DB’s Medical Rants

Thanks to our favorite Dinosaur for writing this - Guidelines Gone Wild

I cannot add to Dino’s outstanding rant.

Risks of Tight Glucose Control in ICU May Outweigh Benefits

Against conventional wisdom, tight glucose control in critically ill patients has not reduced in-hospital death rates. Instead, according to a meta-analysis here, it increases the risk of hypoglycemic episodes.

With data pooled from 27 randomized trials involving 8,315 patients, the relative risk of hospital mortality was 0.93 (95% CI 0.85 to 1.03) for tight glucose control versus usual care, reported Renda Soylemez Wiener, M.D., M.P.H., of the VA Medical Center here, and colleagues in the Aug. 27 issue of the Journal of the American Medical Association.

The American Diabetes Association and several other medical societies have recommended tight glucose control for all critically ill patients, mainly on the basis of a 2001 study that found it reduced hospital mortality among critically ill surgical patients by one-third, said Dr. Wiener and colleagues.

"Subsequent large randomized controlled trials of tight glucose control in medical and mixed medical-surgical ICU settings, however, have failed to replicate this mortality benefit," the researchers said, prompting them to undertake the systematic review.

In an interview, Dr. Wiener said the meta-analysis results warrant a re-evaluation of recommendations of tight glucose control for all ICU patients.

Tight glucose control generally means seeking to keep blood glucose below 150 mg/dL with an insulin infusion during some or all of the ICU stay. Some guidelines, including those endorsed by the ADA, call for glucose levels of 80 to 110 mg/dL.

This study does not surprise me.  Achieving tight control while providing intensive care does not have an obvious biologic theory.  Of course, if glucose is your focus of attention, then you would be attracted to a glucose theory.

Generally patients in an ICU have so many different problems, that achieving balance seems more important than focusing too deeply on one factor.

I am quoted in American Medical News today.  I was interviewed to respond to the JGIM article which states:

"Some of these bloggers are talking about patients in a way that physicians usually only talk behind closed doors," Dr. Lagu said. "The Internet is a public space, even though when a person is in their little room writing a blog it may not feel that way."

Another concern is the lack of disclosures about financial conflicts. One in 10 medical bloggers promoted health care products, the study showed. A 2006 health care marketing survey found that nearly one-third of bloggers were asked by public relations companies to write about or endorse products.

Long time readers know that I am a social and internet libertarian.  I do not want any medical organization telling me what I can or cannot write.  I write at my personal risk, regardless of their "rules."

Some physicians disagreed with the notion of formal medical blogging standards.

"That’s a horrible idea," said Robert M. Centor, MD, a blogger and member of the American College of Physicians’ Board of Regents. "The beauty of the Internet and blogging and personal Web sites is that you can do with them what you want to do."

Now I try to maintain standards.  I do not hide behind anonymity.  But the beauty of the internet is that you can express yourself (obviously at your own risk.)

Everyone who writes on the internet does so at their own risk.  Rules are unnecessary.  If a physician (or nurse or other health care professional) blogs in such a way as to put themselves at a HIPAA violation, we do not need a new guideline.  Let common sense prevail.

I often write about biases.  Many studies have exposed the biases of guidelines.  This study exposes the biases in meta-analysis - The interpretation of systematic reviews with meta-analyses: an objective or subjective process?

The interpretation of systematic reviews with meta-analyses is at least partially subjective. Evidence-based practitioners need to be aware that any conclusions and recommendations based on a systematic review with a meta-analysis should be read with caution even if the methodology is rigorous.

We champion evidenced based medicine, because the name has such face validity.  As a skeptic, I remain reserved whenever a new meta-analysis proclaims that we have evidence to do or not do something.  This article suggests strongly that we should be careful that meta-analyses do not have the same biases that we now know guidelines have.

We try to make decisions based on evidence, but we should not become enthralled with evidence based pronouncements unless that fit our previous understanding of the world. 

Medicine remains an art informed by scientific data.  The bean counters want to make medicine a pure science, but medicine can never be a pure science.  Patients have too many variables to fit the evidence.  The evidence allows us to make informed decisions, but we must always apply the evidence to the patient, not to the disease.

The diabetes brouhaha that Dinosaur created represents a great example of this problem  Intelligent, well intentioned scientists can disagree about the management of a diabetic patient with a HgbA1c of 7.4% who is already taking 8 medications.  Those who insist that we should always treat a number without understanding the patient’s context is demonstrating a pedantic attitude. 

