Thursday, January 31, 2013

Layers of Nonsense

Wrong site surgery is never acceptable.  A surgeon ought never to find himself in a situation where he has to inform the family that he just operated on the wrong body part.  It is embarrassing, unprofessional, and an egregious violation of the patient/physician covenant. 

That being said, we have allowed this issue to be defined entirely in terms of "systems management".  And hence the rise of the Time-out and the Checklist.  The ultimate responsibility for identifying the proper surgical site has been diluted.  No longer is it at the sole discretion of the operating surgeon.  Now we have a Team-Based approach involving nurses, anesthesia personnel, mid level providers, and surgeons.   Performance of a group time out (of which I am actually a strong proponent) has quickly become the standard of care at most American hospitals prior to initial incision.

Wednesday, January 30, 2013

CTE continued

Two quickie links:
  • A harrowing interview with former Browns running back Leroy Hoard exploring his post-football struggles with memory loss, depression and severe headaches--- “My legs are both numb. I can’t feel my toes. I can’t feel this arm, and I’m getting a headache from these damn lights. Other than that, I feel great."
  • Ta-Nehisi Coates, from the Atlantic, has a great timeline detailing the NFL's culpability in downplaying the long term effects of repeated head trauma sustained over time
I also need to address the argument that "these men know exactly what they are getting into, they are grown men, mature adults, they are well compensated for assuming a certain element of known risk, etc etc".

Monday, January 28, 2013

Safety Net Hospitals Squeezed

The weakest aspect to Obamacare is in its cost control strategies, or lack thereof.  The predicted savings from converting to Electronic Medical Records (EMR) have failed to materialize.  And the Rube Goldberg-esque plan to save money by penalizing hospitals and doctors for having poor HCAHP scores has reaped its own set of unforeseen complications.  HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) is the Press-Ganey survey tool that Medicare has decided to use as its sole objective instrument in determing relative hospital/physician "quality" rankings.   A low HCAHPS score puts a hospital system at risk of forfeiting up to 1% of its Medicare reimbursements.  High scoring systems can actually receive bonus payments.  Further penalties are accrued by hospitals for having high readmission rates after coronary events or pneumonia.

Sunday, January 27, 2013

"Justice"----Post Modern American style

The Aaron Swartz suicide is one of those momentous events that will be covered ad nauseum by a certain tiny subset of living humans who give an actual shit about things like democracy, openness, liberalism (in the John Locke, Rousseau sense), transparency in government, and blinded justice---and very little by the mainstream media.  Niche fiefdoms of the Interwebs will express outrage via a series of finely articulated blog posts and columns denouncing the bullying by the American government and the disproportionality of punishment meant to be dealt out to this talented, intelligent young man who believed in the free exchange of knowledge, a young man who seemed to have abided by a set of principles-- so unusual in this post modern era-- a young man who believed that the internet existed precisely for the purpose of potentiating the unfettered flow of ideas, facts, research, anything that could potentially advance the state of the human condition.  It was imperative to him that information not be controlled by any one entity, that anything potentially advantageous to human beings collectively, be put in the public domain.   

Thursday, January 24, 2013

Abraxane and Pancreatic CA

The new drug from Celgene for metastatic pancreatic cancer, Abraxane, has been shown to add a little less than 8 weeks of life to patients with the terminal disease. 
Celgene’s drug Abraxane prolonged the lives of patients with advanced pancreatic cancer by almost two months in a clinical trial, researchers reported Tuesday, signifying an advance in treating a notoriously difficult disease but not as big a leap as some doctors and investors had hoped.  
“It was not the breakthrough we were anticipating,” said Dr. Andrea Wang-Gillam, an assistant professor and pancreatic cancer specialist at Washington University in St. Louis, who was not involved in the trial.
The cost for this amazing advance in futile care?  $6000-8000 per month.  And there is already a drug on the market, folfirinox, that has demonstrated longer survival expectations that Abraxane.  I'm sure signing off on Big Pharm profiteering FDA approval is right around the corner. 

Wednesday, January 23, 2013

CTE Diagnosed in the Living?

From what I have read and heard, the NFL playoffs have been quite the little Entertainment this year, what with the high scoring and down to the wire finishes.  And now some sort of sibling rivalry theme awaits in the Super Bowl, apparently.  Since my very public declaration a few weeks ago that I was quitting football cold turkey, I have not watched a single game.  So far, it hasn't been too terribly challenging.  The true test of my principles will come next year when Urban Meyer is BCS-eligible and Chud has the Browns steaming toward an AFC North title.....

