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Malpractice Rates Favorable R
esidents and fellows llows who start practice in n the next few years will enter one of the most favorable malpractice actice environments of the last st decade, according to insurance e providers and practicing surgeons. ns. “The news is good for the foreseeable future. ure. The rates have stabilized, ed, they are probably not ot going to go up, and we’ll e’ll continue to see some me decreases in the mararketplace in the years rs ahead,” said Lawrence Smarr, president and chief executive officer of Physician Insurers Association of America, a Maryland-based trade association that represents medical professional liability companies owned and operated by health care providers.
However, Mr. Smarr and others warn that the medical liability insurance market is h igh ly cyclical; repeals of state tort laws or broader economic changes could increase pressures on insurers and physicians. “Some insurers do fear that we’re going to see the frequency of claims and premiums go back up again. It’s just a question of when because there is a cyclical nature to medical liability insurance.” Experts who spoke with In Training cautioned residents and fellows to educate themselves about the medical professional professiona liability insurance
INSIDE: IN TECHNOLOGY Trainees who wish to pursue a career in minimally invasive thoracic surgery can train at 1 of 130 centers in the United States.
IN PRACTICE This year, the ABSITE was administered online for the first time—residents offer insider tips on taking the exam.
see MALPRACTICE, page 6 se Brought to you by the publisher of
Medical Mobile Apps on the Rise
sk fourth-year general surgery resident Dorothy Sparks, MD, what she uses her smartphone for and that’s asking the wrong question. “What don’t I do with it?” would be the better question according to the resident at Danbury Hospital in Connecticut. In the course of a day, she might use her iPhone to calculate a patient’s surgical AGPAR score or translate a medical term into Spanish for a patient. When another
patient pulls out an unknown pill that he’s taking, Dr. Sparks uses an app to identify the drug, based on the color and markings. When describing an operation to a patient, she shows the patient an anatomy illustration on WebMD. In the operating room, she plays music with the Pandora app. During her break, she takes a picture of her paycheck and uploads it to her bank account. see MEDICAL APPS, page 4
VOL. 2, ISSUE 1 • 2011
MITS: A Training Opportunity for Residents M
inimally invasive thoracic surgery (MITS) is considered a major advance for surgery of the chest cavity—most notably, lung cancer operations. Instead of opening the chest with a rib spreader, the surgery is performed through small ports in the chest cavity. Two techniques can be used to assist MITS and allow the surgeon to see inside the chest cavity: video-assisted thoracic surgery (VATS) or robotic thoracic surgery; VATS currently is the more common technique. To become proficient at MITS, physicians can train at 1 of the 130 centers in the United States that offer courses for residents and surgeons. “The best practices for MITS include a combination of expertise and experience. Quality programs will have well-trained surgeons and experienced surgeons teaching the techniques and will turn out residents who understand how to do the procedure. This is a mentordriven process. A mentor takes you through it step by step, and residents should choose the programs with the best reputations,” said Scott Swanson MD, director of MITS at Brigham and Women’s Hospital and professor of surgery at Harvard Medical School, both in Boston. Although MITS has shown advantages over open procedures, not all patients are candidates for MITS. Open surgery is a better choice for patients with large tumors or areas of disease, disorders that interfere with normal blood clotting, and patients who require chemotherapy and radiation prior to surgery.1,2 When feasible, surgeons prefer MITS to open surgery, as it is associated with reduced trauma and pain, minimal blood loss, an easier recovery, shorter hospital length of stay (LOS), and faster return to normal functioning.1 “Although these advantages apply to all types of minimally invasive surgery compared with open procedures, outcomes are magnified in procedures in the thorax,” said Dr. Swanson. “The incision to perform an open surgery of the thorax has greater morbidity than that of the abdomen.” Despite the advantages of MITS over open thoracic surgery, many thoracic procedures amenable to a minimally invasive approach are still performed via the open method. Some surgeons do not consider MITS a “real” operation. “This is mostly due to training. It’s an educational situation, where older surgeons in practice are less likely to transition to a minimally invasive approach,” said Dr. Swanson. When applying for a training program, it is important to consider the range of procedures that each center offers. Effective MITS training programs offer guidance from surgeons with a high level of expertise and experience in performing these procedures. In lobectomies, for example, experience and expertise are important to consider. Of the 40,000 lobectomies performed in the United States each year, approximately 5% are performed using VATS.1 “There
Figure. This stapler is the Echelon Flex™ Articulating Endoscopic Linear Cutter.