I am currently listening to this mystery novel.  The narrator, Will Patton, is outstanding as always.  James Lee Burke writes about violence, its reasons, and its outcomes.  He includes this classic quote:

"He closed his cell phone and flipped it over his shoulder onto the bed. If ever reincarnated, he vowed, he would live in a stone hut on top of a mountain in Tibet, thousands of miles away from people whose lives were modeled on the lyrics of country-and-western songs."

As a physician we often care for those people.  As we often say on rounds, you cannot make up these stories.  I like the way James Lee Burke says it better.

That is the title of the article that I have worked on for the past 3 weeks.  The writing process involves thinking for a long time, writing a first draft, and then revise, revise, revise.

Clearly my recent Grand Rounds presentation was the impetus for writing and submitting this article (I do plan to submit it tomorrow).

This is not the first article that blogging has stimulated.  As I tell the story at Grand Rounds, my interest in Lemierre’s comes directly from a 2002 rant.  Each time that I would write about Lemierre’s I would learn more and thus realize that no one else in the US is currently writing about this syndrome.

I hope that I can get this published at my first choice journal, but if not, I will keep submitting until I find the proper journal.

In advance, I thank the readers who have kindled my interest.  I especially thank the families of Lemierre’s syndrome victims.  I think about them whenever I discuss this disease.

I am working hard on finishing an article titled, "Can we decrease the morbidity and mortality from Lemierre’s syndrome?".  I hope to submit this article before I leave for a golf vacation in Scotland next week.

All of my creative energies are being directed to the article, thus blogging has suffered.  Once the blogger’s muse returns, I will post a new rant.  Perhaps later today, but it may not occur for another day or two. 

The article is based on the grand rounds presentation that I gave.  I hope to find a journal to publish it in the near future.  The article writing process is quite intense.  It requires many rewrites.  Fortunately I have wonderful colleagues who have read the article and provided appropriate brutal commentary.  In order to produce the most effective paper, you did need honest colleagues who will provide honest critiques.  I am fortunate to have such true friends and colleagues.

Despite finishing my residency in 1978 and writing many papers about strep pharyngitis, I first heard of Lemierre’s syndrome in the late 1990s.  During my training, I suspect the incidence of Lemierre’s syndrome was extremely low.  As I slowly became more aware of Lemierre’s syndrome, I started to put this disease into context.

In 2002, during the early days of this blog, I wrote this rant - Some sore throats are VERY serious.

Very interesting story appears on the BBC site - Warning over killer throat disease. I have done sore throat research early in my career. This article describes a condition so unusual that I know little about it.

It follows a significant rise in the number of cases of Lemierre’s disease this year.

The disease, which is most common in young adults, can cause serious illness and even death if left untreated.

With this disease patients can go downhill quite quickly

The disease is cause by a bacterium called Fusobacterium necrophorum that normally lives harmlessly in people’s mouths.

However, for reasons unknown to scientists, it can start to attack the body of previously healthy people.

It mostly affects young people between the ages of 16 and 23 and is more common in men.

The disease is rare and affects just a handful of people each year. However, there have been 30 cases so far this year - as much as the total for all of last year.

…

“Most viral sore throats get better of their own accord in a few days but with this disease patients can go downhill quite quickly.”

Lemierre’s disease starts off as a very sore throat and leads to a fever, swollen glands and a general feeling of being unwell.

During this time my awareness of Lemierre’s syndrome continued to grow.  In 2006 my focus on this disease solidified - More on the “forgotten disease”.

For the past 30 years, the infectious disease community has worked to decrease the use of unnecessary antibiotics. They have assumed that group A beta hemolytic streptococcal infection is the only pharyngitis cause which needs “necessary antibiotics”. They have assumed that group C and group G streptococci do not need antibiotics. They have excluded the possibility of unknown bacterial infections. Now it appears that Fusobacterium necrophorum may indeed be an “unknown bacterial cause” of pharyngitis.