Speed Bumps

Modern science, as they say, advances at warp speed.  This article from the British Journal of Medicine is emblematic of the phenomenon.  Researchers in the UK, using sophisticated surveys, were able to identify a heretofore unacknowledged clinical indicator of acute appendicitis:  the Speed Bump Sign. 


The analysis included 64 participants who had travelled over speed bumps on their journey to hospital. Of these, 34 had a confirmed histological diagnosis of appendicitis, 33 of whom reported increased pain over speed bumps. The sensitivity was 97% (95% confidence interval 85% to 100%), and the specificity was 30% (15% to 49%). The positive predictive value was 61% (47% to 74%), and the negative predictive value was 90% (56% to 100%). The likelihood ratios were 1.4 (1.1 to 1.8) for a positive test result and 0.1 (0.0 to 0.7) for a negative result. Speed bumps had a better sensitivity and negative likelihood ratio than did other clinical features assessed, including migration of pain and rebound tenderness.


Presence of pain while travelling over speed bumps was associated with an increased likelihood of acute appendicitis. As a diagnostic variable, it compared favourably with other features commonly used in clinical assessment. Asking about speed bumps may contribute to clinical assessment and could be useful in telephone assessment of patients.

Tuesday, January 22, 2013

Interview: Phillip Hornbostle,MD Bariatric Surgeon

This is the first in a series of  interviews I plan on publishing.  Dr Phillip M. Hornbostel, M.D., FACS, FASMBS is an accomplished bariatric surgeon in Missouri who has performed thousands of weight loss procedures over the years.  He is also the resident dean of the commentariat at the physician-only social media website Sermo.  The following represents a series of email exchanges he and I had over the holidays:

Monday, January 21, 2013


The family of an elderly German man named Dirk Schroeder is suing a hospital in Hanover because, allegedly, the surgeon who did his prostatectomy in 2009 left 16 foreign bodies inside him. 
When surgeons operated on Schroeder again, they were stunned to find 16 pieces of medical equipment in the man's body. This included "a needle, a six-inch roll of bandage, a six-inch long compress, several swabs and a fragment of surgical mask," writes the Daily Mail.

Words fail.  I mean I've left 8 or 9 items inside a patient before, but 16?  Just kidding.  I don't do that sort of thing.  The best was the hospital's official response:
 The facility claims that the instruments may have found their way into Schroeder's body "post-operation," according to German publication Osnabrücker Zeitung.

Very similar to OJ Simpson's claims that Nicole's exsanguinating throat wounds must have occured "post-visit" after a lovely afternoon of scones and green tea and pleasant conversation about the kids and the coming Mostly Mozart Festival at the LA Symphony.

Sunday, January 20, 2013

Post Call Operating

A new paper from JACS reviews outcomes of elective procedures performed by surgeons operating the night after being on trauma call.


Performance of general surgery operations the day after an overnight in-hospital trauma shift did not affect complication rates or readmission rates. At this time, there is no compelling evidence to mandate work-hour restrictions for attending general surgeons.
This is right up my alley.  I am a general surgeon in a practice of two who takes call every other night, every other weekend.  I also cover the trauma pager 7-8 times a month.  Most of my post call days involve attending to electively scheduled cases.  All I can say is that I agree with the above findings.  I do not need naps post call.  I do not feel compromised by interrupted sleep.  This is my life.  I am a general surgeon.  This is what I bought into all those years ago.  Perhaps the paradigm and the expectations are changing.  Perhaps the millennial generation of surgeons will see me as some sort of strange anachronistic oddity-- what the hell is he doing trying to operate this morning?  I heard he only slept 4 hours last night???

Unfortunately the effects of such papers are doomed to fall on deaf ears.  The wheels of change are grinding.  Work hour reform is already entrenched at the residency level.  Papers such as this have an ever diminishing audience.  A generation of super-specialized, fellowship-heavy, shift work ingrained surgeons cannot comprehend what a paper like this even means.  It's inexplicable, a relic from an expired era.  The loss of an old ethic, a noble professionalism goes unacknowledged. 

