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.

Plastic surgeon sues former patients for comments made in on-line reviews

Jay Pensler, a plastic surgeon in Chicago, was unhappy with some on-line reviews of his work and is now suing three former patients for defamation. The patients, who are named in various reports of this story, apparently made scathing remarks about his care, his attitude and even his wife who apparently serves as his nurse. According to one report, the comments, recently removed from the websites Citysearch and Yelp, described the doctor as “…’dangerous,’ ‘ruthless,’ a ‘liar’ and ‘horrible.’" And the surgeon was called a “'rude jack***’ and ‘his wife … is a very rude unprofessional b****.’” Another report states that photographs of the alleged botched breast surgery were posted as well and quotes the woman as saying she now had “Frankenstein” breasts. The doctor says the photos have been altered.

One of the more interesting features of the story is that the names of what was thought to be anonymous reviewers were obtained from the two websites by subpoena.

Diligent research by the Skeptical Scalpel reveals the existence of a similar story from earlier this year in Marin County, California. A plastic surgeon named Kimberly Henry is suing former patients for posting critical reviews on the website DoctorsScorecard.com. This report mentions that a 2009 suit by a San Francisco dentist in another such case was dismissed by a California court, which cited that states anti-SLAPP [Strategic Lawsuits Against Public Participation] law, and awarded the patient $43,000.00 to be paid by the dentist for her legal fees. A law professor from UCSF said that the California law protected this type of review as long as the reviewer did not post “false facts [sic].”

A number of talking points arise:

Should a doctor ever sue his patients?
Will these suits simply invite more scrutiny of his work?
Are anonymous on-line reviews really anonymous?
Can people say anything they want on-line [except “false facts”]?
What did the monster's breasts look like or was the reference to Dr. Frankenstein's breasts? Either way, I don't recall seeing them in any of the movies.

Community Outreach: Fake Surgeon Makes (Road)House Calls

I know it’s late on a Friday afternoon and maybe few will read this but as a budding journalist, I feel compelled to write this story as it is a tale that cannot wait to be told.

Today, MSNBC reports that a woman pretended to be a plastic surgeon and talked two or more other women into allowing her to examine their breasts in bars in the Boise, Idaho area. She told them her name was Berlyn Aussieahshowna, which believe it or not, “was bogus” or so the account reads. She gave them the phone number of a real plastic surgeon whose office staff became increasingly concerned after receiving “a number” of calls looking to make appointments for liposuction and breast augmentation with Berlyn Aussieahshowna, whose real name is Kristina Ross.

Then the story gets a little weird as it turns out the Ms. Ross is a “transgendered” individual formerly known as Kristoffer Jon Ross.

The perpetrator has been charged with two felony counts of impersonating a physician.

Not mentioned in the article but follow up questions come to mind. For example, what were the victims thinking when they allowed themselves to undergo breast examinations in bars (not that such a thing has never happened before)? However, it probably has not occurred too often under the guise of a medical procedure. And what sort of woman undergoes the exam (OK, she had a few drinks. She figured she’d get a free exam.) but then apparently when sober, calls for an appointment to schedule surgery with the good doctor? In retrospect, does this still seem like a good idea?

And who says health care is not accessible to the masses?

Update: In April of 2011, Ms. Ross, who had pleaded guilty to two counts of misdemeanor battery, was sentenced to 360 days in jail.

Don't Scan Me, Bro'

The huge uproar about full body scans and harassment of air travelers misses an important point. Yes, there is concern about invasion of privacy, perceived near sexual assault and radiation exposure. Even mild-mannered Captain Sullenberger commented on the absurd practice of x-raying and searching pilots. For God’s sake, if a pilot wanted to make mischief, she wouldn’t need to put C4 in her bra. She could fly the damn thing into a building herself.

