Preoperative Medical Consultation May Increase Risk

Attention readers: Unlike my previous post on the reasons medical students do not choose primary care careers, this post is serious. I feel I have to explain because when my blog on primary care appeared as a guest post on the blog KevinMD, someone commented that I should have said up front that it was satire. I found that hard to believe.

Similarly hard to believe, but appearing in the current issue (August 9/23, 2010) of Archives of Internal Medicine is an article that has the following conclusions: “Medical consultation before major elective noncardiac surgery is associated with increased mortality and hospital stay, as well as increases in preoperative pharmacologic interventions and testing.”

The study was a retrospective cohort study of 269,000 patients who underwent intermediate and high-risk noncardiac surgery in Ontario, Canada. Over 90% of the more than 104,000 patients who underwent preoperative medical consultation were matched to similar patients who did not have a consult. While the increases in mortality rates and length of stay are small, they are real. In addition to the increased 30-day and one-year mortality rates and length of stay, patients receiving consults had more preoperative testing such as unnecessary echocardiograms and were given more drugs including beta-blockers. The beta-blockers were probably not indicated and were associated with increased rates of postoperative stroke in abdominal and thoracic surgery patients. Interestingly, consults with specialists such as cardiologists led to higher mortality rates.

In fairness, the authors mentioned several limitations of the study including the fact that they used an administrative database which did not include certain complications and that it was a retrospective study. But evidence is evidence, and a prospective study on this topic would be impossible due to ethical considerations. Reminder: This is factual information from an internal medicine journal. I leave you to ponder the implications of this study.

Freelance Editing Opportunity

I am practicing surgery but would love to get more involved with editing and writing. To that end, I have started this blog. And I have an idea for a writing/editing venture. I would like to offer my services to all the scammers out there whose command of the English language, particularly English as spoken in the U.S., is lacking. I believe I could greatly enhance the credibility of the scam with some deft copy editing. Here are three examples taken from real emails.

1. I recently received this email from a former resident. The subject line read “Help!!!” The unaltered body of the email is as follows:

” Hey, Am in a deep mess right now,I came down here to London,England for a short vacation unfortunately I was mugged at the park of the hotel where I lodged,all cash,credit card and cell were stolen off me but luckily for me i still have my life and passports with me.

“I've been to the embassy and the Police here but they're not helping issues at all and my return flight leaves in the next few hours from now but I'm having problems settling the hotel bills and the hotel manager won't let me leave until I settle the bills. The hotel manager have been so kind by taking me to a local library to shoot an email to you as i have explained to him that the bills is going to be taken care of by you.

“Am freaked out at the moment.

“Stephen”

As you can see, there is a lot to work with here. Ignoring the multiple punctuation, spacing, grammar and capitalization errors, deep mess, lodging, shoot an email and Am freaked out are red flags that something may be amiss. My resident’s email had been hacked and no money changed hands.

2. Another to my son who offers private swim lessons:

“I want to Schedule and reserve for a swimming class/lesson for my clients.You are to provide an instructor for my clients. They(my clients) will be total of Five(5) Adults in number that will be part of the swimming classes for one week(1st of October-7th of October 2010). One(1) hour class or session or learning per day.

“Get back to me with the total cost(in USD or EURO or GBP) of the swimming classes for the Five(5) Adults for the one week.One hour per day. Note that my clients' Logistics Agent will take care of their Feeding,Accommodation,Air flight/Transportation and others Logistics while they are in your country.So you should not bother about that. Hear from you.”

Again, there are a number of areas that require attention. It looks like proofreading is not their strong suit.

3. Response to a Craigslist posting involving furniture:

“…I will give you an extra $25 if you take down the advert immediately.”

Who says “advert” in the U.S.?

So, to all scammers: if you are experiencing poor responses to your email inquiries, contact me and I will help. Just send me your bank account number and any relevant passwords and my Logistics Agent will take care of everything.

“Common Sense is Very Uncommon”—Horace Greeley

As the New York Times pointed out in an article on 8/20 about misplaced tube feedings, system problems can be the cause of complications and deaths in many instances. And it is certainly easier on everyone to blame the system rather than an individual. However, sometimes it really is someone’s fault. The problem with tube feedings which has existed for at least 30 years is that the connections for the tubing are often similar to the connections for intravenous fluid tubing. If one is not careful, feeding meant for the GI tract can be delivered intravenously with disastrous results.