Everyone gets tired.  The call comes in.  The alarm goes off.  It's time to rise again.  You say to yourself: That patient needs me.  Somebody loves him.  This is what you are meant to do.  Rise.  Run the cold water across your face.  Somebody loves her.  It's time to work again.  With all your heart and all your mind.  Do your job.  There is a transcendent joy for you too, if you just hang in there.....

Thursday, January 17, 2013

Transplant Morality

In our aging society, older Americans are increasingly receiving organ transplants.
 The number of kidney transplants performed annually on adults over 65 tripled between 1998 and last year, according to data from the Scientific Registry of Transplant Recipients. In 2001, 7.4 percent of liver transplant recipients were over 65; last year, that rose to 13 percent.
The allocation of certain organs in this country is determined by need and severity of underlying illness.  It's not like at the deli where you draw a number and simply wait your turn.  Length of time spent on the wait list has nothing to do with your likelihood of getting the next available liver or lung.  Each potential recipient is assigned a score (MELD, Lung Allocation Score) based on clinical factors, bloodwork, functional capacity, etc etc.  (Kidney allocation still relies heavily on wait times, length of time on dialysis, etc). 

Wednesday, January 16, 2013

Who Decides on Surgery?

The American Journal of Surgery had a nice little (38 patient cohort) study from the VA database that tried to determine the process by which patients make informed decisions on elective surgery.  The results were rather surprising, at first glance.   
Sixty-nine percent of patients decided to have surgery before meeting their surgeon, and 47% stated that the surgeon did not influence their decision. Although the surgeon was an important source of information for most patients (81%), patients frequently described using information gathered before meeting the surgeon, such as other health care providers (81%) or family members (58%).

Sunday, January 13, 2013

How Nurses Save Lives (and make surgeons look better)

I had seen the lady in the ED at around noon.  She presented with a 1 day history of non specific crampy abdominal pain and nausea/vomiting.  The CT demonstrated a garden variety small bowel obstruction (SBO), likely related to adhesions from a hysterectomy from years ago.  Her labs were all normal and her belly exam was not especially impressive.  Nonetheless, I placed an NG tube and admitted her to the hospital for close monitoring.

In over 70% of cases, an SBO will resolve on its own just with nasogastric decompression, bowel rest, and appropriate hydration.  Typically we will initiate a trial of conservative therapy in these cases.  Lack of progress or outright worsening over the next 24-72 hours then warrants operative exploration. 

Friday, January 11, 2013

Goodbye to All That

Junior Seau had CTE, chronic traumatic encephalopathy, the degenerative brain disease known to afflict individuals who have sustained repeated head injuries over time.

Junior Seau played football his whole life and was never officially diagnosed with a concussion.  Last May he sat down one day and shot himself in the heart.  Dave Duerson, the former Bears safety, did this too, as a way to preserve his cadaveric brain for post-mortem study.  The official report from the NIH confirmed a diagnosis that surprises exactly no one.  A lifetime of small, seemingly minor, but accumulative traumatic head blows sustained playing the sport he loved lead to a degenerative brain disease associated with depression, despair, and cognitive deterioration.

EMR Savings Fall Short

Well, well, well.  This is entirely unsurprising.  The NY Times this morning reports on a new assessment from the RAND Corp regarding implementation of electronic health records:
The conversion to electronic health records has failed so far to produce the hoped-for savings in health care costs and has had mixed results, at best, in improving efficiency and patient care, according to a new analysis by the influential RAND Corporation.
This is the same RAND Corp whose analysis back in 2005 predicting $81 billion in health care savings triggered the mad rush by practices and hospitals to adopt EMR.  That report was sponsored by the very same corporate conglomerates who stood to benefit the most from mass implementation (GE, Cerner, AllScripts, etc).  So this is not some fringe Luddite organization drumming up data to support an anti-EMR creed.

Thursday, January 10, 2013


I saw a patient recently who described a four day history of severe RUQ abdominal pain that started shortly after consuming a slice of extra cheese meat lovers pizza.  The pain was piercing, like a through and through spear wound.  She had been vomiting and febrile and she looked quite a bit like absolute hell.  Her CT done by the ER showed an ugly distended gallbladder.  Her labs demonstrated an elevated WBC (over 20k) and mild early acute renal failure (creatinine 1.9, up from baseline).  On exam, in addition to peritoneal signs in the upper abdomen, she had some sort of complex pressure dressing on her right groin. 

