Opportunity Costs: PA Or A Physician?


By:  The Musing Medic (@TheMusingMedic)



Blast From The Past


During my sophomore year of undergraduate school, I was required to take an economics course. Now, I don’t remember much from that class, but I do remember one particular concept: opportunity cost. It’s a simple idea really. Assuming the best choice is made, the opportunity cost is the lost benefit–it’s the benefit(s) you would have had if you chose the other option.


For example, pretend you can only eat at one restaurant on one particular night. By choosing Restaurant A, you cannot have the food from Restaurant B. The cost of choosing A, then, includes missing out on the food from Restaurant B…which may or may not be better than the food at Restaurant A.


Choosing PA School Over Medical School?


Let’s apply this idea to choosing an occupation within the field of Medicine.


Let’s say a student has been accepted to both medical school and a physician assistant program. Choosing to attend medical school means at least 7-10 years of formal didactic and clinical education. It means incurring extensive amounts of debt from student loans. There is also delayed gratification in buying a house, new car, or having a family. By choosing this route, your “cost” includes what the PA program/profession offers such as shorter training, less debt, and lateral mobility within the profession.


Of course, choosing the PA route also has its own set of “costs”. Choosing PA means less autonomy, simpler cases, lower income, and initial limitations in medical knowledge. You may be a competent provider that works similarly to a physician but you will never be the expert. And, the truth is, one day you will be a twenty year veteran PA who will be supervised by a newly minted attending who is younger than your own children. Talk about a kick in the ego!


A Call To Action:  Tell Me What You Think!


Why do I bring this up?  It’s because I am currently in this position. If I had to choose right now, it would be medical school hands down. But if we examine the current climate of medicine as well as the future, the PA role may be a more economical and conservative one to embrace. As Medicine continues to grow as a multi-billion dollar business, there will be more impetus on hospitals and health care companies to lower costs. This puts the PA in prime position to move up the professional ladder and have continued employment opportunities across all specialties. That is not saying physicians will be without opportunity, as they will always have the top position in the medical hierarchy. (At least that’s how it looks right now.) But I can see their roles progressing to a more supervisory position over physician assistants who carry out a majority of the tasks. Perhaps, in a busy ED, you will see one or two physicians overseeing three to five physician assistants.


Now this is all speculation…but I’m not alone in thinking this way. In Doctored: The Disillusionment of an American Physician, Sandeep Juhar (an interventional cardiologist) comments extensively on the state of Medicine in America and its depressing trend of moving away from doing what is best for the patient and more towards customer satisfaction. He illuminates studies done over the past decade that indicate a number of physicians regret their career choice at the present moment and would steer their children and those interested away from the field. Such a depressing thought.


The opportunity costs riding on my decision really are very high no matter which direction I choose. I desire the autonomy and knowledge but at almost thirty years old, with ten years as a medic under my belt, the prospect of another decade of school is daunting. Throw in the overwhelming number of studies highlighting the unhappiness of American physicians in the 21st century and the conservation decision seems more and more clear. Still, potential regrets exist and the only thing I can do is attempt to minimize them.


…so, what do you think?  Are you a PA or physician?  Let me know what you decided and why!  Would you do the same nowadays?

The Mailbox Rule In Modern Life: What Happens When The Text Isn’t Delivered?


By:  ML Student (@1L Student)


The Mailbox Rule:  A Classic In Contract Law


The mailbox rule is a classic in first year law student coursework. That weathered rule, taken from the 17th century English case Adams v. Lindsell, states that an acceptance of a valid offer is effective when the offeree deposits the acceptance in the mailbox. There are lots of reasons why this rule evolved; the court chose to create the rule in that case based on an argument that, if acceptance were only effective on delivery or receipt, the back and forth between parties could go on ad infinitum. Clearly, that is a very specious argument for many reasons.  For example, couldn’t one party simply accept and end the back and forth?  Regardless of the many flags we could throw, that case remains as the progenitor of our current mailbox rule. Here, let’s consider the applicability of the mailbox rule away from the 17th century and in more modern context. What happens, for example, if we send a text accepting the offer and the text is never delivered?


The Restatement’s Take On The Rule


First, it is useful to site current thought on the mailbox rule. The Restatement, Second, of Contracts describes the mailbox rule in section 63. The expectation, as explained, is that the manner in which the acceptance is transmitted be a ‘reasonable’ method. That means, in the modern day, acceptance by hot air balloon is probably suboptimal. Similarly, carrier pigeon is right out. So, in our fast paced world, how do we apply the mailbox rule if at all? What if we are negotiating, for example, by text message?