Here is my question. How could a nurse make such a mistake? Yes, it would be better if the tubing connections were different and regulations requiring this are long overdue. But where are the elements of due diligence and common sense? No doubt the order for the GI tube feeding stated that it was to be given via the stomach tube. Even when diluted, GI tube feedings have the consistency [but not the color] of pea soup. With the exception of blood and a few other special items, intravenous solutions are clear. How could anyone look at a solution containing GI tube feedings and assume it would be OK to infuse it through a vein?

System issues must be addressed but the human element still exists. A 2007 paper from a highly regarded trauma center showed that the leading causes of preventable and possibly preventable trauma deaths were delays in treatment and errors in judgment, which are two factors unlikely to be eliminated by changes in systems.

I think all of this represents a slide toward mediocrity and lack of accountability our country has been on for many years. This is highlighted by another Times story in the 8/22 edition on stupid things people do in our national parks. Among the many sadly believable tales is one recounting a group of hikers summoning a rescue helicopter on two occasions [at $3400.00 per flight funded by us, the taxpayers] because first, they were low on water and second, the water in the park “tasted salty.” Regarding the problem of hikers becoming lost, spokesman for one of the parks is quoted, “We have seen people who have solely relied on GPS technology but were not using common sense or maps and compasses, and it leads them astray.”

Go ahead and make all the system changes you can think of. I guarantee you that after the GI feeding tubing connections are finally mandated to be incompatible with IV tubing, someone will still find a way to mistakenly deliver food meant for the stomach into a vein.

World-Wide Violence Against Doctors and Nurses

“Everyone participate in the sorting out of the law and order problem!” reads a sign in the lobby of Hospital No. 5 [catchy name, but I prefer it over the practice in the U.S. of glorifying a simple community hospital with a name like University Medical Center, usually with no affiliation to a university] in Shenyang, China. According to an August 11 article in the New York Times. the sign was erected in response to increasing numbers of attacks on doctors and nurses. The article recounts several disturbing incidents of disgruntled patients or families taking out their frustrations on medical workers throughout China, including the following: “…a doctor was stabbed to death in Shandong Province by the son of a patient who had died of liver cancer. Three doctors were severely burned in Shanxi Province when a patient set fire to a hospital office. A pediatrician in Fujian Province was also injured after leaping out a fifth-floor window to escape angry relatives of a newborn who had died under his care.”

Coincidentally on the same day, the Associated Press reported a story about assaults to emergency room personnel in the U.S. While there are some similarities in the two accounts, the root causes of the violence are different. If the reports are accurate, it seems that medical care in China is of very low quality with issues such as poorly educated doctors being paid by drug makers for writing prescriptions. In the U.S., the problem seems to be related to drug and alcohol abuse and mental illness [among the patients, not the medical people].

Who among us hasn’t occasionally thought of committing physical harm to the ED staff at 3 in the morning after being consulted to see a patient who has been there being “worked up” since 5 pm? I certainly have but so far, I’ve been able to suppress the urge.

Interestingly, the solution proposed by organized medicine in both China and the U.S. is the same—increase police and/or security guard visibility in hospitals. Police presence might help, but a determined psychopath could surprise even an alert cop. It’s analogous to terrorism. If someone is fanatical enough and undeterred by conscience or consequences, there is no foolproof way to stop that person.

Acetaminophen Use Linked to Asthma

It looks like acetaminophen (Tylenol) may be the cause of asthma in 40% of children. I hate to say “I told you so.” [Not really. Honestly, I love to say it.] I’m not claiming I knew acetaminophen caused asthma. But I am on record [reference available on request] as stating that fever is good for you and should not be treated with anti-pyretics, antibiotics, ice baths, cooling blankets or anything else.

Fever is a natural and useful response to illness. Research shows that cold blooded animals given febrile illnesses prefer warmer temperatures and those animals forced to maintain normal temperatures have higher mortality rates. It appears that suppressing fever in critically ill humans is equally detrimental.

Now that acetaminophen has been identified as being harmful, why don’t we stop giving it to febrile children [and adults] and stop trying to “treat” fever as if it were something evil?