-It's the same pain I told them on the other day, she said
-Told who?  You went to an urgent care?
-No, I was here.  They sent me home.  I told them I was still hurting.
-What's that bandage on your groin?
-They did a heart scan, made sure I wasn't having a heart attack
-I see, I said.  I'm not going to be sending you home.  You don't have a heart problem.  You need an operation.

I checked the medical record on the computer to confirm what I already knew.  She came in three days prior with a diagnosis of "chest pain".  Now, to be fair, many gallbladder attacks present with upper abdominal/lower chest pain.  However, rather than a complete work up to determine the source of her discomfort, she went directly from the ER to the cath lab where angiography was performed in order to prove she had completely normal coronary arteries.  She was discharged home 6 hours later.  She had been seen and examined (allegedly) by an internist and cardiologist.  The electronic medical record appeared pristine.  Discharge summary airtight.  The home medications had been reconciled.  Explicit post-procedure instructions provided.  Follow up care had been documented.  She had been processed, on paper, perfectly. 

I called the OR to book the case.  It was 11pm on a weekday. 

McChrystal on Drones/Guns

No one would ever mistake General Stanley McChrystal for some sort of bleeding heart pacifist.  His take on the escalating Drone Wars of the Obama Administration:
"What scares me about drone strikes is how they are perceived around the world," he said in an interview. "The resentment created by American use of unmanned strikes ... is much greater than the average American appreciates. They are hated on a visceral level, even by people who've never seen one or seen the effects of one."
Of course, this is the same man who wanted to increase the number of troops in Afghanistan, indefinitely (kind of a Perma-Surge).  So maybe he just finds drones distasteful because they allow for reduction in troop levels.  But still.  The former top commander in Afghanistan thinks maybe we are over-doing it with unmanned terror sorties from the sky.  Perhaps that is a viewpoint worth considering.....

In addition he also has an interesting take on assault rifles:
“I spent a career carrying typically either an M16 or an M4 Carbine. An M4 Carbine fires a .223 caliber round which is 5.56 mm at about 3000 feet per second. When it hits a human body, the effects are devastating. It’s designed for that,” McChrystal explained. “That’s what our soldiers ought to carry. I personally don’t think there’s any need for that kind of weaponry on the streets and particularly around the schools in America.”
Only an effete, Ivy League elitist liberal would ever claim such a thing, right?  An actual soldier who served in combat couldn't possibly believe that we would be safer without free access to military ordinance.  This is not possible.  GUNS DONT KILL PEOPLE, PEOPLE KILL PEOPLE, la la la la.

Wednesday, January 9, 2013

Cardiology Greed

This is embarrassing.  A hospital in Eyria, Ohio just settled a federal lawsuit for almost $4 million in response to allegations of hospital cardiologists performing unnecessary coronary angioplasties and stent procedures.
The high rate of heart procedures at the hospital was the subject of a front-page article in The New York Times in August 2006. Medicare patients in Elyria, Ohio, where the hospital is located, were receiving angioplasties at a rate nearly four times the national average, a figure that prompted questions from insurers and raised concerns about overtreatment.
The concerns included whether many patients in Ohio and elsewhere were receiving expensive and inappropriate medical treatments because of the high fees the procedures generated.

Tuesday, January 8, 2013

Over Transfused

A new paper from NEJM indicates that perhaps we need to re-calibrate our blood transfusion strategies in patients with severe upper gastrointestinal bleeds.  Patients were randomly assigned to liberal (transfuse for HgB under 9) vs restrictive (transfuse only for HgB under 7) transfusion treatment protocols and outcomes were measured (survival, bleeding, portal venous gradients, etc). 
The probability of survival was slightly higher with the restrictive strategy than with the liberal strategy in the subgroup of patients who had bleeding associated with a peptic ulcer (hazard ratio, 0.70; 95% CI, 0.26 to 1.25) and was significantly higher in the subgroup of patients with cirrhosis and Child–Pugh class A or B disease (hazard ratio, 0.30; 95% CI, 0.11 to 0.85), but not in those with cirrhosis and Child–Pugh class C disease (hazard ratio, 1.04; 95% CI, 0.45 to 2.37).

Soldier Suicides

Last year, more active duty soldiers died from suicide than in the field of combat.  There were 177 documented suicides in 2012, up 54% from 2007.  And even these appalling statistics underestimate the true suicide epidemic when you factor in discharged or retired soldiers.

