- Email: [email protected]
Response to New US Medical Schools to Open Doors
Correspondence potential for outcome bias suggests that outcomes should be stripped whenever possible from these cases, as well. Random peer review, with outcomes removed, might ultimately prove most useful for generating consistent understanding of the quality of care actually provided. In the realm of malpractice litigation, cases submitted for expert review, particularly court-appointed expert review, might also be stripped of evidence of the outcome. In states that require a certificate of merit or other preliminary review, removing details of the outcome might add appropriate nuance to the process. Alternatively, expert review might require comparison with one or more similar cases, each with unknown outcomes, hiding the actual case and therefore the actual outcome from the reviewer. Stripping real cases of information about their outcomes before review comes with its own challenges. Most case review allows full access to the medical record, an approach that could arguably emphasize outcomes bias as complications lead to more extensive documentation. How to develop cases with sufficient detail for review but without the detail that leads to bias will require its own investigation.
Malkeet Gupta, MD, MS David L. Schriger, MD, MPH UCLA Emergency Medicine Center UCLA School of Medicine Los Angeles, CA
Stephen M. Schenkel, MD, MPP Department of Emergency Medicine University of Maryland School of Medicine Department of Emergency Medicine Mercy Medical Center Baltimore, MD
To the Editor: I applaud Jan Greene’s “New US Medical Schools to Open Doors: But Residency Shortage Still the Bottleneck,” especially her analysis of how the recent and projected growth in medical education will solve neither the challenges associated with current residency slot restrictions nor the geographic maldistribution of physicians practicing in the United States. In addition to the growth among MD schools Ms. Greene discusses, osteopathic medical colleges also are growing. During the last decade, osteopathic medical education has grown from 19 colleges with just over 10,300 students to 26 colleges with more than 19,400 students. The nation’s 26 colleges of osteopathic medicine, 4 branch campuses, and 4 additional teaching sites are now educating more than 20% of all new US medical students. Osteopathic medical schools graduated 3,631 new physicians in 2010, a number that is expected to increase to 5,849 by 2019. Some 360 (nearly 10%) of last year’s graduating osteopathic physicians (DOs) entered emergency medicine residencies, a number that will increase as the number of new DOs entering the workforce increases annually. Colleges of osteopathic medicine have a long history of dedication to training physicians to work in America’s smaller communities, rural areas, and underserved urban areas, allowing DOs to have a greater influence on the US population’s health and well-being than their numbers would suggest. I am hopeful that, with the help of the nation’s growing number of DO and MD medical colleges and the emergency physicians they graduate, and with support from the federal government agencies that are being encouraged to broaden programs to improve both residency funding and the distribution of US physicians, we can avert a crisis.
doi:10.1016/j.annemergmed.2011.05.022
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The author is an unpaid board member of the Maryland Patient Safety Center. 1. Gupta M, Schriger DL, Tabas JA. The presence of outcome bias in emergency physician retrospective judgments of the quality of care. Ann Emerg Med. 2011;57:323-328. 2. Wears RL, Nemeth CP. Replacing hindsight with insight: toward better understanding of diagnostic failures. Ann Emerg Med. 2007; 49:206-209. 3. Schenkel SM. Morbidity and mortality conference and patient safety in emergency medicine. In: Croskerry P, Cosby KS, Schenkel SM, et al, eds. Patient Safety in Emergency Medicine. Philadelphia, PA: Lippincott Williams & Wilkins; 2009:295-301.
In reply: We thank Dr. Schenkel for his kind letter and endorse his recommendations for limiting outcome bias from a number of education, clinical, and medicolegal settings. Dr. Schenkel’s ideas represent the type of discussion that we had hoped would occur as a result of our research. We encourage other readers to similarly develop and apply their ideas for limiting outcome bias. Volume , . : November
Jeffrey A. Tabas, MD UCSF School of Medicine San Francisco, CA doi:10.1016/j.annemergmed.2011.05.023
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). Dr. Schriger is supported by an unrestricted grant from the Korein Foundation.
Response to New US Medical Schools to Open Doors
Annals of Emergency Medicine 499
Correspondence The American Association of Colleges of Osteopathic Medicine represents the 26 US colleges of osteopathic medicine and their faculties, students, and administrators. Stephen C. Shannon, DO, MPH American Association of Colleges of Osteopathic Medicine Chevy Chase, MD
doi:10.1016/j.annemergmed.2011.05.026
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The author has stated that no such relationships exist.