PS: Don’t bring up febrile seizures. There is no evidence that giving acetaminophen or any other drug prevents febrile seizures.

Appendicitis: Diagnosis, CT Scans and Reality

UPDATED 4/11/2013

ADDENDUM: Dear Readers,

I am grateful that this post has been read by so many people and that several of you have written for advice about your abdominal pain. While I would sincerely like to help you, it occurs to me that answering your questions has taken on a predictable scenario. You ask a complex question. I respond that not having examined or spoken to you nor having seen your CT/ultrasound reports or images, I cannot give you medical advice.

From now on, I will not be able to answer specific questions via this blog or by email. Please read through the numerous questions and answers and you are very likely to find a situation like yours that has been asked and answered.

Best wishes to all,

Skeptical Scalpel

Yesterday, medical writer and pediatrician Perri Klass wrote in the New York Times about evolving issues regarding the diagnosis of appendicitis in children, which are also applicable to adults. There is well-documented concern regarding the excessive radiation exposure associated with CT scans. For example, a recent paper reported that a single abdominal CT scan with contrast delivers a radiation dose equal to undergoing more than 200 regular chest x-rays. The implications of this large dose of radiation are that an increase in cancer rates may arise in the future, especially if the CT scan is performed in a child.

The problem is how does one curtail the use of CT scans for the diagnosis of appendicitis when the test has become extremely accurate? Although Klass states that a normal appendix can be expected in 10-20% of appendectomies, those numbers are no longer valid. Even in a non-teaching community hospital, the rate of removal of a normal appendix during emergency surgery for the diagnosis of appendicitis should be well below 10%. She also repeats a commonly held misconception that a high rate of removal of normal appendices results in a lower rate of perforated appendicitis, which is not true. Some authors even believe that perforated appendicitis is a different disease than simple acute appendicitis.

I do not see the rate of CT scans for appendicitis decreasing because of three major factors.

1. Patients [or their parents] have come to expect accuracy in diagnosis. On more than one occasion, I have had the experience of seeing a teenage boy with classical symptoms and signs of appendicitis where the emergency physician has called me and said he did not think a CT scan was necessary. I examined the child and agreed. After I explained everything to the mother, she said, “What about the CT scan?” It then becomes hard to go ahead without the scan because in the unlikely event the boy did not have appendicitis, the mother would have accused me of performing unnecessary surgery. In fact, of my last 80 appendectomies, I have operated without a CT scan only four times. My rate of removal of a normal appendix is 6%. This is in a non-teaching community hospital with out-sourced CT scan readings at night.

2. Klass mentions the use of ultrasound as a substitute for CT scan. Although ultrasound does not involve radiation and is accurate according to some studies, the reality is that it is not always readily available at night [when most people with abdominal pain show up] in many community hospitals. The test is useless when the appendix is not identified, a situation that occurs frequently outside of academia. And unlike CT scan, ultrasound is far less likely to reveal an alternative diagnosis when the appendix is normal.

3. In a non-teaching hospital where there are no residents, it is very difficult to have every patient with a suspicion of appendicitis seen by a surgeon. When the emergency physician calls and says she has a patient with a positive CT scan for appendicitis, the diagnosis is correct more than 95% of the time. They rarely call when the CT scan is negative. Some scans are equivocal and the surgeon does have to see the patient and make a clinical decision. Regarding patients with positive CT scans for appendicitis, it pains me to say this but the history and physical exam are probably no longer relevant. This is particularly true now that all patients with abdominal pain receive narcotics within a few minutes of arrival to most EDs. It takes cojones to not go ahead with surgery when the CT scan is read as positive for appendicitis. I have done it once [successfully] in the last 19 months. Of course, I look at all the CT scans myself to usually confirm or rarely question the reading.

It comes down to this. Do you want an accurate diagnosis for yourself or your child with the possible increased risk of cancer years later or would you accept a higher rate of normal appendix removal? I believe that the general public would opt for the former.