You will hear calls for increased military spending on mental health resources.  Greater funding will be sought for Defense Department anti-suicide initiatives.   Although certainly warranted, do not think for a moment that simply hiring more psychiatrists and mental health professionals is the solution. 

The solution is to turn away, finally, from Endless War and the permanent occupation of lands and people who resent our presence. 

It's time to bring everyone home from Afghanistan and wherever else young Americans are needlessly placed in harms way. 

Saturday, January 5, 2013

Radiology Stress?

One Dr Matthew Rifkin had a post up on KevinMD the other day expressing the fearful notion that radiologists are facing unprecedented challenges.  And by "challenges", what he means is that his specialty is starting to experience some push back from private insurers and Medicare on their heretofore rather generous reimbursements. 

He writes:  "The nice 9-to-5 lifestyle and never being on call started to fade away, making the stress associated with radiologists lives become more apparent"

Horror of horrors!  Next thing you know, someone will demand that radiologists wear pagers. Or actually talk to each patient after a study is performed.  Or take less than 6 weeks of vacation per year.  Pajamas/slipper ensembles could be banned from darkened viewing rooms.  It's like something out of Germinal.  You can only push a man so far until rebellion erupts from his heart. 

Of course this silly rant is all in the context of radiology inexplicably  being one of the most lucrative specialties one could choose.  From Medscape:
 In 2011, radiologists were the highest-compensated of all specialties surveyed, tied with Orthopedists. Respondents earned a mean income of $315,000 – about 10% less than in Medscape's 2011 survey. Fully one third of radiologists earned $400,000 or more, although this proportion was down from the 2011 survey. Almost one half (48%) earned from $300,000 to about $500,000.

Residency Blues

Last month, JACS published results from a national web-based survey completed by general surgery residents.  The findings paint a bleak picture of overall morale:


A total of 464 completed surveys were analyzed. Overall, 75% of residents expressed dissatisfaction with the new duty hour limitation. PGY II to V residents reported a higher level of dissatisfaction compared with PGY I residents (87% vs 54%, p < 0.01). Eighty-nine percent of PGY II to V residents responded that there has been a shift of responsibilities from the PGY I class to PGY II to V residents, with 73% reporting increased fatigue as a result. Seventy-five percent of PGY I and 94% of PGY II to V residents expressed concerns about the adverse impact of the restrictions on the education of PGY I residents (p < 0.01). Residents at all PGY training levels reported encountering problems due to inadequate sign-outs (PGY I, 59%; PGY II to V, 85%; p < 0.01). Sixty-two percent of PGY I residents and 54% of PGY II to V residents believed that the new 16-hour duty restriction contributes to inadequate sign-outs (p = NS). Most PGY II to V residents (86%) believe there is a decreased level of patient ownership due to the work hour restrictions.
(emphases added by me)
The first thing to point out is that surgical interns are not allowed to work more than 16 consecutive hours.  Because they might get sleepy.  And those bedhead hairdos on morning rounds were just too distracting for well coiffed Attendings.  Or something.

So we have unsurprising findings that residents being sent home from apprenticeship based on arbitrary time limits are concerned about both their own education (less time in hospital/OR equals decrease in comfort level with complex surgical issues) and patient safety (compromised patient-info sign outs).  That's fantastic.  I can't wait when I'm old and broken down  and these folks will be taking care of me at 3AM.     

Thursday, January 3, 2013

Poo-Poo Platter

This article was, for some odd reason, the front page story in today's Plain Dealer.  (Slow post-holiday news day?)  Two gastroenterologists from New England are working on a randomized controlled trial comparing the efficacy of fecal transplantation vs placebo in cases of refractory, recurrent clostridium difficile (c. diff) colitis.  What exactly is "fecal transplantation" you ask? 

Just what you what might expect, alas:
Transplants can be performed in a number of ways. Most often, doctors use a colonoscopy-like procedure, sedating a patient and depositing liquified, donated stool through a tube in the rectum. But sometimes they use a nasogastric tube, that goes through the nose, down the throat and into the gut. Other times, the stool is administered as an enema.

