honest way in which the results are presented. The trial gives me confidence that in giving AC early there is a small chance that I am increasing harm, and a higher chance that I am marginally improving outcomes, and that gives me real peace of mind. If I choose in an individual case to delay AC, I can feel comfortable knowing that it probably doesn't make a difference.
Thanks very much for the work you do spreading the gospel of smart application of EBM and medical conservatism!
“Just because we can, doesn’t mean we should” and “do nothing TID” are phrases I’ve lived by in my entire career to date, and I believe have served me and my patients well. But trying to resist the latest craze and/or shiny new thing requires constant effort, and vigilance.
Interesting to characterize ELAN as a randomized observational study but seems appropriate. I agree we can’t do many studies this way, but this seemed like an area where there was no Bayesian prior as to the “right answer”. It seems, for appropriate clinical questions, you can do a study like this once; but the follow up has to test a proper hypothesis. In the same vein, I would push back a bit on saying results are “inconclusive” simply because of a “positive” point estimate but wide CI’s that cross 1: the trial IS negative....the investigational concept failed in this instance....that’s not inconclusive....you could say it’s underpowered, and a larger trial may generate tighter CIs around the same positive point estimate...but the burden remains on proponents to go out and prove it. But it remains negative until proven otherwise...nothing inconclusive about that.
re: residents. I come from the era of shame based learning. And in expected “get off my lawn” fashion, I feel trainees have it easy these days. If I expected a day off after call, I would’ve been laughed out of the program back in my day. And we were apprentices in our profession....it’s called putting in our time, and paying our dues. Alas, in an era of micro aggressions and safe spaces, this too is but a sign of the times.
I hear you about the younger generation, being an old fart myself. However, you probably know what our elders said about us when young, so there's always some of that. I would also say that being challenged by the youngsters to teach in a manner that shows respect is not necessarily a bad thing. I'm not saying to baby them or give "safe spaces;" but some professors seem to think teaching by disdain and humiliation is OK. It's not. Oh, and having enough sleep to avoid medical errors is probably not a bad thing either. :)
I agree. I trained in an era when there was still plenty of shame-based learning. I do think there is a kindler gentler way. Altho I will also say, the times where I was lit up by my attendings most memorably, I only made those mistakes once.
I do try to ask residents and fellows now open-ended questions (what’s your approach to this; what’s your DDx for that) unlike the “guess what I’m thinking” Qs of yore. But I do also think the pendulum has swung a bit far.
As a psychologist who has worked in both schools and private practice, factors that impact learning/performance is my wheel house. Emotions can certainly affect learning, and the relationship is complex and not always univalent (first link). You said that when you got "lit up" by your attendings most memorably, you only made those mistakes once. Does that mean when you didn't get "memorably lit up" for mistakes, you made those mistakes more than once? You didn't say how often you got "lit up," but when a person is in a learning environment in which mistakes are always (or almost always) followed by shaming from the teacher, that is highly stressful, and I assume you're aware of the negative impact of stress on learning and performance. Some teachers still think humiliation is the most effective teaching tool for mistakes, but there is no evidence of that. Some people have greater coping resources and internalized self-esteem than others, and thus some are more resilient than others in how they handle such environments. Your use of open-ended questions is one of the more effective teaching tools, as it requires deeper thinking and processing of the material. As for the pendulum and where it's swung, I'm not there, so I don't know, but it probably varies by institution. Again, I'm not advocating any extreme measures, simply treating people with respect and not shaming them, which it sounds like you do. I don't know about you, but I learned best from teachers with whom I had good relationships, and that's what I've observed in schools. That doesn't mean I never got corrective feedback, but the best teachers know how to do that without shaming, and that's quite memorable! :)
On the subject of resident pay, I feel like its a bit shallow to not delve into the financial burdens new residents are under right now. Correct me if I'm wrong, but we are seeing unprecedented rises in inflation, student debt, and cost of housing in cities (where most residents are forced to live)
I guess I'm biased, but I just feel like it's not a good look to reinforce the party line on the side of a literal monopoly thats trying to suppress a rebellion amongst their debt slaves.
As a 73 yo Retired FM(Geriatrics&Obesity Med), I trained where I had to be OnCALL q3days!! Not easy. Esp after 8th ICU Admit pt in24h. We were taught well. No yelling or humiliation like in Med School. BUT I think that many find themselves married,with children, and do deserve to have enough. I can’t imagine being under a 250K debt load. Who are we helping? Hospitals need to give adequate Benefits. If they need to prolong their servitude to fulfill the mandate, so be it - with Pay!