My problem with all of this is that the government seems to have an endless reservoir of bad ideas, starting with the thankfully now obsolete question, “Did anyone else pack your bags?” Did they really expect someone to say, “Well, a man named Ahmed knocked on my door this morning and offered to help me pack, so I let him.” And we always seem to be reactive rather than proactive. A guy hides explosives in his shoe in 2001 and to this day, we all have to take off our shoes at the airport. Unless this shoe removal is taking place everywhere else in the world, it seems to me that asking grandma to put her flip-flops on the scanner is unlikely to stop a terrorist. Last year another guy hides explosives in his underwear, and now we need to scan everyone’s underwear and frisk 3-year-olds. Are these procedures really thought to be effective or are they simply window dressing to reassure the public that stern measures are being taken?

Memo to the TSA: they’re going to try something other than a bomb in a shoe or Jockey shorts next time. Good intelligence such as the discovery of the plot to send explosives via cargo planes last month will do far more than all of the airport screening measures.

The public is fighting back. Just Google “TSA boycott” and see that a number of people are calling for a boycott of air travel altogether. Over 5000 people “Like” a Facebook page suggesting that all passengers opt out of the full body scan on 11/24 (the day before Thanksgiving), although I am not sure just how that will hurt the TSA. And there are courageous individuals like John Tyner ("If you touch my junk, I'm gonna have you arrested.") refusing to play the game at all. But of course, he did not get to take his trip either.

For me, the terrorists have already won. If their goal was to disrupt air travel and cause the American people to lose confidence in their government, they have succeeded.

[TSA logo by Ogel Volk via The Consumerist]

Liver Transplant Denied Medicaid Patient

Medical Quack, a blogger/tweeter on various topics, posted a story about a man who was denied a liver transplant in Phoenix. Due to budget cuts, Arizona Medicaid recently decided not to pay for such transplants for patients who had liver failure due to hepatitis C. The hospital would have had to absorb the cost of the procedure, estimated at some $200,000 to $500,000, and a hospital spokesman pointed out that there are 22 other patients with Medicaid on their liver transplant waiting list. The local news reports deplored the situation as did Medical Quack.

This is a sad story but what is the solution to the problem? Who is going to pay for this man's (and the other 22 patients') liver transplant? Both the news reporters and Medical Quack did not offer any suggestions. I have always been amazed that people seem to believe that the money will appear like magic. The fact is that health care for people without money has to be funded by people with money. It can come from taxes, surcharges on insurance or whatever. The reality is that some degree of health care rationing is inevitable, especially in a down economy.

Other ethical questions to ponder:

What if the patient had been an illegal alien lacking even Medicaid coverage? Should the taxpayers foot the bill? The cost of care of illegal aliens has been paid for by the taxpayers or absorbed by hospitals for years but how much longer can it continue?.

Did the Phoenix patient acquire hepatitis C while abusing drugs? If so, should it matter? Should the taxpayers have to fund all of his medical care including a liver transplant?

Should the taxpayers have to pay to support people who abuse themselves by using drugs,alcohol or tobacco? What about obesity? Somewhat of a precedent exists regarding alcohol. Over 2/3 of states still have the Uniform Accident and Sickness Policy Provision Law on their books. This law permits insurers to deny coverage for any policyholder who is injured while under the influence of alcohol or narcotics. I recently participated in the care of a patient who was readmitted to the hospital for the umpteenth time with acute respiratory failure secondary to chronic obstructive lung disease. She is on oxygen at home and continues to smoke. Yes, it can be done. She removes the oxygen tubing and lights up.

Research Study of the Day: Postoperative Outcomes Worse in COPD Patients

Internal Medicine News reports that a paper recently presented at the American College of Chest Physicians annual meeting found that patients with chronic obstructive pulmonary disease [COPD] fared much worse after all types of surgery than patients who did not have COPD. The authors reviewed outcomes of over 468,000 patients in a clinical database, 5% of whom had COPD. Not surprisingly, the COPD patients had significantly longer hospital lengths of stay and higher rates of complications and mortality.

The database contained no information about how the COPD patients were managed in preparation for their operations. Thus, the authors could not recommend any specific advice on how to limit the adverse outcomes.