are myriad reasons, but the major one is volume. Centers that train for MITS, such as Cedars-Sinai [Los Angeles], perform about 250 lobectomies per year, but there are surgeons who do just a few lobectomies per year, so that environment is not conducive for transitioning to a minimally invasive approach,” said Robert McKenna, MD, chief of thoracic surgery at Cedars-Sinai Hospital. Beyond the common VATS procedures for wedge resection, spontaneous pneumothorax, and pleural effusion, a quality MITS program should include minimally invasive lobectomies plus lymph node sampling, thymectomies, and minimally invasive esophagectomy. “We are in an era where top-quality programs should be doing all of these types of procedures,” said Dr. McKenna. Cedars-Sinai is one of the pioneers in MITS and VATS training opportunities. It offers courses once or twice a month that include lectures, videos, and most important, the opportunity to observe actual surgeries. “The most common MITS we do are lobectomy and node dissection for lung cancer and currently, 95% of lobectomies are performed with VATS [at Cedars-Sinai],” said Dr. McKenna. When it comes to approaches to MITS, it varies institutionally and personally. “Leaders in MITS have slightly different approaches based on their philosophies. Surgeons at Duke University [Durham, NC] will do a specific procedure differently than those at Cedars-Sinai, and than those at Brigham and Women’s Hospital. The surgeon needs to choose an approach that appeals to them and make the incisions the same way every time they do that type of procedure, so it becomes a ritual.” For example, when removing lung cancer and the lymph nodes—the most common MITS applications—Dr. McKenna noted that surgeons can perform either lymph node sampling or full dissection. A recent study of 1,111 patients with non–small cell lung cancer (NSCLC) found that lymph node sampling in prespecified areas of the chest had equal outcomes compared with complete lymph node dissection.3 Ultimately, the main way to create widespread adoption of MITS in the surgical landscape is through training, training, and more training. Dr. McKenna suggests surgeons go to a training center twice: once to learn the
2011 â€˘ VOL. 2, ISSUE 1
IN TECHNOLOGY basics, then again 6 months later after performing MITS procedures to address any issues they have encountered. Proper port placement is an important part of MITS training and varies for each type of surgery. The target area must be triangulated using 3 ports placed symmetrically around the target, â€œbut the specific location [of these ports] depends on the surgical site,â€? said Dr. Swanson. A 2010 VATS lobectomy study found that a 3-incision technique provided quality outcomes that maximize the benefits of this minimally invasive approach.4 The surgeons created a 2-cm camera port, a 2-cm posterior port, and a 4-cm utility incision on 600 patients with stage I NSCLC. There were no operative deaths, and the average LOS was 4 days.4 A crucial aspect of MITS is a thorough understanding of the relationship between staple lines, tissue, and quality outcomes. Adequate tissue compressionâ€” typically 15 secondsâ€”is of vital importance to ensure that all fluids leave the area before firing the stapler.5 Proper compression lowers the risk for edema and bleeding while promoting healing. In terms of complications, air leak is serious and has an estimated incidence of 15% for all patients undergoing lung surgery.6 Lung cancer patients with emphysema have severely damaged tissue and a greater risk for leaks, so selecting the proper staple height is vital and applying adequate tissue compression is of the utmost importance. Normal lung tissue is thin and friable, so shorter staples are sufficient to promote pneumostasis. Thicker lung tissue, especially that caused by inflammation or edema, requires larger staples for adequate compression. Current linear cutters can both cut tissue and deliver 2 double-staggered rows of staples (Figure). These devices feature system-wide compression to create uniform, consistent staple formation. They offer reloads with multiple staple sizes, which minimizes the number of instrument exchanges required during procedures. The new generation of energy delivery devices also offer improved versatility. These devices produce safer tissue seals by reducing thermal spread and minimizing collateral damage. They can simultaneously seal and transect tissue, expanding the opportunities for MITS applications. Dr. McKenna believes that 12-month MITS fellowships offer an excellent training opportunity. At Cedars-Sinai, 2 fellows are accepted each year, and they get to experience about 500 to 600 MITS procedures during that time (about 100 are lobectomies). â€œThere is a learning curve for attending physicians to figure out how to do MITS, and then there is another learning curve for them to teach a resident,â€? Dr. McKenna said.