IMAGES IN EMERGENCY MEDICINE (continued from p. 496)
DIAGNOSIS: Black widow spider bite. The insect was identified as a black widow spider because the patient brought it with him to the emergency department. The patient was treated with multiple dosages of intravenous diazepam and morphine for pain control and control of his hypertension and tachycardia. He improved overnight and was discharged home in good condition, not requiring administration of antivenin.
500 Annals of Emergency Medicine
Volume , . : November
Malkeet Gupta, MD, MS David L. Schriger, MD, MPH UCLA Emergency Medicine Center UCLA School of Medicine Los Angeles, CA
Stephen M. Schenkel, MD, MPP Department of Emergency Medicine University of Maryland School of Medicine Department of Emergency Medicine Mercy Medical Center Baltimore, MD
To the Editor: I applaud Jan Greene’s “New US Medical Schools to Open Doors: But Residency Shortage Still the Bottleneck,” especially her analysis of how the recent and projected growth in medical education will solve neither the challenges associated with current residency slot restrictions nor the geographic maldistribution of physicians practicing in the United States. In addition to the growth among MD schools Ms. Greene discusses, osteopathic medical colleges also are growing. During the last decade, osteopathic medical education has grown from 19 colleges with just over 10,300 students to 26 colleges with more than 19,400 students. The nation’s 26 colleges of osteopathic medicine, 4 branch campuses, and 4 additional teaching sites are now educating more than 20% of all new US medical students. Osteopathic medical schools graduated 3,631 new physicians in 2010, a number that is expected to increase to 5,849 by 2019. Some 360 (nearly 10%) of last year’s graduating osteopathic physicians (DOs) entered emergency medicine residencies, a number that will increase as the number of new DOs entering the workforce increases annually. Colleges of osteopathic medicine have a long history of dedication to training physicians to work in America’s smaller communities, rural areas, and underserved urban areas, allowing DOs to have a greater influence on the US population’s health and well-being than their numbers would suggest. I am hopeful that, with the help of the nation’s growing number of DO and MD medical colleges and the emergency physicians they graduate, and with support from the federal government agencies that are being encouraged to broaden programs to improve both residency funding and the distribution of US physicians, we can avert a crisis.
doi:10.1016/j.annemergmed.2011.05.022
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The author is an unpaid board member of the Maryland Patient Safety Center. 1. Gupta M, Schriger DL, Tabas JA. The presence of outcome bias in emergency physician retrospective judgments of the quality of care. Ann Emerg Med. 2011;57:323-328. 2. Wears RL, Nemeth CP. Replacing hindsight with insight: toward better understanding of diagnostic failures. Ann Emerg Med. 2007; 49:206-209. 3. Schenkel SM. Morbidity and mortality conference and patient safety in emergency medicine. In: Croskerry P, Cosby KS, Schenkel SM, et al, eds. Patient Safety in Emergency Medicine. Philadelphia, PA: Lippincott Williams & Wilkins; 2009:295-301.
In reply: We thank Dr. Schenkel for his kind letter and endorse his recommendations for limiting outcome bias from a number of education, clinical, and medicolegal settings. Dr. Schenkel’s ideas represent the type of discussion that we had hoped would occur as a result of our research. We encourage other readers to similarly develop and apply their ideas for limiting outcome bias. Volume , . : November
Jeffrey A. Tabas, MD UCSF School of Medicine San Francisco, CA doi:10.1016/j.annemergmed.2011.05.023
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). Dr. Schriger is supported by an unrestricted grant from the Korein Foundation.
Response to New US Medical Schools to Open Doors
Annals of Emergency Medicine 499
Correspondence The American Association of Colleges of Osteopathic Medicine represents the 26 US colleges of osteopathic medicine and their faculties, students, and administrators. Stephen C. Shannon, DO, MPH American Association of Colleges of Osteopathic Medicine Chevy Chase, MD
doi:10.1016/j.annemergmed.2011.05.026
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The author has stated that no such relationships exist.
IMAGES IN EMERGENCY MEDICINE (continued from p. 496)
DIAGNOSIS: Black widow spider bite. The insect was identified as a black widow spider because the patient brought it with him to the emergency department. The patient was treated with multiple dosages of intravenous diazepam and morphine for pain control and control of his hypertension and tachycardia. He improved overnight and was discharged home in good condition, not requiring administration of antivenin.
500 Annals of Emergency Medicine
Volume , . : November