Sleep-Deprived Surgeons: Idealism and Reality

An editorial in the this week’s New England Journal of Medicine proposes that sleep-deprived surgeons should tell patients that information and obtain written consent from patients acknowledging that they have been so informed. This article garnered a “hat trick” of coverage as it was featured by Science Daily, Medpage Today and Eurekalert. First, let’s look at the coverage. Understanding that these three sites simply rehash press releases, they do tend to resemble news reports. Only Medpage Today, while publishing a photo [at right] of a seemingly fatigued surgeon, chose to mention a rebuttal to the editorial by the American College of Surgeons [ACS]. One the other hand, CNN Health published a somewhat balanced report that included excerpts from the ACS response but follow-up answers were forthcoming only from one of the editorial’s co-authors and not the ACS spokespersons.

I would point out that this sentence from the proposal, “In surgery, there is an 83% increase in the risk of complications (e.g., massive hemorrhage, organ injury, or wound failure) in patients who undergo elective daytime surgical procedures performed by attending surgeons who had less than a 6-hour opportunity for sleep between procedures during a previous on-call night” is grossly misleading. The JAMA paper cited says no such thing. Yes, there is an increased risk of complications but the paper does not specify exactly which complications occurred. They may in fact have been minor complications. Of course, “massive hemorrhage, organ injury, or wound failure” sounds much more dramatic.

Although the rebutting ACS leaders made a decent point that issues such as marital problems, a sick child or financial difficulties might also degrade performance and are not subject to disclosure, the argument that surgeons should be trained to recognize fatigue was extremely weak and was deftly parried by one of the co-authors of the proposal. You can read those comments in the CNN Health article.

Now, what do I think of the proposal? In a perfect world, the idea of a surgeon telling patients that he is sleep-deprived would be wonderful. Alas, we don’t live in a perfect world. The reality is the proposal is highly impractical. The example cited in the proposal was that a surgeon who was up all night had an elective colostomy scheduled for 9 a.m. The proposal’s authors would mandate that he inform the colostomy patient that he is sleep-deprived and offer the patient the option to postpone the procedure or have another surgeon perform it. What is involved in postponing the case? The patient may have taken laxatives to prepare the bowel for surgery. She may have had lab work done, taken time off from work, arranged for child care, have important business three weeks later etc. The hospital’s operating room likely would go unused for the two hours originally booked for the colostomy.

Having another surgeon operate on the patient would mean loss of a fee for the tired surgeon. [I know that shouldn't matter but it's not a perfect world.] And just which surgeon is going to be sitting around doing nothing that morning and hoping a colleague was sleep-deprived? Assuming another surgeon was readily available, how does the conversation between the patient and the new surgeon go? “Hi, I’m your new surgeon. I’m not sleep deprived. By the way, what’s wrong with you? Oh, you need a colostomy.” Does the patient have a chance to Google the new surgeon? Is the new surgeon on the patient’s insurance panel? What if the patient doesn’t bond with the new surgeon in the 10 minutes she has had to get to know him? Can she ask for a third surgeon to be introduced? Will all of this take so long that the original surgeon might have had a chance to take a nap and now be refreshed? How long of a nap is long enough?

Maybe the solution is for every hospital to establish a surgical hospitalist service to do all the acute care surgery. This would allow some surgeons to focus on elective surgery exclusively. This too would cost significant money in terms of supporting the hospitalist service and loss of income and new patients for surgeons who no longer take call. Also, where are all these surgical hospitalists going to come from? [Full disclosure: Skeptical Scalpel is a surgical hospitalist.]

Bottom line. I see no way that the proposal that a sleep-deprived surgeon must obtain informed consent from patients is practical in today’s medical setting.

Christmas Morning Then and Now

It’s a quiet Christmas morning sitting by the fire with my wife. The children aren’t awake yet. They are all grown up now but I’m glad they are home with us today. My fondest memory of Christmas morning is from their pre-teenage years. We had a rule that none of the kids could go downstairs to see what Santa brought until every one of the six of them were awake.

Inevitably, one of them would sleep late. So my oldest son, who was then about 8, would be the first to crawl into bed with us to wait. As he lay between my wife and me, his heart was pounding with excitement. Each beat almost shook the bed. One by one the others appeared until our bed was filled with a quivering mass of high anticipation.

Finally the last one arose, and they all raced down the stairs. In those days, I videotaped the fun of Christmas. At some point amid the mountains of strewn wrapping paper and boxes, one of them would always look up and say, “This is the best Christmas ever.”