Meaning no disrespect to the authors of this study and knowing how hard it sometimes can be to think of ideas for research, I wonder what they expected to find. Is there anyone who would not surmise that patients who have a major medical illness such as COPD would do worse than those who are not?

Research Study of the Day: Seeing Meat Makes People Less Aggressive

Who thinks up these experiments? According to a study from McGill University in Montreal, people who look at pictures of meat are significantly less aggressive than those who don’t. The report on Science Daily states that subjects were asked to punish a script reader for mistakes he made while sorting photos, some of which depicted meat and some which did not. The subjects were told that the punishment consisted of varying degrees of noise to the point of actual pain. It seems that photos of meat made the subjects less prone to inflicting the severest punishment. The study’s leader was surprised by the finding having felt that the sight of meat would have the opposite effect because of its association with hunting and other aggressive behaviors.

The report also contains the following amusing sentence. “The idea that meat would illicit aggressive behaviour [sic] makes sense, as it would have helped our primate ancestors with hunting, co-opting and protecting their meat resources.” This is another example of the mischief that can result from too much faith in spell-checker.

Just how crazy are people?

[“Contrail” is short for “condensation trail,” which is a visible plume of water vapor or ice crystals formed by condensation created when the hot exhaust of a jet or rocket meets cold air at high altitudes.]

While researching the story of Mick West, the computer programmer who runs the website ContrailScience.com and who identified and explained in detail the November 8 “mystery missile” seen over Los Angeles (where else?) as an airliner contrail even providing the flight number, I discovered a rather incredible mass delusion.

It seems that numerous people think that the government is spraying chemicals into the air for nefarious purposes. The deluded ones see long-lasting contrails as what they call “chemtrails.” There is a website called ChemtrailCentral.com which is filled with all manner of paranoid ramblings about this. For example, this gem from the FAQ section of the site describes the possible reasons for the government’s alleged activity:

Weather Modification
NASA is currently conducting several programs that are studying the effects of contrails on weather and the effects do not appear to be beneficial. [Truncated by me.]

Population Control
The use of chemical and biological agents by a government against it's own people is, unfortunately, a historical fact. Even unintentional accidents can occur. But, some people suggest that Chemtrails could actually be part of a program to reduce the population and many feel Chemtrails have caused them to become ill and perhaps they are right. If the Chemtrails contain biological agents then people already weakened by other factors may have even died as a result of the additional strain on their systems, but could such a diabolical purpose be the ultimate goal? History has taught that even the most unconscionable schemes can be made into reality by men filled with fear and hate, and with such weapons in the hands of government we must remain vigilant until answers are forthcoming.

Inoculation Program
Chemical and biological weapons have been used for centuries but have recently entered the world stage as a primary threat. Biological agents have the ability to spread and multiply in casualties. These bioweapons are easy to produce and difficult, but possible, to defend against. The recent actions of the military to require anthrax vaccines for all service personnel show that this matter is of high importance. Some propose that the government may be quietly releasing bioagents to vaccinate citizens via the air. This could account for reported illnesses since a vaccine sometimes makes a person sick. Municipal water supplies might not be universal enough and could be easily sampled and tested, but everyone breathes the air. And the federal government rules the air.

By my rough count, there are over 1500 registered users of the ChemtrailCentral website. Apparently these folks are allowed outside unsupervised and can vote. They also have access to Twitter. Just search "#chemtrail" on Twitter to read the current speculation that the government is spraying aluminum and barium or my favorite, that North Korea is spraying Ebola virus. Or you can Google "chemtrail" to find out more.

Sometimes the Internet makes me nervous.

Surprising common sense from website Cracked.com: “5 common medical procedures that secretly aren’t worth it”

Yesterday, the humor website Cracked.com published a list of 5 common medical procedures that, in its opinion, aren’t worth it. They are CT scans, physical examinations, circumcisions, Cesarean sections and antibiotics. OK, antibiotics are not really procedures, but you get the point. Of course, the author uses exaggeration to bolster his case but there is a lot of truth in the article. Let’s take them one by one.