And include mandatory Counseling and/or Coaching from those that know how and WHAT medicine is all about. Making mistakes we all do - BUT Shame means we are worthless and unloveable. Suicide rates should be no worse than other similar professions!! We always had several 3-5 day Staff retreats/yr to work some of this out. We are not nuts but the Stress can be profound!! Keep up good stuff!!
ps. Don’t forget Gabe Mirkin MD and John Ioannidis MD. Two strong Foundations!!
Once again - top-notch!
I enjoyed your recent podcast dealing with conservative versus progressive decision making in medicine. In the second segment, you discussed the recent study in the NEJM in which P values were not assigned. Dr. Mandrola felt that this was an advance, Dr. Foy was less sanguine. I lean more towards Dr. Foy's point of view. I think it's very interesting that the New England Journal has published papers recently that eliminate P values. This is the most prominent example, although a masking analysis that they published from 11/2022 indicating that it was beneficial to retain masking in schools, although showed an absolute benefit, there was no discussion of P values to indicate which strategy may have been superior statistically or the increase may have been random. Dr. Mandrola heralded this approach, but I am much more of a skeptic. I'm inclined to believe that the New England Journal is switching over to this method not because they've seen the light regarding the dubious statistical benefit of a P value in medicine, it's because they are becoming increasingly more willing to align with the powers that be, and they need the wiggle room when a study doesn't have the proper P value to tout its results.
Industry and government will love this! No P value, no problem. They can push more dubious products to market, or mandate crazy behaviors simply because they say they believe they are right. In the real world it is valuable in that one can apply the results intelligently to good effect. In an individual with a very high bleeding risk defer. In a healthy youngish guy - early.
By the way as a Cardiac intensivist who saw a lot of consultations in the Neuro ICU, that question regarding anticoagulation timing came up daily.
I must say I am aghast that as one of his teachers in residency, Dr. Foy doesn't worship the ground I walk on! As a former program director in Cardiology, my opinion is that the educational experience of trainees has been so watered down, I worry that they may not have enough clinical experience by the time they graduate.
Regarding guidelines, I think the very first line in every guideline should be: "Patient autonomy should always be respected, regardless of the guidelines." Perhaps the second line should be: "Always provide informed consent, which means providing risks and benefits in absolute terms, including for primary prevention when relevant." The absolute risks and benefits should be provided in the guidelines, based on high quality evidence, because I suspect many doctors don't have a clue what they are. As for ELAN, I'm unclear whether the wide CI's were due to a moderate sample size (it didn't seem highly underpowered), due to a large amount of variability, or both. If large variability played a role, wouldn't the logical next step be to analyze outcomes by relevant patient characteristics? Maybe I'm missing something....
You guys should consider getting a resident on the podcast and continuing that convo. I think there is some great potential talking points about the state of med ed. Residency is not broken, but it is passively becoming less and less about learning as patient complexity, documentation, and volume increases. Grateful for the podcast, thanks for your efforts!
Kind of shocking to me how blase our hosts are about residency. If residency was a choice, I think that case would be much stronger. That is to say, if you graduated medical school and could work as a clinical physician and attain licensure without any further training, through a free market of jobs, and residency was a choice for those who wanted to specialize and improve their training, then it would make sense. This isn't crazy at all; a new physician graduate is better trained than an APP but is unable to be legally employed in a similar capacity. And frankly, if you graduate from medical school with an MD and can't actually work in the capacity for which you've trained, you've been defrauded. The only thing needed to practice should be to pass the exams and attain an MD; if this isn't the case, then it is possible that someone can attain a doctoral degree in medicine but not be a doctor in any meaningful sense.
Given that residency is mandatory, certainly practicing in a supervised capacity is not the same as being an attending, but a resident or fellow should easily be paid as much as a PA.
It's also much harder to get a residency even than when our hosts would have been searching, with several thousand perfectly qualified unmatched grads and growing and the slots not expanding to match demand.
In Australia, where I studied, all domestic medical school graduates are guaranteed employment as an intern, and can continue working thereafter and apply for a specialty at their leisure, or not apply and perhaps become a GP. They also get paid substantially more than we do, and they work a 40 hour work week like a normal person, maybe stretching up to 60 in high-demand circumstances. They think our system is insane. I agree.
The fact that young single people with money can make it work in the short term and reap the benefits in the long term does not mean that the system is not abusive. And the obvious fact that many people work harder for less money under worse conditions does not mean that we as physicians should keep our mouths shut until we are the worse off. We're supposed to be leaders.
Re residents striking, Coincidentally the tv show Greys Anatomy recently had a few episodes about the same topic
Excellent talk. It is so difficult to do little, even when it is in the patient's best interest; when big pharma and big business profit from when you do more.
Hi John,
I’m a vascular neurologist and a huge fan of Sensible Medicine. Would like to provide the stroke doc perspective on the ELAN trial, which you wonderful cardiologists openly stated you did not grasp on the recent pod.