I’m thankful that they are all happy adults. In a different way it’s still “the best Christmas ever.”

NY Times Wedding Profile Ignites the Internet: Grammatical and Medical Implications

So there’s this big dustup about a couple whose wedding was profiled in the NY Times on Sunday. It seems in the process of discovering they were soul mates, they broke up two marriages, both with children, the two couples had been friends and blah, blah, blah. The Times had to shut down the comments section of the story because of the furor.

Then Slate posted some sort of blog about it and among the comments is a biblical reference by a person with the apparent pseudonym “Guest.” [Or maybe it was Christopher Guest but I doubt it because he likely would have known better.] Anyway, include in Guest’s numerous ramblings was this “Let he who is without sin throw the first stone.”

Forget about the wedding. I have to unload about the comment. The exhortation “Let he who is without sin throw the first stone” is from the Book of John something:something. Various versions of the passage exist [Google it yourself and see]. But the correct way to say this is “Let him who is without sin throw the first stone.” If you don’t believe me, try this. Delete the clause “who is without sin” and say what remains “Let he throw the first stone.” Can you appreciate that it just don’t sound right?

By the way, two comments by others suggested the bride and groom are narcissists. Please don’t forget that narcissism is no longer a disease. It’s been relegated to the status of just being a very annoying personality trait.

Does Hospitalist Co-management of Surgical Patients Improve Care?

A report from the University of California, San Francisco in the December 13/27, 2010 issue of Archives of Internal Medicine shows that co-management of neurosurgery patients by medical hospitalists and neurosurgeons had no effect on patient outcomes or satisfaction but did lower costs by over $1400 per patient. Co-management led to a perception among other hospital staff that the quality of care was improved especially regarding patients with medical co-morbidities.

The before-and-after-study included 7596 neurosurgery patients, 45% of whom were admitted after the Co-management on Neurosurgery Service [CNS] was established in July of 2007 because of reductions in neurosurgery resident work hours. Prior to that date, the patients were managed by a single neurosurgery resident who was responsible for as many as 50 inpatients.

The lead author, medical hospitalist Dr. Andrew Auerbach, was asked whether the paper might also be interpreted as finding that before co-management, the lone neurosurgery resident did a good job. He agreed that “…the NS resident [care] was not all that different (in terms of our outcomes) from the CNS service model.”

He was most pleased with the responses of the staff to the changed service stating, “…the perceptions of safety and quality improvement among everyone (including the NS residents) are profound.”

The cost savings estimate did not include data on professional fees generated by the increased level of medical hospitalist participation in the service nor was the outlay for the reimbursement of the hospitalists factored in. Dr Auerbach said, “The CNS service did not produce substantial revenue; however, it required substantial subsidies from the Medical Center. As much as 70% of the total costs to operate the service came from the subsidy.”

Although the authors concluded that the service worked well especially in the area of patient safety and quality, there was no objective evidence that co-management was of value. They suggested that future co-management efforts should focus on improving outcomes.

Is Medical School Tuition Debt Deterring Prospective Students?

Yesterday I received a call from the son of some old friends. This 30-year-old man has been an elementary schoolteacher for the past few years and recently decided that he would like to go to medical school and eventually become a surgeon. He wanted to know what I thought of the idea.

Suppressing the urge to tell him not to even consider becoming a doctor, I tried to help him think it through. He is looking at about 10 years of hard work including taking a year of post-graduate pre-med science courses, four years of medical school and five years of surgical residency training before his dream becomes reality. Here are the issues.

He is still paying off his college tuition loans. He will have to pay tuition for his post-grad year. Medical school tuition alone will cost at least $40,000 per year [private] or $20,000/$40,000 per year [public, resident/non-resident]. Fees, health insurance, books, housing, food etc are not included. According to the AMA, the average debt facing graduating medical students in 2009 was $156,000. Here is a Wall Street Journal story about the worst case scenario for medical school tuition debt, a whopping $550,000 tab run up by a family practitioner.

He will not be able to earn much money during his five years of residency training. The average salary for a surgical resident is about $56,000 per year, which will force him to defer paying the principal on his loans while the interest keeps on accruing. By the time my young friend is ready to start his residency [2015], I fully expect the current allowable work hours to be significantly lower than the current 80 hours per week. This may lead to a lengthening of the duration of surgical training to six or seven years.

At best he will be 40 years old when he is ready to start practice. No doubt Medicare reimbursement for physicians will be reduced as this was barely averted for 2011 by a last-minute compromise band-aid bill passed by Congress. The insurance companies will surely follow with decreases of their own.