5. CT scans. No doubt about it, they are overused and they are expensive. And there is a theoretical and possibly real risk, albeit small, of an increase in cancer rates in the future. Cracked thinks the increase in the use of CT scans is about money and greed but the fact is that doctors who order CT scans almost always do not own the scanner and do not profit from ordering the test. I think it’s about the public’s demand for diagnostic accuracy (I blogged about this in August) and the pervasive practice of defensive medicine. Physicians feel compelled to cover their asses by over-ordering confirmatory tests before doing anything and they fear being sued for missing something. As an alternative, Cracked.com suggests increasing the use of MRI. Although MRI does not involve radiation to the patient, it is also very expensive and not routinely available on a 24/7 basis. For some illnesses, it is just not as good as a CT scan for diagnosis.

4. Physical examinations. I could not agree more that they are useless in asymptomatic patients.

3. Circumcisions. More than 35 years ago, circumcision was shown to be not only unnecessary, but probably harmful in that occasionally a child was mutilated by technical errors with the procedure. Children with unsuspected hereditary bleeding disorders have even died during circumcision. Why the practice continues is inexplicable. I tweeted about this a few months ago and am proud to be now listed by the tweeter “Intact by Default” as disfavoring circumcision.

2. Cesarean sections. There are certainly too many Cesarean sections done in the U.S. Some are performed for the convenience of the patient or the obstetrician. However, the procedure can be “worth it” in selected patients. Examples of necessary Cesarean sections are the baby is too big to be delivered vaginally, the mother has a major complication of pregnancy or labor, some multiple births and others. Cesarean sections may also fall into the defensive medicine category as one can always question why a baby with a subsequent problem was delivered vaginally instead of by Cesarean section.

1. Antibiotics. Please, don’t get me started. Again although not a procedure, Cracked.com is spot on that antibiotics are vastly overused in medicine (and agriculture, by the way). In most hospitals, anyone who develops a fever gets antibiotics. Everyone wants antibiotics for a cold despite the fact that colds are caused by viruses (not affected by antibiotics) and colds are self-limited, non-fatal diseases. Overuse of antibiotics leads to bacterial resistance, which is now a major problem worldwide. They also cause diarrhea and a sometimes lethal infection called C. difficle colitis, which often attacks hospitalized, debilitated patients.

So let’s give Cracked.com an A- for its list. Too bad more physicians don’t read it. And too bad we live in a litigious society which fosters defensive medicine.

20th Century Archeological Discovery in New England

Nov. 8, 2010. An amazing find, a fully functioning communication device of the 20th century, was unearthed in New England this morning. Researchers found and photographed a rarely seen “pay telephone.” Investigation revealed that this phone could only transmit voices through its rather bulky apparatus. Attempts to send text messages and pictures were unsuccessful. The internet also could not be accessed, nor could music or games be played on it. It seems there is no screen display.

As can be seen in the photograph, a giant keypad must have been used to input numbers. Even more curious was the revelation that when the large hand piece was lifted from its cradle, a continuous sound could be heard. It was later identified as a “dial tone.” This tone apparently signaled the user that a series of numbers could be input after inserting coins in a receptacle.

A team of scientists from the Smithsonian Institution has been dispatched to the scene to run further tests and attempt to decipher the meaning of an inscription having to do with “collect calls.” As more information becomes available, we will bring it to you.

Key to Solving Obesity Crisis Discovered

Nov. 5, 2010. FLASH!!! From the EurekAlert! Website.

As confirmed by a group from Norway who studied 924 fourth-graders, overweight children have different eating patterns than normal weight children. Obese children ingest more sugar. In addition, they are less active and more likely to have obese parents.

I imagine that you are as astounded by these revelations as I am. Perhaps this is the spark that will ignite the reversal of the worldwide epidemic of obesity. All we need to do is get children to eat and drink less sugar, exercise more and convince their parents to lose weight.

Now that this is settled, let’s address the second most important health problem of this century, chapped lips. If we focus all of our resources on finding a cure, we should be able to lick chapped lips by the year 2020.

Alcohol Is the Most Harmful Drug? Nonsense!