Surgeons as Employees

AMA Physician Masterfile data was examined to determine the shifting paradigm in surgical practices.  The results are unsurprising:
Results The number of surgeons who reported having their own self-employed practice decreased from 48% to 33% between 2001 and 2009, and this decrease corresponded with an increase in the number of employed surgeons. Sixty-eight percent of surgeons in the United States now self-identify their practice environment as employed. Between 2006 and 2011, there was a 32% increase in the number of surgeon in a full-time hospital employment arrangement. Younger surgeons and female surgeons increasingly favor employment in large group practices. Employment trends were similar for both urban and rural practices.
Interesting that younger surgeons are gravitating toward an employed model.  I suspect that onerous educational debt loads contributes to the decision to opt for a "safer" earnings environment.  When you are forking out $1500 a month to Wells Fargo, it's nice to know you have bi-monthly checks coming in regularly.

Also, don't forget that the majority of graduating general surgery residents are pursuing fellowship training in various subspecialties.  A general surgeon can hang his shingle pretty much anywhere in the USA.  A trauma surgeon?  Cardiothoracic?  Vascular?  Hand specialist?  You pretty much need to link up with the giant tertiary care centers (as an employee) to guarantee a steady, sufficient referral base. 

Secrecy Triumphs Once Again

An attempt by the NY Times to obtain memos from the Justice Department that provided the legal rationale for the due process-free assassinations of Anwar Al Alaki and his son (American citizens, both) has been summarily shut down by a federal court.  Once again, the US government has successfully made the argument that anything deemed a "state secret" cannot and will not be made available to the American people.  Nothing to see here.  Move right along.  Most Transparent Administration Ever, indeed. 

Again, this was not an attempt by the Times/ACLU to publish Top Secret intelligence data.  They simply wished to make public the mere legal rationale that our Noble President uses when determining which American citizens he can execute. 

Just trust us, they say with a wink.  It's only a brown-skinned terrorist with an unpronounceable, strange-sounding name.  They would never think of exercising such unprecedented state powers on Caucasian dissidents with names like Smith and Jones.  Right?

Wednesday, January 2, 2013

High Cost of Robots

I'll have more on the Da Vinci robotic surgery phenomenon in the near future.  But a good taste of what's to come is nicely elucidated by this article in Archives, describing the ungodly costs of taking a perfectly good operation (in this case open thyroidectomy) and foisting the robotic technique on it:

Results The relative costs calculated were $2668 for ST vs $5795 for RT. This represents a 217% increased cost of RT compared with ST. The mean operative times were 113 minutes for ST vs 137 minutes for RT.

Nothing like doubling the cost of a medical procedure in this era of cost containment.  Sounds like a winner.    

Universal Care???

Yet another example that complex, poorly understood Obamacare is anything but a template for universal healthcare:
Employers asked for guidance, and the Obama administration provided it, saying that a dependent is an employee’s child under the age of 26.  
“Dependent does not include the spouse of an employee,” the proposed rules say. 
Thus, employers must offer coverage to children of an employee, but do not have to make it affordable. And they do not have to offer coverage at all to the spouse of an employee.
We can stop with the self-congratulatory "healthcare for everyone" claim from Obamacare advocates anytime now.  Is it an improvement over the status quo?  Inarguably.  But we are long ways from a just society.....

Accelerated Degrees

Amen to this:
But now one of the nation’s premier medical schools, New York University, and a few others around the United States are challenging that equation by offering a small percentage of students the chance to finish early, in three years instead of the traditional four. Administrators at N.Y.U. say they can make the change without compromising quality, by eliminating redundancies in their science curriculum, getting students into clinical training more quickly and adding some extra class time in the summer.
Not only, they say, will those doctors be able to hang out their shingles to practice earlier, but they will save a quarter of the cost of medical school — $49,560 a year in tuition and fees at N.Y.U., and even more when room, board, books, supplies and other expenses are added in.
It is a well-known fact amongst physicians that the fourth year of medical school is, for the most part, a tremendous waste of time.  Granted, you have to bust your ass in July/August of fourth year in order to secure the necessary GLOWING RECOMMENDATIONS from faculty members in your chosen specialty, but once the leaves start to turn, it's slacker time.  I vaguely seem to recall numerous days where my clinical responsibilities were over by noonish and I was lacing up my shoes for a four hour session of pickup basketball at the gym. 

Certainly, one could choose to work a lot harder, i.e. by voluntarily signing up for demanding fourth year clinical subspecialty rotations in fields like pulmonology, cardiac surgery, etc.  But if you're planning on being an radiologist or an endocrinologist, why, other than pure intellectual curiosity, would you want to do that?  Is it worth an extra 50 grand of debt?

At least put the option out there.