Kristie Estes, who daughter had Lemierre’s syndrome 3 years ago, had written me about their ordeal.  Lemierre’s syndrome started to become very personal.  I received a number of emails and comments from patients and families.  At the same time, the Europeans wrote several very important articles about Lemierre’s syndrome and Fusobacterium necrophorum pharyngitis. Fusobacterium necrophorum is the organism responsible for most cases of Lemierre’s syndrome.  As I wrote in 2006,

The problem with Lemierre’s Disease is that it represents a “long tail” disease. Most sore throats are viral or due to streptococcal disease. At least we thought that until recently. Evidence from 2005 in two articles suggests that the organism thought responsible for most Lemierre’s Disease - Fusobacterium necrophorum - may cause as much as 10% of pharyngitis.

During the next 2 years I voraciously read the appropriate literature.  I was slowly becoming an expert on this condition, despite never personally seeing a patient suffering from Lemierre’s syndrome.

Important ideas take time to mature.  I was fascinated with this syndrome, and believed that we could markedly decrease both the morbidity and mortality from this disease.  This year, an article appeared which crystallized my passion, and provided me with a cause. 

Hagelskjær Kristensen L, Prag J. Lemierre’s syndrome and other disseminated Fusobacterium necrophorum infections in Denmark: a prospective epidemiological and clinical survey. European Journal of Clinical Microbiology & Infectious Diseases 2008; 779-789.

Finally we had an epidemiologic study which defined the extent of this disease.  I have extrapolated the Danish data to the United States.  Assuming the same incidence, I estimate that we have approximately 1000 patients with Lemierre’s yearly and 100 deaths.  I would put the confidence range of these estimates at 50% greater or less than this estimate.

So Lemierre’s is truly an orphan disease if you just look at the numbers.  We have some advantages though in attacking this disease.  Routine antibiotics can treat this syndrome very well.  We do not need new drugs.

As readers know, I gave my new Grand Rounds presentation on Adult Pharyngitis: Morbidity and Mortality in late July.  I am already scheduled to give this talk 4 more times (Oct and Nov.)  I hope to find venues to present this talk much more over the next year or two.

I am currently finishing an article (for submission) titled "Can we decrease the morbidity and mortality from Lemierre’s syndrome?"  Giving this Grand Rounds and writing this article have inspired me to champion this orphan disease on a national stage.  Fortunately, my name is well known in the sore throat literature, so I hope that other physicians will listen.

For my article I have developed a 5 step plan to decrease morbidity and mortality from Lemierre’s syndrome.  I will share my plan after I submit my article for publication (or perhaps sooner.)  I would love for you, the readers and thinkers, to suggest action steps for addressing Lemierre’s.  All thoughts are greatly appreciated.

I will say that the first step must be education.  I know that my blog is fairly well read, and thus some physician have learned.about Lemierre’s from reading my rants.

My 2007 perspective on adult pharyngitis -  Pharyngitis Management: Defining the Controversy  -  included this paragraph:

Another potential reason for antibiotic therapy for severe pharyngitis is to treat Fusobacterium necrophorum. Recent data suggest that these bacteria may cause endemic acute pharyngitis. F. necrophorum infections can cause Lemierre’s Disease, peritonsillar abscess and persistent sore throat symptoms. While we do not yet know the probability of progression to these complications, certainly empiric antibiotic treatment would likely decrease their incidence. A recent pediatric paper has documented the increasing incidence of F. necrophorum infections (including Lemierre’s Syndrome) over a recent 6-year period. The authors speculate that decreased empiric antibiotic use may be contributing to the resurgence of this infection.

As I enter the final decade of my full time career (I doubt that I will soon leave medicine completely), addressing Lemierre’s syndrome has become my passion.  I do not want to hear from families or patients.  I do not want to read newpaper articles.  I want us to either totally prevent Lemierre’s or at least consistently diagnosis it soon enough to have no major morbidity or mortality.  I believe this is an achievable goal.  I pledge myself to that goal.

I remember M2 - I hated it.  I have taught M2 students - I really do not enjoy teaching them.

I received this comment yesterday on a year old post:

I’m about to enter 2nd year and I am not looking forward to it! I can feel the depression sinking in already, and classes are still 2 weeks away! How the hell am I going to get through this year?

Wow - how do I help this student?  I tell second year students that the 3rd year is great.  The second year is a necessary evil.  Many of the lectures actually are quite good, but second year students are not ready to hear those lectures.  They are emotionally crippled, and really need to get out of the classroom.

My advice - the struggle is really worth it.  Set aside 1 hour each day for personal time - exercise or reading or just listening to music.  Study each day and do not cram.  Try to learn even though they are testing you on memorization.