Medical School and Surgery

A rising second year medical student read some of my posts and wrote me a kind note asking if I would write something for students. I taught students and ran surgical clerkships at community teaching hospitals for my entire career until about 19 months ago. I also was prompted to address this subject after reading a recent New York Times story about a new admissions policy at Mt. Sinai Medical School. The school is accepting some students who are majoring in the humanities and are not required to take the usual science courses or the MCAT. In the words of one of the participants in the program: “I didn’t want to waste a class on physics, or waste a class on orgo [organic chemistry]. The social determinants of health are so much more pervasive than the immediate biology of it.” I agree that possibly “orgo” and probably physics are not necessarily essential for medical school applicants. But I think these courses are still relevant because they assess one’s ability to think. According to the article, these humanities students are faring as well as traditional students as far as grades and class rankings are concerned. Is this because science doesn’t really matter or could there be another reason?

Grades in medical schools are a joke. Let’s talk about the third year. If you look at the explanation of grades that comes with a student’s medical school transcript, you will find that the average distribution of grades in third-year clerkships in all subjects is something like this: honors 30%; pass 68%; low pass 2%. It is almost impossible to flunk out of any medical school in the United States. I once received an application for residency from a student who had been matriculating at a single medical school for TEN YEARS! I assure you that dean’s letter was a masterpiece. [More on deans’ letters below] And the fourth year of medical school is even worse. With few exceptions, most schools allow students to choose electives which may be taken just about anywhere on the planet. There are no objective measures of performance on electives and students are even more likely to receive honors grades in electives than in required courses.

“‘When I use a word,’ Humpty Dumpty said, in a rather scornful tone, ‘it means just what I choose it to mean—neither more nor less.’" [Lewis Carroll, Through the Looking-Glass. See also Bill Clinton "It depends on what the meaning of the words 'is' is." And "It depends on how you define alone…"] Carroll's quotation is not only applicable to Humpty Dumpty but it also describes most deans’ letters supporting student applications to residency training programs. Obfuscation is the name of the game. Until just a few years ago, deans did not even have to mention such things as failing a course, dropping out of school for a year or disciplinary actions. The letters all continue to read like public relations releases. The best part is the end where the dean uses an adjective, which in many instances is a code that tells the reader what the student’s class rank is, to describe the student. Some of my favorites from real dean's letters are as follows [highest to lowest and, where indicated, % of the class receiving that adjective]:

School A—outstanding, excellent, superior, very good, good;
School B— superior 20%, outstanding 20%, excellent 30%, very good 20%, good 7%, solid 3% [I guess “solid” could mean the student is dense as a rock.];
School C—superior “a few,” outstanding 25%, excellent 65%, very good 20%. I know it doesn’t add up to 100% so talk to the dean. Also, the worst student in the class was very good.

Yes, medical school resembles that famous fictional town in the Midwest. “Welcome to Lake Wobegon, where all the women are strong, all the men are good-looking, and all the children are above average.” [Garrison Keillor]

As far as I know, most medical schools are teaching surgery just like they did 40 years ago. What is Hesselbach’s triangle? What is Charcot’s triad? Second assist on a bunch of cases. Get the lab results from the computer so they can be re-entered in the computer in a progress note. And so on. Now that an entire surgical textbook can be carried in your cell phone, why don’t we change the paradigm? Rather than forcing you to memorize information, we should be teaching you how analyze and synthesize information as it relates to your patient.

The third-year surgery rotation in medical school is not a necessarily a good simulation of what it’s like to be a surgical resident. I can’t say what goes on in every school, but the last school I was affiliated with allowed students to take off the day after call. I never could figure out why since we only woke them for major cases at night and they usually slept most of the time. All I could say was, “It’s your tuition [$45K/year] and if you want to go home, it’s OK with me.” By the way, we at the affiliated hospitals never saw a penny of that tuition money. I’m not sure exactly where it was spent. I think that the way students are coddled on surgery rotations might be a factor resulting in the high attrition rate [about 25%] of surgery residents; i.e., it looks easy from the perspective of a student who does not do much.

Fourth year is out of control. In addition to the grade problem mentioned above, students are permitted to choose just about any rotation they want in the fourth year. This leads to tragic situations such as the student who takes four or five orthopedic electives in order to get noticed and then does not secure an orthopedic residency in the match. He will have wasted a good part of his fourth year.