God only knows what will happen to malpractice insurance premiums, the cost of running an office and other practice expenses. One thing for sure is that decreases are unlikely. “Private practice” may not even exist by 2020. Every doctor may be salaried as regulated by the government.

So do you want to invest ten years of your life to become the 21st century’s version of an indentured servant who runs up a debt so big that it can never be repaid for the privilege of working 60-80 hours per week for the rest of your life? If that sounds like a good deal to you, then go for it.

Science Daily: News or What?

Guest Blog
by Phil Space

Skeptical Scalpel was recently taken to task by a leading medical journalist for seeming to confuse the website Science Daily with an actual news organization.

It took a while to catch on but for the last couple of months Skeptical Scalpel says he has been aware the website Science Daily simply publishes press releases received from journals, organizations, research laboratories and other entities. Despite having this knowledge, he feels that Science Daily at least simulates news and does have some impact on the way stories are perceived. I asked Skeptical Scalpel to explain.

He said, “Science Daily comes across as something resembling news in four ways. First, someone over there has to decide which of the hundreds of press releases received every day will be featured. Second, the articles are written as if someone has indeed interviewed a member of the research team. This tends to make the piece read as if it were real news. Third, look at the way the information is presented on the website. The masthead clearly states ‘Your source for the latest research news.’” [See photo below]

He went on to say, “And fourth, you will note the grossly misleading headline ‘Estrogen Alone Is Effective for Reducing Breast Cancer Risk, Study Finds,’ which belies the fact that the study it refers to concerns a subgroup of patients who had undergone hysterectomy as part of a larger study. The finding is not only not applicable to all women, it may not be even applicable to women who have had hysterectomies because of the pitfalls of post hoc subgroup analysis. In fact, the press coordinator of the symposium at which the study was presented as a poster has expressed regret that a press release was issued.”

Skeptical Scalpel went on to say that he had queried Science Daily in the August and again in the past few days regarding how it chooses articles to display and said, “I never received a reply.”

It may not be journalism but is it news? You decide.

Posters at Medical Meetings: The Real Story

A study presented as a poster at the San Antonio Breast Cancer Symposium received widespread notoriety because it reported that certain subgroups of patients from a much larger study who had undergone hysterectomy and were on estrogen therapy actually had a lower risk of subsequent breast cancer. For some reason the symposium distributed this information in a press release and it was swallowed whole by some media outlets such as Science Daily and MedPage Today. The resulting confusion [most studies show that estrogen use is associated with a higher risk of contracting breast cancer] has caused the symposium’s press conference moderator to regret having featured the poster according to Crystal Phend, a MedPage Today blogger.

Some members of the medical press may be unaware of the manner in which posters are chosen for presentation. In many organizations it works like this. Abstracts are submitted to the organization for oral presentation, which is much more prestigious than simply presenting a poster. An oral presentation requires that the completed paper be submitted to one or more discussants for rigorous peer review prior to the date of the oral presentation. Papers rejected for oral presentation are often accepted as posters without any critical review at all.

For example, the Society of Critical Care Medicine [SCCM] has accepted 1025 posters for its upcoming meeting in January of 2011. The quality of some of the research is quite spotty. One abstract [title available on request] states, “While comparing pre and post [intervention] patients, survival to discharge showed a non-statistical but clinically significant improvement from 29% to 42%. (OR 1.76, 95% CI 0.5-5.9)” This of course is a scientifically inaccurate statement.

Why do organizations accept all submitted abstracts as posters? I believe it is because accepting all submitted abstracts as posters significantly increases meeting attendance. At least one author of the 1025 accepted posters will probably attend the SCCM meeting to be present when the poster is briefly discussed at sessions known as “Professor’s Walk Rounds” or similar names.

There is reward for the authors as well, who can pad their CVs with references to their research as having been “accepted as a poster presentation at SCCM.”

Bottom line. Exercise extreme caution when reporting the results of research presented in a poster.

Suicide in Hospitals or Why the Joint Commission Drives Me Crazy

If you’ve ever wondered why the Joint Commission [an organization that somehow has managed to become the be-all and end-all for accrediting some 18,000 health care entities in the U.S.] is reviled by many people in health care, you need only look at their latest pronouncement regarding suicide by hospitalized patients. Based on the fact that 827 patient suicides have occurred in hospitals since 1995, the JC [ironically godlike initials] has mandated that hospitals should screen all patients for suicide and depression risk. According to an article in amednews.com, the screening should include the following four steps:

•Check for contraband that could be used to commit suicide.
•Alert staff to any warning signs.
•Engage the patient at risk and his or her family in formulating a post-discharge plan.
•Communicate the suicide risk during hand-off procedures.