The question of when to start anticoagulation in patients with afib after ischemic stroke might be the most pressing unknown that I face in my day to day practice. There IS enormous equipoise on this question, and it is a decision that stroke doctors have to make every day. One of my fellowship mentors talked about “spinning the wheel of anticoagulation” to decide on what day after stroke to commence AC. The tension between the risks of recurrent ischemic stroke—known to be most prevalent in the first days after an index event—and hemorrhagic transformation of the existing stroke weighs heavily on us. Over time, based on observational studies (and probably on a general bias towards doing more things more quickly—we medical conservatives are certainly in the minority in medicine), the trend has been towards earlier initiation. But many of us in the field worry about whether, in following this trend, we are really doing the right thing for our patients, or whether we are being seduced by misleading, biased, non-randomized data. So for me, this trial provides assurance that I am probably not hurting people by starting AC early. Like you, I appreciate the honest way in which the results are presented. The trial gives me confidence that in giving AC early there is a small chance that I am increasing harm, and a higher chance that I am marginally improving outcomes, and that gives me real peace of mind. If I choose in an individual case to delay AC, I can feel comfortable knowing that it probably doesn't make a difference.
Thanks very much for the work you do spreading the gospel of smart application of EBM and medical conservatism!
Sheva Coleman
Medical conservative here ✋.
“Just because we can, doesn’t mean we should” and “do nothing TID” are phrases I’ve lived by in my entire career to date, and I believe have served me and my patients well. But trying to resist the latest craze and/or shiny new thing requires constant effort, and vigilance.
Interesting to characterize ELAN as a randomized observational study but seems appropriate. I agree we can’t do many studies this way, but this seemed like an area where there was no Bayesian prior as to the “right answer”. It seems, for appropriate clinical questions, you can do a study like this once; but the follow up has to test a proper hypothesis. In the same vein, I would push back a bit on saying results are “inconclusive” simply because of a “positive” point estimate but wide CI’s that cross 1: the trial IS negative....the investigational concept failed in this instance....that’s not inconclusive....you could say it’s underpowered, and a larger trial may generate tighter CIs around the same positive point estimate...but the burden remains on proponents to go out and prove it. But it remains negative until proven otherwise...nothing inconclusive about that.
re: residents. I come from the era of shame based learning. And in expected “get off my lawn” fashion, I feel trainees have it easy these days. If I expected a day off after call, I would’ve been laughed out of the program back in my day. And we were apprentices in our profession....it’s called putting in our time, and paying our dues. Alas, in an era of micro aggressions and safe spaces, this too is but a sign of the times.
I hear you about the younger generation, being an old fart myself. However, you probably know what our elders said about us when young, so there's always some of that. I would also say that being challenged by the youngsters to teach in a manner that shows respect is not necessarily a bad thing. I'm not saying to baby them or give "safe spaces;" but some professors seem to think teaching by disdain and humiliation is OK. It's not. Oh, and having enough sleep to avoid medical errors is probably not a bad thing either. :)
I agree. I trained in an era when there was still plenty of shame-based learning. I do think there is a kindler gentler way. Altho I will also say, the times where I was lit up by my attendings most memorably, I only made those mistakes once.
I do try to ask residents and fellows now open-ended questions (what’s your approach to this; what’s your DDx for that) unlike the “guess what I’m thinking” Qs of yore. But I do also think the pendulum has swung a bit far.
As a psychologist who has worked in both schools and private practice, factors that impact learning/performance is my wheel house. Emotions can certainly affect learning, and the relationship is complex and not always univalent (first link). You said that when you got "lit up" by your attendings most memorably, you only made those mistakes once. Does that mean when you didn't get "memorably lit up" for mistakes, you made those mistakes more than once? You didn't say how often you got "lit up," but when a person is in a learning environment in which mistakes are always (or almost always) followed by shaming from the teacher, that is highly stressful, and I assume you're aware of the negative impact of stress on learning and performance. Some teachers still think humiliation is the most effective teaching tool for mistakes, but there is no evidence of that. Some people have greater coping resources and internalized self-esteem than others, and thus some are more resilient than others in how they handle such environments. Your use of open-ended questions is one of the more effective teaching tools, as it requires deeper thinking and processing of the material. As for the pendulum and where it's swung, I'm not there, so I don't know, but it probably varies by institution. Again, I'm not advocating any extreme measures, simply treating people with respect and not shaming them, which it sounds like you do. I don't know about you, but I learned best from teachers with whom I had good relationships, and that's what I've observed in schools. That doesn't mean I never got corrective feedback, but the best teachers know how to do that without shaming, and that's quite memorable! :)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5573739/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6416111/
STOP SAYING "LIKE"
"Right?"
Love 💕 listening to these various subjects that you discuss!