Begin with the end in mind.

Happy states:

The fact that hospitals see value in hospitalists is a striking indication that hospital internists/FP’s save money when a head of the ship takes control. Insurance companies don’t see the benefit of prevention because it happens years down the road when most of their premium paying customers have moved on. For them to pay more now only to have another insurance company reap the benefits of prevention would be counter productive to their bottom line. Hospitals see the benefit here and now. And that’s why hospitalist salaries are soaring above their respective counterparts.

There are several possibilities for the willingness of hospitals to pay hospitalist salaries.  Happy suggests that they save the hospital money.  Some early studies suggest that, while others studies show no difference.

Let me postulate a couple of other motivations.  At teaching hospitals (note that they are the largest employers of hospitalists), the increasing number of adult medicine patients requires new physicians for patient care.  They cannot rely on house staff to provide all the patient care, and meet all the demand for admission.  Thus, hospitalists become the safety net for training programs.  Now many groups have taken those positions and expanded beyond patient care.  They have become important contributors to quality and safety programs for the hospital.  These programs are becoming increasingly important for hospital payment.

Another reason fo hospitalist growth is demand from primary care physicians and surgeons.  Hospitalist programs make hospitals more competitive, thus increasing admission rates.  We all know that patient volume drives hospital income.

While I find Happy’s idea intriguing, hospitalists should have no leadership advantage over combo physicians (those who do both inpatient and outpatient.)  Unfortunately, being a combo physician is very time consuming, without being financially rewarding.  Physicians do better financially when focusing on either inpatient or outpatient.  That is a shame.

The value of excellent outpatient physicians is not just in prevention.  Outstanding internists and family physicians can decrease hospitalization and referral rates through excellent in chronic disease management and outpatient diagnostic evaluations.  Outstanding outpatient physicians limit health care costs by limiting (appropriately) consultation and expensive diagnostic testing, because they think before they refer.  That is the concept behind the patient centered medical home.

I have no objections to hospitalist salaries.  Hospitalists have made themselves valuable to hospitals in many ways.  I do have objections to the current payment system for outpatient physicians.

Society of Hospital Medicine (SHM) 2007-2008 Productivity and Compensation Survey

In 2006, there were approximately 15,000 hospitalists in the country. Today, the number has risen to an estimated 20,000. The highest number of hospitalists are found in the East (31%) and South (28%) compared with the Midwest (20%) and West (21%). Since the 2005-2006 survey, the percentage of hospitalists in the East has increased slightly, whereas the percentage of hospitalists in the Midwest has decreased slightly. Hospitalists are still found in all parts of the country.

Hospitalist groups continue to rapidly expand in size. Over the past year, hospitalist programs have experienced a mean growth of 31% in number of hospitalist full-time equivalents (FTEs). This rate of growth is very similar to the results of the 2005-2006 survey, which reported an annual growth in hospitalists’ staffs of 29%.

Hospital medicine groups are maturing and expanding their work beyond the confines of 1 hospital: The median age of hospitalist groups is now 5 years. Thirty percent of groups cover more than 1 hospital. The mean number of hospitals supported by a hospitalist group is 1.9.

The median size of hospitals in which hospitalists work is 310 beds, and they include all types:

* 56% of hospitalists work in teaching hospitals;

* 83% work in nonprofit hospitals;

* 12% work in for-profit hospitals; and

* 5% work in government hospitals.

Hospitals remain the single largest hospitalist employer, and the percentage of hospitalists who are employed by hospitals continues to rise, whereas the percentage of hospitalists who are employed by multispecialty groups continues to fall. In the 2005-2006 survey, 34% of hospitalists worked for hospitals and 14% worked for multispecialty groups. The current survey shows the following:

* 40% of hospitalists are employed by hospitals;

* 24% of hospitalists are employed by academic centers;

* 14% of hospitalists are employed by local hospitalist-only groups;

* 11% of hospitalists are employed by multispecialty groups; and

* 8% of hospitalists are employed by management companies.

The overwhelming majority of hospitalist programs continues to operate with a deficit. The mean deficit per hospitalist group is $954,000 and the median deficit is $750,000. The mean deficit per hospitalist group continues to grow. Considering these increasingly large deficits, it is shocking to learn that 37% of hospitalist group leaders are unaware of their group’s annual expenses, and 35% of hospitalist group leaders do not know their group’s revenue. What is not clear, however, is whether these leaders chose not to divulge this information or whether there is, indeed, widespread ignorance among hospitalist group leaders with regard to their group’s financial matters. Of those who did report their group’s finances, 85% reported a deficit.