Let’s do some math. The 827 hospitalized patient suicides divided by 15 years equals 55 suicides per year. The American Hospital Association reports that in 2009 there were 37,479,709 hospital admissions in the U.S. Thus, the percentage of hospital admissions that resulted in suicide every year is about 55 divided by 37,479,709 or 0.00014%. So to possibly identify 0.00014% of patients, the JC will require hospitals to screen all patients.

I estimate that well over half of the general surgery patients I encounter are on anti-depressant medications, usually more than one. Primary care docs prescribe anti-depressants like Tic Tacs. Are these people really clinically depressed or do they just tell their doctors the feel depressed and receive a prescription?

How is one supposed to ask patients about suicide? How about a woman admitted in labor or a man with appendicitis or a child with pneumonia? I recall a similar mandate a few years ago which involved asking every patient entering the hospital if he wanted to be resuscitated should his heart stop. You can imagine the unsettling effect that had on, let’s say, a woman admitted in labor or a man with appendicitis or the parents of a child with pneumonia. Needless to say, we don’t currently ask most patients whether they want to be resuscitated.

What is going to be the impact of searching all patients for contraband? Maybe hospitals could outsource this component to the TSA. We already have the radiation capability. If you want to commit suicide in a hospital, you don’t need to bring contraband in. You can find things to use or jump out a window.

Knowing the JC as I do, I have no doubt that all of the screening steps will require extensive documentation.

By the way, there are many instances of people committing suicide while under intense psychiatric care both in and out of hospitals. Can all suicides be prevented? I think not.

Should our efforts be better directed at something that occurs more often?

And people wonder why there is burnout in health care workers.

Mickey vs. Tiger: A Tale of Two Eras

I just finished reading The Last Boy, Jane Leavy’s interesting focused biography of Mickey Mantle. The tale is told from her personal and unique perspective and it’s not a typical sports biography filled with scores and stats. She tells of his upbringing, his fear of dying young and his self-destructive behavior, and she doesn’t hold back. He was an epic womanizer, the Tiger Woods of his day, and cheated on his long-suffering wife throughout the course of their marriage. He even hit on Ms. Leavy back in 1983 when she first met him for an interview. Mickey was also a world-class alcoholic, eventually receiving a liver transplant and dying of liver cancer in 1995.

Sportswriters in the old days protected the athletes and there was no Internet, no Twitter and no such thing as a cell phone with a camera. But tabloid newspapers and expose’-type magazines [see photo] published stories about Mickey’s escapades, which the public didn’t seem to care about. Yet the '50s and '60s were a time of sexual denial and public modesty. You would have thought that people back then would not have tolerated Mickey’s behavior, but he kept endorsing products and was beloved until he died.

Fast forward to the present and the Tiger Woods scandal. Why was it a scandal? In contrast to Mantle’s heyday, anything goes when it comes to sex today. Pornography is delivered unsolicited to your email. Sexuality, vulgarity and nudity can be seen on television at all hours. Senators, congressmen and governors and even a president commit sexual indiscretions on an almost daily basis and continue in public life without apparent consequences. Yet when Tiger’s infidelity (what a quaint term) came to light, he was universally reviled, and he lost millions of dollars in endorsements.

What strikes me is the contrast between the eras. The uptight mid-20th century tolerated the unbridled Mantle and the “anything goes” first decade of the 21th century shunned the prowling Tiger.

Other than the fact that Tiger is back to playing golf in a relatively protected environment, he is a virtual recluse. I’m sure he will eventually be more visible but meanwhile, why did he have to disappear? I don’t condone his actions. His goody two shoes family man persona was obviously a sham. But why is he a pariah and Mantle a god to this day?

The Old Man and the Sex

From the Dec. 7, 2010 issue of Annals of Internal Medicine comes a study to ponder. A survey of almost 2800 Australian men between the ages of 75 and 95 not living in nursing homes reveals some sobering information.

Fewer than half of the men (48.8%) considered sex “somewhat important.” Here’s the interesting part: 69.2% of the respondents had not experienced even one sexual encounter within the last year. Of the 30.8% who did have at least one sexual encounter, 43% said they would like to have sex more often. Not addressed in this paper is what would the percentages be if men aged 30-50 or 40 to 60 were surveyed?

Factors associated with a decrease in sexual activity included increasing age, osteoporosis, prostate cancer, diabetes, partner's physical limitations or lack of interest, drugs such as antidepressants and β-blockers and one issue pertinent to men of all ages, lack of a partner.