McKenna RJ Jr, Houck W, Fuller CB. Video-assisted thoracic surgery lobectomy: experience with 1,100 cases. Ann Thorac Surg. 2006;81(2): 421-425; discussion 425-426.
McKenna RJ Jr, Houck W. New approaches to the minimally invasive treatment of lung cancer. Curr Opin Pulm Med. 2005;11(4):282-286.
3. Darling GE, Allen MS, Decker P, et al. Randomized trial of mediastinal lymph node sampling versus complete lymphadenectomy during pulmonary resection in patients with N0 or N1 (less than hilar) non-small cell carcinoma. J Thorac Cardiovasc Surg. 2011;141(3):662-670. 4. Flores RM. Video-assisted thoracic surgery (VATS) lobectomy: focus on technique. World J Surg. 2010;34(4):616-620. 5. Baker RS, Foote J, Kemmeter P. The science of stapling and leaks. Obesity Surg. 2004;14(10):1290-1298. 6. Downey DM, Harre JG, Pratt JW. Functional comparison of staple line reinforcements in lung resection. Ann Thorac Surg. 2006;82(5):1880-1883.
Editorial Board Frederick Greene, MD Chairman, Department of Surgery Carolinas Medical Center Clinical Professor of Surgery University of North Carolina at Chapel Hill School of Medicine Chapel Hill, NC William B. Inabnet, MD Chief, Division of Metabolic, Endocrine and Minimally Invasive Surgery Director of Surgical Sciences, Metabolism Institute Mount Sinai Medical Center New York, NY Adrian Park, MD Campbell and Jeanette Plugge Professor Vice Chair, Department of Surgery Head, Division of General Surgery University of Maryland Medical Center Baltimore, MD J. Scott Roth, MD Associate Professor of Surgery Commonwealth Professor of Minimally Invasive Surgery Chief of Gastrointestinal Surgery and Director of Minimally Invasive Surgery University of Kentucky, College of Medicine Lexington, KY Copyright ÂŠ 2011
1CAB=;;327/ 545 West 45th Street, New York, NY 10036. Printed in the USA. All rights reserved, including the right of reproduction, in whole or in part, in any form. June 2011. Supported by
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MEDICAL APPS continued from page 1
“I use my iPhone for everything from calculating APACHE scores to making restaurant reservations,” said Dr. Sparks, the creator of several surgical apps, one
Useful Surgical Apps
edical publishing companies offer textbooks as apps through a “living” medical book where books are updated as more evidence becomes available. Books available as apps include: • “Zollinger’s Atlas of Surgical Operations,” “Schwartz’s Manual of Surgery,” and “The Oxford Handbook of Clinical Surgery.” Anatomy programs available as apps include: • IMAIOS (highly rated by the physician reviewers at www. imedicalapps.com), Netter’s Atlas of Anatomy and Gray’s Anatomy Deluxe, which features high-resolution images of 1,247 anatomy plates; • Residents studying for their ABSITE exams have several exam-study apps to choose from. Dr. Sparks’ free Pass the ABSITE app, recognized as one of the best poster presentations at the American College of Surgeons 96th Annual Clinical Congress, is now available on iTunes. Specific apps for surgeons include: • I-surgery Notebook ($1.99), a surgical logbook that allows users to track cases and procedures, including pre- and postoperative diagnoses and the type of anesthesia used; • SurgAware ($2.99), a reference list for the informed consent process; • Surgery On Call ($3.99), which covers clinical evaluation and management for surgical problems; • DrChrono, an electronic health record (EHR) iPad app (which can be integrated with Smartphones to pull basic patient information and track appointments) allows physicians to perform full H&Ps (with customizable templates), write SOAP notes, e-prescribe, capture videos and images, schedule patients, input data using real-time medical speech, and fax patient records. Four different price tiers are offered (free versions with basic EHRs through a $199-per-month option, based on the number of users per institution). Popular free apps for health care professionals include: • Medscape, which offers 7,000 drug references, 3,500 clinical disease references, 2,500 clinical images and procedure videos, a drug interaction tool checker, and CME activities; • The New England Journal of Medicine, a highly successful app of the journal, which provides access to 7 days worth of published articles, illustrations, and how-to procedure guides; • Epocrates, which is one of the highest-rated medical reference tools by health care professionals with content on drug monographs, drug interactions, and medical calculators; • Radiology 2.0: One Night in the ED, simulates casebased CT scans to teach residents and med students how to interpret them based on pathology and relevant findings.