Text Messages Present A Special, Complex Issue


Text message presents several problems. First, when it is discussed in a typical 1L class, text messaging conjures an illusion that it is fairly instantaneous. However, we all know better. For example, texts are not always delivered in a timely fashion–if at all. We have all seen attempted text messages that are not received owing to issues like the prospective recipient being in a crowded place. You may have attended a football game where texts look like they are sent but are not, in fact, received. This is often because the network is locally overloaded.



Some “What Ifs”


There are other challenges with text message as a vehicle for acceptance. Consider, for example, whether messages sent by SMS (Short Messaging System) are all ‘texts’. By this, we mean that sometimes phones like the iPhone look like they are sending text messages when in fact they are using iMessage or another platform. So, we are left with the question, “Are all text messages created the same?”


At the end of the day we are left wondering how the mailbox rule applies in the text messaging situation. Is an acceptance of an offer valid if the text message is never received? Can we even be sure that, at times, it was sent? This can be challenging for reasons such as the fact that to the user it can appear that a text message was sent when in fact the message hasn’t left the phone. We have all been there, haven’t we?


At the end of the day the mailbox rule’s application in modern day is very challenging for multiple reasons. Where modes of message transport such as snail mail, email, and other modes may leave a more distinct fingerprint, we are often left wondering what exactly it means when a user thinks a text has been sent and it hasn’t. At times it is not as definite as depositing a letter in a box.   Modern thoughts on mode of acceptance are many.


More Unique Situations Are Bound To Arise


At the end of day, in the modern world, we are still wrestling with what constitutes acceptance given the fast pace of modern electronic communication. Clearly, we have not even touched upon more unusual ideas such as text messages that are scheduled to be sent in the future, and similar interesting situations that arise because of the current state of communication.


In conclusion, the mailbox rule’s application in the modern world is very challenging. Some contend that the mailbox rule is in line with the objective theory of contracts in that it allows courts to see an action on the part of the offeree as they execute their power of acceptance. Clearly, there is an equally strong argument for the mailbox rule as part and parcel of subjective contract theory in that it focuses highly on intent and which party knows what at which time. Still others see the mailbox rule as a bridge or stopgap measure that tries to clarify the obvious challenges inherent in the object theory of contracts (focusing on tangible action) and the inherently subjective nature of who knew what and when they knew (more subjective theory of contracts).


The rule will no doubt continue to be explored by the courts in the modern era. When the next communication revolution occurs, we will be wondering what it means to accept a contract via Apple watch and other similar devices.

We All Fail When A Resident Fails Boards

By:  The Generation Y Surgeon (@GenYSurgeon)

This post is for surgeons, surgical residents and future surgeons.  This post is more than a rant–it’s information.  For surgeons and residents, this should be a wake up call. For my future surgeons, this is what no one tells you before match.  Please read on and take the time to comment because I’m interested in your thoughts…

Venturing Into The Light To Take The Test

It’s board season.  Well, it recently was boards season.  This is when tired and bitter chief residents first enter the ranks of the attendings (or fellows) and the dinosaurs emerge from their clinics, operating rooms and labs to re-certify.  No one is spared…the chairman, the worker bee, the non-operative surgeon, the researcher….everyone must participate at some point.  A mountain of paperwork, $1400 in registration fees, and 320-something questions for one exam with very high stakes.

18% Fail?!  Are You Kidding Me?!

Let’s talk a minute, however, about the results of the boards.  Per the ABS, pass rates are, at best, 82%.  So 18% do NOT pass…that means 1 in 5 fail!  Whether you’ve passed or failed, taken the exam once or thrice…you shouldn’t feel good about our testing schema.  What does this failure rate say about our training programs and surgery as a profession?

The way I see it this means one of three things:

One in 5 board eligible surgeons are retarded.

The exam is too difficult, too tricky or is testing information that is not included in surgical training. 

We aren’t teaching residents what they need to know to be considered a passable surgeon–or we’ve just testing them in a whacky way.

Obviously, by the time someone is taking their surgical qualifying exam, we can assume that they aren’t retarded.  So that leaves point 2 and 3 to discuss further.  First, consider the exam itself.


What Is The Purpose Of The Boards Really?