Limitations of the study are as follows: the men may have exaggerated [you know how men are]; the surveyed group may not represent all old men; the study was done in Perth, a small, rather isolated city in Western Australia so who knows what state of mind these guys were in?

Taking the study at face value, what have we learned here? Don’t get old and don’t get sick. Oh, and don’t forget the partner.

The Future of Nursing. What about the Present?

Last month, the Institute of Medicine [IOM] issued a report called "The Future of Nursing: Leading Change, Advancing Health." The report stated that nurses should “assume leadership roles in redesigning care in the United States” and organizations “should remove scope of practice barriers that hinder nurses from practicing to the full extent of their education and training.” IOM also said more nurses should obtain advanced degrees and proposed creating “a residency program to help nurses transition from education to practice and additional opportunities for lifelong learning.” A number of other suggestions were made including elevating nurses to a “full” partnership level with other health care professional [doctors?].

This has generated some predictably positive responses from organized nursing and from the Center for Medicare and Medicaid Services (CMS) chief, Donald Berwick, MD, who effusively praised the report during a fawning speech to nursing leaders in Washington.

Not everyone agrees. IOM member George Lundberg, MD, blogged that if nurses want to be doctors, they should go to medical school. This received some passionate comments from both sides.

Here is my take. I currently work in an excellent non-teaching [no MD resident trainees] community hospital. There are some great nurses, many of whom function at the level of junior residents. But my experience in general over the last few years is that the level of nursing care has declined. As an aside, I think some of the problems can be traced to the nurses’ burden of inordinate amounts of “charting” mandated by various agencies and facilitated by point and click electronic medical records. Trust me, no one reads these mountains of redundant and mostly irrelevant data.

I don’t need a “partner.” While I am delighted when a sharp nurse alerts me to something important or suggests a change in treatment based on an observation, what I need is a nurse who knows the following: what medications my patient is on and why; what procedure he’s had and why; what his intake and output was over the last 24 hours; whether he has any new complaints; if anything out of the ordinary has occurred; how to give an enema, etc.

If nurses are going to assume some other lofty role, will someone please tell me who is going to take care of my patients at the bedside?

Full Disclosure: I am happily married to a nurse and have been for almost 37 years.

Isolation Pros and Cons

In a recent NY Times column, Pauline Chen discussed the downside of isolating patients with serious infections. She described an all too familiar scenario of a man who had a multidrug resistant infection of the abdominal wall and gradually withdrew from life as caregivers, frustrated by the elaborate isolation precaution rituals [gowns, gloves and sometimes masks], stopped interacting with him. I have observed many other problems with the isolation process.

The hospital infection control staff is quick to post signs isolating patients with methicillin-resistant staph aureus [MRSA] but other types of infections such as methicillin-sensitive staph aureus [MSSA] do not seem to require isolation. I don’t quite understand that philosophy. MSSA is just as virulent as MRSA. MRSA is simply harder to eradicate.

Most hospitals have a policy that if a patient has ever had MRSA, he must be isolated even if there is no evidence that he has a current active infection. Yes, he may be a carrier of MRSA, but so might any other patient [or by the way, hospital employee] who has not been tested for the organism. I recently took care of a patient who had a history of an MRSA urinary tract infection [UTI] many years ago. She was dutifully placed on isolation despite no proof that she was actively infected with or carrying MRSA.

In certain areas of the hospital such as the emergency department, radiology and the operating room, it is very difficult to maintain isolation due to the geography of those areas, the lack of familiarity with the details of the patient’s past history and the logistics of cleaning the radiology suite every time an isolation patient visits that area. For example, the patient with the previous MRSA UTI was not isolated in the ED because the information about the previous MRSA UTI was unknown to the ED staff.

At times the non-clinical personnel violate the isolation protocol perhaps unknowingly. Housekeeping people seem well-schooled but dietary workers remove food trays from isolation rooms and place them on carts with non-isolation trays. The uncovered trays are returned to the kitchen on elevators and through hallways.

If I visit an isolation patient and change a dressing while wearing gloves and without touching the patient’s bed or linens with my body, why must I wear a gown? Can staph jump and if so, how far?

I agree with one of the points Dr. Chen made in her article which is that all the fuss about isolation may cause the staff to miss the big picture. There needs to be a compromise between the strict but difficult to comply with and often breeched isolation policies and the need to see and relate to the patients. Perhaps the solution of gloves when examining all patients would suffice for even MRSA patients.