One of the many unintended consequences of the electronic medical record [EMR] is the demise of medical student progress notes and orders. There is no provision for such activities in most EMRs. I have no idea how students are learning how to do these things.

My advice to my new friend, the rising second-year student, is that you should work hard and study hard during your surgery rotation in the third year. Be inquisitive. Be skeptical. Ask why. In my 38 years or so of teaching students, I estimate that I was challenged by a student on something I said fewer than five times. [Disclaimer #1: Not all authority figures like to be challenged. Choose your targets wisely. Be respectful.] If you want to be a general surgeon, take one surgery elective in the fourth year just to be sure you are making the right choice. Then take electives in gastroenterology, critical care, radiology [Not just because of the hours. You will need to know how to read a CT scan in the middle of the night unless you want to wait a couple of hours for the nighthawk to fax a reading.], anesthesiology and other non-surgical rotations. [Disclaimer #2: This is my opinion and it may not be shared by others.]

Hospital Profiling: Is Healthgrades the Answer?

In a word, no. Let’s take a look at their most recent rankings. According to Healthgrades’ America’s Top 50 Hospitals list, not a single medical school-based university hospital made the cut. This means that either Healthgrades or the list recently published by
US News and World Report must be completely wrong, since their two lists are mutually exclusive. While I am not so sure US News has it right either, I think I’d take my chances with their top 14 over any of the top 50 listed by Healthgrades.

If you look at Healthgrades ratings by state, you will find some interesting results. Let’s take Maryland for example. There is no question that Johns Hopkins is the best hospital in Maryland and certainly one of the finest in the country. But not according to Healthgrades. Of 20 possible specialty excellence award categories, Johns Hopkins was ranked as one of the top hospitals in Maryland in exactly one, prostatectomy. For fun, search your state and see what turns up.

There is a paucity of scientific research on Healthgrades with very few citations in PubMed. An article published in JAMA in 2002 appears to still be valid today. From the abstract: “Hospital ratings published by a prominent Internet health care quality rating system identified groups of hospitals that, in the aggregate, differed in their quality of care and outcomes. However, the ratings poorly discriminated between any 2 individual hospitals' process of care or mortality rates during the study period. Limitations in discrimination may undermine the value of health care quality ratings for patients or payers and may lead to misperceptions of hospitals' performance.”

A 2005 paper raised questions about Healthgrades’ use of administrative databases to define quality of outcomes. The authors concluded: “Substantial variability of reported outcomes is seen in administrative data sets compared with an audited clinical database in the end points of the number of procedures performed and mortality. This variability makes it challenging for the nonclinician unfamiliar with outcomes analysis to make an informed decision.”

There are some other notable issues with Healthgrades. It is not widely known that they offer consulting services. These are promoted as helping hospitals achieve better quality but may be somewhat ethically challenging. It would be like a gymnastics judge charging for advice on how a gymnast could improve her score at the next Olympics. Would it not be in the best interest of the judge to have said gymnast’s score be better?

While we’re on the subject of ethics, Googling Healthgrades yields an interesting finding on the first page of hits: a web site voicing consumer complaints. The majority of these numerous complaints detail Healthgrades’ practice of charging a fee for a report on a doctor or hospital, which is of course OK. What’s not OK is that they sometimes tack on a monthly “watchdog” fee, which is billed to the consumer’s credit card, in what the consumers claim is a hidden charge that they did not agree to. And it is difficult to have the extra charges removed and refunded.

In case you think this is not big business: Healthgrades has apparently just been purchased by another company for $294 million dollars. But even this deal is coming under fire as some shareholders feel that the company was underpriced. An investigation is under way.

So how does one pick a good hospital? I would say find a doctor you trust, ask for recommendations and do your own research. But I would take all ranking systems with a large grain of salt.

Medical Education Is Changing in a Bad Way and It Will Affect You!

As a former surgical residency program director for more than 23 years, I must comment on the proposed changes in the way physicians, particularly surgeons, are trained. Some history. In 1984, an unfortunate young woman died at a prestigious hospital in New York. The case was followed closely by the media. Several important issues relevant to her death were under-reported. She had taken illicit drugs on the night of her death and she withheld this fact from her doctors. Because of this, she had a reaction to sedation that was administer which led to her death.