An overwhelming majority of hospitalist programs continue to receive financial support. In the 2003-2004 survey, the mean financial support received by hospitalist groups was $400,000. This figure rose to $549,000 in the 2005-2006 survey and to $949,410 in the most recent survey. Currently, 91% of hospitalist groups receive financial support. Financial support includes payment subsidies, services in kind, or case rate reimbursement. Sources of support include the following:

* Hospitals, $897,750;

* Physician organization, $38,550;

* Academic organization, $1850; and

* Other organizations, $11,260.

The mean amount of support per hospitalist FTE is $97,375. This has risen sharply since the 2005-2006 survey when the mean support per FTE was $58,400. I believe that this reflects the rise in hospitalist compensation without a corresponding increase in clinical revenue.

Hospitals help pay hospitalist salaries!  Why?  Obviously hospitals believe that they need to spend this money. 

Many outpatient physicians choose their admitting hospital because of the hospitalists.  Many surgeons (especially orthopedics and neurosurgery) want hospitalists to provide every day care for their patients, allowing the surgeon to spend more time operating and less time worrying about the other aspects of hospital care.  Many hospitalist groups focus on improving quality, and decreasing length of stay.

As a new designation, hospitalists have done a brilliant job of negotiating with hospitals.  Since the demand for hospitalists greatly exceeds current supply, hospitals pay.

Outpatient physicians should have the same negotiation opportunity.  One could argue that the retainer medicine movement represents a supply and demand situation.  I would prefer if insurers began to offer outpatient physicians more money to see patients.  Perhaps they will as the demand for "primary care" is increasing rapidly.  And while that demand increase, the supply decreases.  I suspect that eventually the laws of economics will improve payment for outpatient visits.  If not, we will continue to have a dwindling supply of outpatient physicians - as many move to well paying hospitalist jobs.

My post on night float stimulated significant interest.  Rural Doctoring is currently writing a series of articles in support of night float.  Last month Medscape featured a very interesting perspective on work hours - The Disappearing Doctors.  The author tells the story of discontinuity in patient care and education.

Besides ensuring excellent medical treatment for patients, the ACGME work rules were intended to keep residents alert so that they could fully engage in the work and education needed to become fine physicians. The rules, however, are backfiring. Residents no longer are able to observe the timing of a patient’s response to an intervention; they can’t follow the tempo of a fever or the bloom-and-fade cycles of a rash even when, as responsible physicians would, they sincerely want to. Their heads are crammed with the facts they’ve learned during medical school, but they can’t see firsthand the course of a birth or a gall bladder attack or the phases of recovery from a surgical procedure and then integrate those facts into informed decision making. Instead of producing physicians with high professional standards who see their patients through to the end (of labor, of an operation, of an illness, of a life), the current system is creating a legion of shift-worker physicians who leave when the clock strikes a certain hour rather than when the job has been completed.

In evaluating their training programs, residents often ask for increased autonomy. They realize that in the future they’ll be solely responsible for the care of their patients, and they worry that without a certain amount of autonomy during their training, they won’t be adequately prepared for independent decision making. Yet with their current here-today-and-gone-tomorrow schedules, they can’t be given increased autonomy—they won’t be around for the next step or haven’t been around for the last step. They don’t have the big picture.

The problem with most night float systems stems from a lack of a clear statement of goals.  Does that sentence make sense?  I suspect that I must explain further.  Too many night float systems are developed to meet work hour restrictions without regard for underlying principles.  Some programs have designed their work hour adjustments (including night float) based on underlying principles of maximizing continuity, decreasing the number of "hand offs", and understanding that patients’ need daily continuity (even though night time often has discontinuity.) 

One can develop a night float system that insures team continuity on a daily basis.  The program where I do my internal medicine teaching has developed a system which maximizes team continuity.  This system was not developed just to meet work hour requirements, but rather was designed to preserve patient care and team continuity.  Thus, for a 2 intern and 1 resident team, days off are arranged so that another team member can "pick up the slack."  As the ward attending, I add to the continuity.

Is this the best answer?  While I cannot answer that question, I do know that we work hard to balance education, work hours and optimal patient care. 