designed to quiz residents on ABSITE questions and another to calculate the surgical AGPAR score. Mobile technology has changed residency, both in and out of the hospital, she noted. S mar tph on e s — in clu din g i P ho nes, Androids, and Blackberrys—are quickly replacing the pager by providing means of instantaneous communication in trauma cases, emergency consults, and routine clinical activities. “At work, the residents communicate both among themselves as well as with attendings, almost exclusively by cell phone via text messaging or conversation,” said Dr. Sparks. Tablets and smartphones are rapidly replacing textbooks as a medium for learning. Mobile technology varies by hospital and doctor but, across the board, there’s been a shift in the way residents use technology. Take Toronto’s Mount Sinai Hospital, where the iPhone is now fully integrated into the hospital’s operation, allowing doctors to access patient charts and results whether the physician is in-house or at home. The Toronto experience shows that “a dramatic change in the way that we practice both medicine and surgery really is attainable in the foreseeable future,” wrote the authors of a recent article on iPhones and surgeons.1 Educators and residents say that these devices are particularly useful to trainees, many of whom are adept with the technology before they start medical school. That’s a fact not lost on Stanford University Medical School, where all first-year medical students received iPads this fall. In a statement explaining the decision, Charles Prober, MD, the school’s senior associate dean for medical education, said the iPad and similar devices provide a tech-savvy generation with easy access to huge stores of information. “Part of the challenge facing medical students, and all doctors, is the overwhelming amount of information. Devices like the iPad may be able to help users access that pool of information.” It’s not a question of which device you purchase but what you do with it, said Joseph Kim, MD, an internist and founder of medicalsmartphones.com. He said surgical residents and fellows benefit from mobile technology in 3 ways: education, practice management, and life management. On the education front, smartphones and tablets offer everything that a room full of medical textbooks does and more. In practice management, mobile technology allows physicians to communicate faster than the old pager system. Dr. Kim also noted that devices can be used for clinical decision support such as confirming medications or steps in bedside procedures. He advises residents to answer questions as soon as
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IN TECHNOLOGY possible, “This will improve the process of retention.” The iPad likely will expand mobile technology in the operating room even further, experts predict. In a recent article in Interactive CardioVascular and Thoracic Surgery, Swiss surgeons describe using an iPad to display and manipulate 3-dimensional anatomic images during a lung segmentectomy.2 In the Journal of Surgical Radiology, Georgetown University Hospital orthopedic surgeon Felasfa Wodajo, MD, describes using his iPad during surgeries to view patient images and records, after covering it in a plastic sheath.3 HIPAA regulations are currently the major limiting factors for mobile technology, said Howard Luks, MD, associate professor of orthopedic surgery at New York Medical College who tweets and blogs about his work. Mobile technology has yet to catch up with the privacy laws, thereby limiting its applicability in the hospital. He warns residents against snapping photos in the operating
Lost in Translation
ressed for time, appointments scheduled back to back, surgeons may realize that the patient in front of them does not speak English. Waiting for an interpreter to come to the room seems like a time-guzzling hassle. And despite federal requirements, many hospitals offer less than stellar in-house translation services, especially for the second and third most common languages spoken by their patients.1 Approximately 55.4 million US residents speak a language other than English at home, a number that is expected to increase for decades to come, according to the US Census Bureau.2,3 Most of these people—34.5 million—speak Spanish at home; however, more than 1 million people each speak Chinese, French, Vietnamese, German, or Korean at home. With language translation apps now available for mobile phones, surgeons have immediate access to translation services. The apps require physicians to speak into the device or choose a phrase on its screen. Then the patient listens or reads the translated language on the mobile device. Medical translation apps include: • MediBabble (www.medibabble.com), a free app that offers 2,000 physician-approved queries and directives to communicate with patients who speak Spanish, Cantonese, Mandarin, Russian, and Haitian Creole. Available for iPhone and iPad and works without an Internet connection—a plus because reception in the hospital can be unreliable and WiFi nonexistent; • Medical Spanish (www.medicalspanishapp.com; $6.99), made by Batoul Apps. Created by health care providers and offers over 3,000 phrases with playback audio. It features a pharmacy section that offers advice for instructing patients on taking medications, and a search function where key phrases can be bookmarked. It also offers a section on medicinal herbs commonly used by the Hispanic population; • Xprompt Multilingual Assistance app (http://xprompt.com; $6.99), made by Blue Owl Software. The basic package includes English, German, and Spanish; 20 additional languages are available for $2.99 each. Every language includes 800 commonly used medical phrases, and includes British and German sign language options with video playback.