There was a suggestion that the residents may not have been properly supervised. The residents who treated her had been on duty for UNDER 24 HOURS. Her father, a reporter for the New York Times, started a crusade against what was perceived to be the main cause of her death, doctors-in-training working long hours.

This case resulted in the creation of the Bell Commission which formulated regulations limiting doctors-in-training in New York State to a maximum of 24 hours of work per shift and 80 hours per week. [Note to any non-physicians reading this: being on-call for 24 hours straight does not mean that one is necessarily always awake for all 24 hours.]

Several years later, the national organization that governs medical resident training, the Accreditation Council for Graduate Medical Education (ACGME), adopted similar rules. The ACGME has now decided to ratchet down the hours for first year trainees to a maximum of 16 hours per day with a mandatory 10 hour rest period thereafter.

It is amazing to realize that in the so-called era of evidence-based medicine, none of the current or proposed work hours rules are based on any solid evidence that tired doctors are harming patients or that limiting hours worked will lead to better patient outcomes. In fact, Bertrand Bell, head of the commission that first limited resident work hours, admitted that the limit of 80 hours was based on no data, but rather just seemed like a good number.

Here is what Dr. Bell said in a letter to the Journal of the American Medical Association in 2007, “The specific “80-hour week” was actually determined by a colleague ON MY PORCH [my emphasis added] and was based on the following informal reasoning: (1) there are 168 hours in a week; (2) it is reasonable for residents to work a 10-hour day for 5 days a week; (3) it is humane for people to work every fourth night; (4) subtracting the 50-hour week (10 hours per day × 5 days) from 168 hours leaves 118 hours; (5) divide 118 by 4 (every fourth night) and add to the 50 hours and, eureka, that equals an 80-hour week.” How’s that for evidence? I particularly like “… eureka, that equals an 80-hour week.”

There is good evidence that limiting work hours can be detrimental to surgical resident education and possibly to patient care due to a lack of continuity and frequent “handoffs” of patient care. Certainly, there are no studies proving that patient outcomes are better since the initial work hours changes went into effect and there are several that show it has made no difference. Don Nakayama, a surgical program director in Georgia, pointed out an unintended consequence of the rules that has occurred as supervision was increased as well.

He said, “The unanticipated problem is one of excessive supervision of residents at all levels where residents never have the experience with practicing independently.” This has led to a feeling among graduating residents that they must take further fellowship training because as Nakayama put it, they “…feel unsure and avoid going into independent surgical practice right out of training. The effects (of excessive supervision) aren't going to be seen until the pre-duty hour, pre-malpractice crisis, pre-health care crisis generation retires.”

A program director who wanted to remain anonymous said, “Where is the response from organized medicine on this (the work hours rules)?” Another program director asked, “How can a first year resident advance to the second year and supervise next year’s first year residents if he/she has never even worked a 24 hour shift?”

What about the projected shortage of general surgeons within the next few years? A decline in the number of general surgeons per capita already exists. If restricting work hours leads to a lengthening of surgical residency training, how will the future need for surgeons be met? How can surgery training be lengthened from what is now 5 years in the face of massive debt for college and medical school tuition incurred by most residents? Absent the first year residents in the wee hours, who is going to pay for physician extenders to help care for patients? Well, I can only think of these questions, not answer them. Maybe someone else has an idea.

Frivolous Musings on Obesity from the New York Times

“Plus-Size Wars” in the August 1, 2010 issue of the New York Times magazine documents the travails of obese women looking for fashionable clothing and designers and manufacturers attempting to make clothes that fit. The article also mentions the burgeoning movement of the obese accepting their bodies and resisting the societal pressure to lose weight. If only the problem of obesity was limited to lack of suitable couture.

As a practicing general surgeon, I would like to point out that while obese people are coming to grips with their body images, they are also killing themselves. Just about everything involving medical care is exceedingly more difficult in the obese patient from the simple acts of having blood drawn, IVs inserted and blood pressure measured accurately to undergoing and recovering from even basic operations such as appendectomies.

Obesity is linked to decreased life expectancy and higher rates of diabetes, cancer, lung disease, hypertension and death from all causes. Finally, the cost of medical care is significantly higher for the obese. Compared to health, the clothing issue is of miniscule importance.