Start by asking yourself, what is the purpose of the surgical boards?  The boards should be a final test that double checks the core knowledge that all surgeons should have mastered.  The boards should cover the concepts that keep our patients safe.  The boards should demonstrate that our residents are trained appropriately and can uniformly pass a straightforward exam designed by senior, practicing surgeons.  It should not be a tricky exam that stratifies good and poor test-takers.  It should not be administered to any person who hasn’t already demonstrated adequate knowledge and skill.  Basically, this exam should be nothing more than a checkpoint for those who have performed adequately during their 9+ years of training–not an exam that lets good surgeons fail and poor clinical performers squeak by with good test taking skills. 

Seriously, should we feel ok about a fail rate of 20%?  Do you know anyone that is so far behind that they should fail?  We are all very smart people, skimmed off from the top of our undergraduate classes and funneled through the most competitive schooling and training to attain doctorates.  If surgeons can’t teach smart people to be surgeons then who can?  And if you know a resident or practicing surgeon who has fallen behind the curve, how long did it take for them to be left behind?  How long were they allowed to train before someone intervened?  Is their failure ignorance or is it failure of the system to identify and remediate theses surgeons appropriately?  Remember, we are a profession.  Therefore it’s our job to police ourselves and maintain the standards by which we mean to present ourselves.


When Someone Fails, It Means We All Failed Together As A System

After 9+ years of education, a surgeon who fails their boards represents more than a person who has inadequately prepared, it represents a person whom the profession of surgery, or at least a training program, has failed…and, oh, if the training program / profession says that person just wasn’t good enough?  Well, why don’t we select residents (future surgeons) well enough to only allow people in who will succeed?  Aren’t we, as people who help train others, good enough to select people properly?

Now here’s a challenging statement: if we did a better job of educating our future surgeons (or at least selected them properly), then after 9 years (4 medical school + 5 residency = at least 9!) there would be no point in even having a board exam.  All of the necessary knowledge and skills would have been demonstrated by each resident by the time they were able to graduate.  There’d be no need for the “final test.”  Did that blow your mind?  Yeah.  This is where the ACGME is really starting to do something right.  With the institution of the “milestone” system of resident education and the growth of the SCORE curriculum (however painfully primitive that website remains), focus is finally shifting toward the quality of time spent in residency while using appropriate measures of competency.  Unfortunately they missed one big thing…no one has taken the time to teach our teachers how to teach.  Once again, the profession of Surgery, despite its good intentions, has fallen short. 

To my generation-Y resident, medical student and junior attending colleagues:  I’m interested in what you have to say about this topic.  Old guys / Dinosaurs:  I’m interested in your perspective as well because you have seen more change in Medicine and in surgical education than the rest of us.  Please take the time to comment below!


Do Not Underestimate The Power Of…The Control Phase

By:  DM Kashmer, MD MBA MBB (@DavidKashmer)



Keep The Gains You Made!


Have you made any gains with your quality improvement project?  If you made meaningful improvements, it is every bit as important to make sure those improvements are sustained. This is the last step in our quality improvement project: the Control Phase.



Do Not Underestimate The Power Of…The Control Phase


The importance of the control phase is difficult to overstate. It is one thing to work through all the steps of the process and to make meaningful, measurable improvements. It is entirely another thing to be able to sustain those improvements as you continue to move ahead. Make sure that routine maintenance is performed so that you can sustain improvements and have something on which you can build the rest of your program or other processes.


The control phase has several important toll gates as pictured here. One of the important steps of the control phase is to transition the project to the project owners. That means that after extended quality team has gathered around the table and measured data from the trenches, it is important to make it very clear in the control phase regarding who the process owners are. The process owners will be responsible on an ongoing basis for maintenance and reporting if there becomes an issue with the end points of the project. If, on repeated measurement at different intervals, there is a new issue with the process the process owners send out a signal that there is a problem and the end points need to be revisited.



What Tool Should I Use For My Data?


From Villanova University's Lean Six Sigma Black Belt Course, 2010
Figure 1:  How To Choose A Control Chart Type.  (From Villanova University’s Lean Six Sigma Black Belt Course, 2010)



Just as important is the question of what tool to use for the control phase. There are multiple tools available for the control phase and here we will focus on one important tool that be easily utilized in healthcare. That is the ImR chart, where ImR means “individuals moving range” chart. The ImR chart is one of the multiple types of control charts that can be performed with your data. Please review Figure 1 regarding how to choose a control chart type for your data. In healthcare processes where individuals come through the system one at a time, the ImR chart works best. This chart demonstrates where individuals fall along a continuum over time. We will discuss some important highlights of the ImR chart now.