room. “That’s not allowed under our hospital guidelines. It’s not allowed under HIPAA. De-identification of patients is actually far more difficult than you think,” he said. However, the technology is adapting. One new tool— Tiger Text—is a secure text-messaging system that allows the sender to delete a message at a set time. The messages are deleted from the phone and the server. “It is a HIPPA-compliant system.” Doximity is another physician communication system that allows for secure texting and emailing, including transfer of high-resolution images.
Dala-Ali BM, Lloyd MA, Al-Abed Y. The uses of the iPhone for surgeons. Surgeon. 2011;9(1):44-48.
Volonté F, Robert JH, Ratib O, Triponez F. A lung segmentectomy performed with 3D reconstruction images available on the operating table with an iPad. Interact Cardiovasc Thorac Surg. 2011 Mar 8. [Epub ahead of print]
The iPad in the hospital and operating room. J Surg Rad. http://www.surgisphere.com/SurgRad/issues/volume-2/1-january-2011-pages-1-112/152-columnthe-ipad-in-the-hospital-and-operating-room.html. Accessed April 6, 2011.
Nonmedical translation apps: • Google Translate (http://translate.google.com), this free service does not require Internet access and works on iPads and all types of smartphones; • Jibbigo (www.jibbigo.com $24.99), no Internet access required. Compatible with iPads and all Smartphones; • SpeechTrans (http://speechtrans.com; $19.99), requires Internet access and is only available for the iPhone and iPad; • myLanguagePro (www.mylanguage.me/applications/ mylanguage-translator; $4.99), requires Internet access and is only available for the iPhone and iPad. One thing to be wary of when using these devices, however, is cultural differences and how phrases can become lost in the translation. “Translation of words is only part of understanding the patient’s response—it’s the connotation of the words and the cultural meaning of them. We tend to lose that part because we’re so focused on verbal communication,” said Laura Robbins, DSW, senior vice president of education and academic affairs, designated officer for the Graduate Medical Association at the Hospital for Special Surgery in New York City. Dr. Robbins recommends that physicians be cognizant of how they communicate through their physical actions. For example, it is important to maintain eye contact and speak directly with the patient, regardless of the mode of translation. “In many cultures, the social interaction and the relationship with the physician—as small as it might be—is very crucial,” she said. Determining the best treatment plan may require a physician to discuss, through an interpreter, what the patient believes the problem is, and what they believe the treatment should be. Otherwise, “You may choose a treatment plan that’s not going to be effective,” she said.
Diamond LC, Wilson-Stronks A, Jacobs EA. Do hospitals measure up to the national culturally and linguistically appropriate services standards? Med Care. 2010;48(12):1080-1087.
Shin HB, Kominski RA. Language Use in the United States: 2007. American Community Survey Reports, ACS-12. Washington, DC: US Bureau of the Census; 2010.
3. US Census Bureau Newsroom Web site. An older and more diverse nation by midcentury. http://www.census.gov/newsroom/releases/ archives/population/cb08-123.html. Accessed May 26, 2011.