Night float is a key component in allowing our residents to meet work hour restriction and yet do our best to maintain a good educational program. 

Night float sucks for the night float intern.  Night float, combined with a thoughtful schedule, improves the residents’ ability to learn for the other 11 months of the year, by making their lives less stressful. 

To me the big message is that we must teach interns and residents how to develop efficient hand offs, write excellent notes so that the cross covering physician has the best chance to provide optimal care.  We must design night float systems, not to meet numbers but to optimize education and patient care.  It can be done.

According to the dictionary, an orphan disease is defined as:

a disease which affects a relatively small number of individuals and for which no drug therapy has been developed because the small market would make the research and the drug unprofitable

Clearly, Lemierre’s affects a relatively small number of individuals.  However, when properly diagnosed, standard antibiotics work very well.  On the other hand, one could argue that it is an orphan disease, because we do not have an easy way to make the diagnosis.

Even though this is somewhat a semantic question, I am interested in your thoughts.  I am preparing a paper about Lemierre’s, and need to decide this question.

This definition would suggest that Lemierre’s is an orphan disease

A rare disease may become an orphan disease for two reasons. In the first instance, any disease which afflicts less than 200,000 people is generally considered to be an orphan disease, because there are not enough patients to make research cost-effective.

Thanks for your opinions.

Say the words "night float" and you get many responses.  Many residents and interns see night float as an undesirable, but necessary evil.  Night float makes the other months more tractable, but that month (or 2 weeks) is a special level of hell that Dante never imagined.  For those who know nothing about night float (and who care) this article tells the story well - The Nightmare of Night Float: Is an ignorant doctor really better than a tired one?  Thanks to the reader who sent me the link!

Night float is the product of reforms in medical education that limit the number of hours that residents and interns—doctors in training—can work. Because they can no longer rely on the same doctor caring for a group of patients day and night, teaching hospitals have had to arrange more cross-coverage when the primary resident is not on duty. Most have created the position of a resident who works the night shift, usually for a few weeks. The upside is that other residents can sleep. The downside is frequent patient handoffs, which can result in the transfer of faulty or inadequate information. The nightmare of night float raises a central question about work limits for interns: Is it better to be cared for by a tired resident who knows your case or a rested resident who does not?

I have a love hate relationship with night float.  Since night float started, post call rounds are actually more educational.  The night float intern allows my interns to be more alert and have education receptors.  Before night float, the interns were doing the cross-coverage for their colleagues on other admission teams.  The cross-coverage activity is the one that wears down interns (both emotionally and intellectually.)

Night float interns make mistakes because they do not understand the context of the patient.  Night float interns create more work for the admitting team, because of their mistakes. 

Night float interns are usually miserable.  Imagine an entire month of vampire’s hours.  Your circadian rhythms are destroyed.  The night float intern eschews education.  Thus, we have had to create a non-educational month. 

If tired residents hurt patients, but the ignorance of night float and cross-coverage also pose a danger, what should hospitals do? No doctor can work 24 hours a day, seven days a week, so cross-coverage is essential. The optimal system would provide rested night floats with all the information they need. The best way to accomplish this is for teaching hospitals to have standardized, electronic handoff systems. In medicine, as in aviation, most errors occur at transitions: by pilots, during takeoff and landing, and by doctors, after handoffs. Because of work limits, an intern today might be involved in more than 300 handoffs during an average monthlong rotation. Too many hospitals continue to rely on one intern signing out verbally to another, an invitation for error. Less than 5 percent of hospitals have electronic handoff systems in place.

Without better handoff systems, work limits may well weaken medicine more than exhausted residents ever did. As a doctor in training, you have to see a patient’s illness through its course—observe the arc—to get a grip on the dynamics of disease. It is possible to overcorrect for even the most serious of problems. And in trying to get young doctors a bit more rest, we may have come up with a cure that is worse than the disease.

As an alter cocker, I worry about the next generation of physicians.  Are the sleep deprivation activists ruining medical training? (As an aside, when will they start boycotting Jack Bauer?) Will the graduates of our programs deliver a lower quality care because they just did not see enough patients?  Will the decrease in educational opportunities which our byzantine scheduling induces leave our graduates at an intellectual disadvantage?

I love night float; I hate night float.  Night float is a necessary evil, but make no mistake it is an evil.  And I see no alternative.