CAUTION:  There are some things the diagram above does NOT tell you.  For example, did you know that control charts generally require normal data? In other words, if your data for a certain endpoint are non-normal, you cannot apply the straightforward, continuous data driven control charts that the diagram lists. If your continuous data are non-normal, that clean Figure 1 just doesn’t apply.  For more information regarding how to determine whether your data are normally distributed look here.


Ok, now you have established whether your data are normally distributed.   If they are non-normal you will need to create a control chart based on non-normal data. We will delve into how to do this in another blog entry. For now, let’s just highlight how ImR and other control chart types are based on normal data.



Why, Here’s An ImR Chart Now!

Beneath please see a typical ImR chart (Figure 2). Notice that if you compressed all the data points to one end or the other of the control chart and remove the factor of time you would create a normal data plot. So, now to some definitions to let you know more about ImR charts and how to know whether your process is still in control or has gone out of control.


Figure 2:  An ImR Chart Example.  Time To OR (in hours)



Before we move on, look at the top plot in Figure 2.  The green bar represents the mean/median/mode of these data.  The red bars represent the 3 standard deviation mark beyond the mean.  Any data beyond three standard deviations is considered to be MORE than the routine amount of variation expected in this system…and that makes sense.  After all, the probability of a data point being more than 3 standard deviations beyond or beneath the mean in a normal data set is less than about 1%.  So, data points outside the red bars make us ask:  “What happened?” Setting the 3 standard deviation mark as what we use to identify outliers balances the risk of type 1 vs. type 2 error here.  Note that identifying cases to review this way doesn’t mean anything was done wrong in those cases by any particular doctor or healthcare provider.  We just have to ask how did the system produce such an outlier?  For more info on type 1 vs. type 2 error, look here.


Now pretend that there was some requirement (perhaps made by your state) that trauma patients needed to be brought to the OR within 2 hours of arrival for severe abdominal injuries (if they need to go at all).  What would you think about that top date in Figure 2?  Maybe draw another line at 2 hours to represent that barrier.  What do you notice?  Well, PLENTY of points on the graph show patients as being brought to the OR outside of the 2 hour mark.  Interesting!  Those points at 2.5 hours, 2.7 hours, are completely “in control” from what we told you earlier YET THEY ARE COMPLETELY UNACCEPTABLE.  Interesting, right?  This tells you that your system is performing at its routine levels, and that routine level of performance is NO GOOD.


This is why we should NOT apply control charts until the end of a quality project:  the control chart can tell us when the system is performing routinely yet lull us to sleep.  It can tell us the system is performing routinely…yet that routine may be NO GOOD!


More On How To Use The Tool


Control charts can be further evaluated with what are called the Westinghouse rules. These have been modified over time but are still a good basic starting point. Here those Westinghouse control chart rules:


1. The most recent point plots outside one of the 3-sigma control limits.

2. Two of the three most recent points plot outside and on the same side as one of the 2-sigma control limits. 

3. Four of the five most recent points plot outside and on the same side as one of the 1-sigma control limits.

4. Eight out of the last eight points plot on the same side of the center line, or target value.

5. Six points in a row increasing or decreasing.

6. Fifteen points in a row within one sigma.

7. Fourteen points in a row alternating direction.

8. Eight points in a row outside one sigma.


However, let me tell you that not everyone exactly agrees with the Westinghouse Rules, and there are different rule sets out there.  That one is pretty standard, however.  One thing we all agree on:  a point outside of the 3 sigma (3 standard deviation red bars) control limits is just not good.  Look at those cases.


Now let’s discuss the other part of the ImR chart, the range chart. The range is a measure of variance between data points. In other words this shows us how wide the swings are in our data. It is possible to have a range which is unacceptably high and which demonstrates that there is a significant amount of variance in the system that was unexpected. This can happen even when the data point itself is in control. If we see an unusual amount of variance between data points the question becomes “Why such a wide swing and why such an unusually wide swing for our data set at our institution?”





At the end of the day the ImR chart is a very useful tool in healthcare for the control phase of the project. Remember, just as important as the particular tool is the fact that we engage in a control phase. The control phase helps us receive feedback from the system when something has gone wrong, something needs maintenance, and the “weeds need trimming”.


There are many options for the particular tools you can use during the control phase for your project. Some are listed above. As usual the question of whether your data are normally distributed is central to being able to apply a control chart in a straightforward manner. Not only are there many types of control charts, but there are also some that do not require this focus on normal data and we will discuss these at another time. Best of luck with your quality improvement project.  Please leave any thoughts or comments beneath!