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MALPRACTICE continued from page 1
industry, saying that they can spare e themselves dollars and distress in n future years by learning how the indus-try works. “Residents spend many yearss perfecting their skills—their clinical skills. kill But stepping out into practice is very different. Medical malpractice insurance is simply not something that many of them are trained in,” said Tom Cotten, chief operating officer of Capson Physicians Insurance Company, based in Texas. It’s important for residents to know what’s going on today in the market and what the history of medical malpractice is in the United States, noted F. Dean Griffen, MD, chair of the American College of Surgeons Committee on Professional Liability and professor of clinical surgery at Louisiana State University Health Service Center, in Shreveport. When Dr. Griffen was a resident in the late 1960s, he moonlighted without insurance. “I never even thought about being sued.” That changed, however, in the 1970s. Litigation increased against all established professions, medicine included. Insurers found it difficult to price coverage accurately and by 1975, many dropped physicians from coverage—sparking the first malpractice
What To Expect Today
he annual Medical Liability Monitor survey revealed that physicians paid the same amount for medical liability insurance premiums in 2010 as in 2009, with 67% of rates remaining stable across the nation.a That represents the largest percentage of stagnant premiums in recent years, according to an American Medical Association policy research report. However, the rates vary dramatically from state to state, region to region, and specialty to specialty. For example, physicians in New York’s Nassau/Suffolk counties paid higher-than-average rates, whereas physicians in Dallas saw their rates decrease by about 8% annually since legislative changes made in 2003. General surgeons in Nassau/Suffolk paid $104,054 in 2009 for claims-made coverage from Physicians Reciprocal Insurers. In Dallas, general surgeons paid $57,140 for similar coverage from The Doctors’ Company. In both states, OB/GYNs paid considerably more than their general-surgery colleagues—$194,935 in New York and $66,625 in Texas. And within a state, rates fluctuate widely, even from a single insurer. In California, The Doctors Company’s rates for general surgeons range from $23,365 in the San Francisco area to $41,775 in Los Angeles. The highest premiums charged to general surgeons were in Dade County, Florida, at $192,982, and Wayne County, Michigan, at $143,445. The lowest premiums were in Minnesota at $11,306 and South Dakota at $12,569. a To obtain medical malpractice insurance rates in your state, please visit http://mymedicalmalpracticeinsurance. com/medical-malpractice-insurance-rates.php.
crisis. The si situation improved after many states created tort reform legislation and some medical ssocieties formed their own insurance carriers.1 Malpractice crises occurred again in the 1980s, 1990s, and 2000s, during periods of high premiums and limited p coverage for physicians due to financial risk. cove Cycles repeat themselves, cautioned Mr. Cotten, “so we C l t are always on the alert to see anything that would indicate that more claims are being filed against physicians or the cost for settling them has gone up.” Today, medical professional liability insurers sell primarily 2 types of coverage—occurrence and claimsmade. Occurrence coverage protects a physician against all claims that arise from an event that takes place during the policy, regardless of when the claim is reported. Claims-made policies cover an insured against claims reported during the policy. A claim must both occur and be reported while the policy is in effect. Claimsmade coverage accounts for about 80% of policies in the United States, according to Mr. Smarr. Because of the “long tail” of occurrence coverage, it’s hard for companies to predict the long-term costs associated with these policies. As a result, few companies offer occurrence coverage. When they do, the premiums are considerably higher. Tail coverage is essential for all physicians, but particularly for younger ones, said Scott Ransom, DO, president of the University of North Texas Health Science Center, in Fort Worth. Tail coverage, also known as reporting endorsement, protects the physician against claims that are reported after claims-made coverage expires. For example, for a physician who leaves a practice to start somewhere new, tail coverage would cover any claims made by patients treated at the first practice but filed after the physician has moved. Given that half of new attending physicians seek new employment within the first 3 years of practice, “it’s very important to have that tail covered up front,” said Dr. Ransom. Most larger and university practices have a tail built into their malpractice coverage. In smaller practices or practices unaccustomed to physician turnover, new attendings “need to be very wary because tail coverage can be an incredibly costly mistake if it’s not dealt with up front.” It can cost about $150,000 to obtain tail coverage at the end of a claims-made policy, noted Dr. Ransom. This coverage is a guarantee by the insurance company that if the doctor dies, becomes disabled, or retires after a certain number of years of insurance coverage, the tail will be paid for by the company. “That’s an important benefit and something I would definitely ask for,” said Mr. Smarr. Most policies range from $1 million to $3 million, noted both Dr. Ransom and Mr. Cotten. It’s important to consider state law, a state’s medical liability limits, and other liabilities.
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Resident Insider Tips on the ABSITE I n January each year, thousands of general surgery residents across the country take the American Board of Surgery In-Training Examination (ABSITE). In 2011, the exam was administered online for the first time. Matthew Koopmann, MD, a general surgery resident at the University of Wisconsin in Madison, has taken the ABSITE 6 times. He began by developing a “fund of knowledge” by reading a standard surgical textbook cover to cover—in his case, Schwartz’s Principles of Surgery. He often dovetailed the section he was reading with the cases he was observing in the wards. About 2 months before the exam, residents should move onto question-based learning. This means “getting in the habit of answering questions over and over again,” said Nancy Harthun, MD, associate professor of surgery at Johns Hopkins School of Medicine in Baltimore. This will help prepare them to rapidly answer 225 questions during the 5 hours allotted for the exam. Many standard surgical textbooks, such as Schwartz’s Principles of Surgery, also have supplementary ABSITE review books; perhaps the most popular review text is Dr. Steven M. Fiser’s The ABSITE Review, which Dr. Koopmann said he used early on. After basic knowledge is established around the third
or fourth year of residency, it’s best to focus on answering problem-based questions. “I do not read review books anymore, I just do test questions,” said Dr. Koopmann. He now uses the American College of Surgeons’ (ACS) Surgical Education and Self-Assessment Program (SESAP), a continuing medical education resource for practicing physicians and a study tool for the Maintenance of Certification exams, which the ABS also now recommends for residents taking the ABSITE. In recent years, the ACS and the ABS have started working together on certification exams. Although “the ABS is not aware that any one review book is better than another,” its test-taking guide does note that the SESAP’s questions are prepared by a panel of prominent surgeons, so “the correct answers are more likely to represent a consensus than a review book that may reflect the view of just one individual.”1 Recently, a number of smartphone apps have been developed to help residents study for the ABSITE. The Pass the ABSITE app was recognized as one of the best poster presentations at the American College of Surgeons 96th Annual Clinical Congress. The free app was created by Dorothy Sparks, MD, and is available on iTunes.
Surgeons should ask about coverage for defense costs. “Make sure that defense costs, such as attorny fees and [procuring] medical records, are paid outside of that $1 million,” said Mr. Cotten. “If you have a lawsuit that drags on for several years, the defense costs can amount to hundreds of thousands of dollars and you don’t want to erode that $1 million worth of coverage in the event that you do have to pay an indemnity payment.” New attendings are offered significantly reduced premiums compared with physicians who have been in practice for many years, with discounts between 35% and 50%, according to Mr. Cotten. “A physician who is just leaving residency probably doesn’t have any claims against them and that’s something we take into account at Capson,” he said. Other things insurers look at include a physician’s specialty, the scope of practice, whether the physician does minor and major surgery, and the liability limits in the states where the practice is located. Although insurers do consider the frequency and severity of past claims, they generally do not look at clinical outcomes. Physicians and other practitioners started forming their own malpractice insurance companies in the mid-1970s, when skyrocketing claims and soaring premiums forced
many commercial companies to stop offering malpractice insurance. About 60% of the country’s doctors are covered by mutual insurance companies, which are owned or operated by physicians.2 Experts advise new surgeons to look at the financial stability of their potential insurance carrier. “It’s important to consider the cost of the premiums as well as the quality of the company itself and its ability to sustain in the marketplace,” said Mr. Smarr. Companies are graded by rating organizations such as AM Best and Fitch, Inc. “They are not always right, but it is one rubric that can help a physician in making that decision.” Physicians should ascertain whether a company will grant them the right of consent to settle their claim, a right not permitted in all states. It gives the physician a role in the decision as to whether or not the claim gets paid.
see ABSITE, page 8
Sage WM. The forgotten third: liability insurance and the medical malpractice crisis. Health Aff. 2004;23(4):10-21.
Physician Insurers Association of America: About us. http://www.piaa.us/ AM/ContentManagerNet/HTMLDisplay.aspx?ContentID=7301&Section= About_Us. Accessed May 7, 2011.
For information on the latest surgical topics, procedures, and devices, please visit the new educational web site www.eeseducation.com.
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The role of intensive review courses is less clear. Residents have a wide range of choices for ABSITE preparation. Online courses, such as www.absite.org, cost around $75; live 2-day seminars offered throughout the winter can cost up to $475, not including accommodations at the review site. One recent survey of program directors found 60% agreed that review courses help the performance of their residents on the ABSITE, but 80% had no institutional or regional review curriculum. Similarly, 90% allowed their residents to attend commercial review courses, but 60% did not reimburse them.2 Ultimately, Dr. Harthun advised that it is important to understand just how competitive the test is and to avoid overreacting about a bad score. “Twenty questions one way or the other can put you at the far ends of the curve,” she said. However, a poor result isn’t the end of a young surgeon’s career. “No one has ever proven a correlation between ABSITE scores and clinical performance, and that has been researched a few times,” Dr. Harthun said. When residents in his department do poorly, Dr. Matthews sees it as a wake-up call to balance their natural judgment and instincts with an increased knowledge base. “I tell them, quite frankly, some of the most gifted surgeons that I have known have initially performed poorly on standardized tests,” he said. Although the test often is seen as a yardstick for a resident’s surgical abilities, this can be a misguided approach. “The real purpose of the ABSITE is to evaluate the programs and not so much the individual taking the exam,” said Dr. Harthun. “Some people lose track of that.” In fact, the American Board of Surgery (ABS) does not provide residents with a score report or “transcript.” Instead, results are given directly to program directors to gauge the progression of the surgeons-in-training in their program. “There is no such thing as failing the ABSITE,” said Jeffrey Matthews, MD, Dallas B. Phemister Professor of Surgery, chair of the Department of Surgery at the University of Chicago Medical Center in Illinois, and associate editor of Schwartz’s Principles of Surgery. In one respect, however, the importance of the test is clear: ABSITE scores directly correspond to passing or failing the General Surgery Qualifying Exam at the end of residency training. Several studies have looked at the relationship and found that scoring below the 30th or 35th percentile during residency leads to a higher risk for failing the exam.3,4 The test itself is familiar to senior-level residents; however, for junior residents, the severity of the exam can come as a bit of a shock. “All residents have had a pretty stellar history of doing well on tests and in school, but the
exam is so rigorous that a certain percentage of people are going to have trouble every year,” said Dr. Harthun. “This can be devastating.” Doing well on the exam begins with understanding its structure and format. There are 2 versions: The juniorlevel exam contains a 60% focus on basic science and a 40% focus on the management of clinical problems during surgery; the senior-level exam comprises a 20% focus on basic science and an 80% focus on managing clinical issues during surgery. All of the questions go through a highly rigorous drafting process, starting with program directors and consultants and ending with psychometric testing that throws out invalid or unclear questions. As a result, the ABS implores residents to not “make any assumptions about the circumstances of the question. Choose your response on the premise that there is no wasted ink!”3 Residents run into trouble when “they get too fancy with it,” said Dr. Matthews. “It’s core knowledge based on a standard curriculum. Focus in on the straightforward scenario and do not make the question more complicated than it is.” Residents who have had success with the ABSITE use study techniques that reflect this advice. Please visit www.intrainingsurgery.com to share your experience taking the 2011 ABSITE online.
American Board of Surgery. The guide to ABS multiple-choice examinations. http://home.absurgery.org/xfer/ABSTestGuide.pdf. Accessed June 2, 2011.
Taggarshe D, Mittal V. Improving surgical resident’s performance in the American Board of Surgery in Training Examination (ABSITE)—do review courses help? The program directors’ perspective. J Surg Educ. 2011;68(1):24-28.
3. de Virgilio C, Chan T, Kaji A, Miller K. Weekly assigned reading and examinations during residency, ABSITE performance, and improved pass rates on the American Board of Surgery Examinations. J Surg Educ. 2008;65(6):499-503. 4. de Virgilio C, Yaghoubian A, Kaji A, et al. Predicting performance on the American Board of Surgery qualifying and certifying examinations: a multiinstitutional study. Arch Surg. 2010;145(9):852-856.
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