An article published yesterday by the prestigious journal The Lancet claims that alcohol is the most harmful drug of all, including crack cocaine and heroin. The story was reported uncritically by the science news media such as Reuters Health, MedPageToday and Science Daily as well as the lay media [CBS News, New York Daily News, and many others]. At least one outlet, The Atlantic Wire, was skeptical, pointing out that the study’s lead author, Professor David J. Nutt [yes, Nutt] had an axe to grind. It seems he was fired as the UK’s adviser on drugs for insisting that alcohol was a worse problem than marijuana. They also added comments from other skeptics.

So far, no one has addressed the “science” of the paper, the full text of which is available free on line. I’ll have a go at it. Dr. Nutt and colleagues established their own rating system for harm. It has not been validated by others. It rates 16 “harm criteria” on a scale from 1 to 100. The paper’s methods section does not indicate how the “harm criteria” were chosen or how the ratings were assigned. It certainly seems rather arbitrary to say the least. The third paragraph of the description of how the scores were weighted is incomprehensible to me. Here it is in its entirety:

“During the decision conference participants assessed weights within each cluster of criteria. The criterion within a cluster judged to be associated with the largest swing weight was assigned an arbitrary score of 100. Then, each swing on the remaining criteria in the cluster was judged by the group compared with the 100 score, in terms of a ratio. For example, in the cluster of four criteria under the category physical harm to users, the swing weight for drug-related mortality was judged to be the largest difference of the four, so it was given a weight of 100. The group judged the next largest swing in harm to be in drug-specific mortality, which was 80% as great as for drug-related mortality, so it was given a weight of 80. Thus, the computer multiplied the scores for all the drugs on the drug-related mortality scale by 0.8, with the result that the weighted harm of heroin on this scale became 80 as compared with heroin's score of 100 on drug-specific mortality. Next, the 100-weighted swings in each cluster were compared with each other, with the most harmful drug on the most harmful criterion to users compared with the most harmful drug on the most harmful criterion to others. The result of assessing these weights was that the units of harm on all scales were equated. A final normalisation [sic] preserved the ratios of all weights, but ensured that the weights on the criteria summed to 1.0. The weighting process enabled harm scores to be combined within any grouping simply by adding their weighted scores. Dodgson and colleagues provide further guidance on swing weighting. Scores and weights were input to the Hiview computer program, which calculated the weighted scores, provided displays of the results, and enabled sensitivity analyses to be done.”

The figures are equally bizarre especially figure 3. The paper does not allow for variations in amount of drug used. For example, is one alcoholic drink per day a problem?

Certainly alcohol abuse can be a quite harmful but what about the recent research showing that 1 to 2 drinks per day improves health? The way this story was reported might actually be detrimental by causing social drinkers to stop thereby possibly harming themselves.

Honestly, I am surprised that The Lancet would publish a paper such as this. It’s not April 1, so I don’t think it’s a joke. Did they just want to be controversial or get publicity? If so, I guess it worked. And what about the media? Should they just report these press releases without question? Widespread uncritical dissemination of junk science like this gives it unwarranted credibility.

Can Wrong-Site and Wrong-Patient Procedures Be Totally Eliminated?

Last week, MedPageToday asked its readers to answer the question “Can wrong-site and wrong-patient procedures be totally eliminated?” About 70% of the 727 respondents said “Yes.” I say, “No.” Here is why.

The paper from Archives of Surgery, “Wrong-site and wrong-patient procedures in the Universal Protocol Era,” which generated a lot of media interest, contains the answer. The paper is a retrospective study of a medical liability insurance company’s self-reported database of adverse occurrences. There were 25 wrong-patient and 107 wrong-site procedures reported over a 6.5 year period [2002 to mid-2008]. The Joint Commission mandated the Universal Protocol as of July 1, 2004. It called for a pre-procedure verification of the patient, procedure and site, marking of the procedure site and a “time-out” or review of the planned procedure involving all care-givers. According to Figure 3 of the Archives paper, the number of wrong-patient and wrong-site procedures was remarkably consistent over the years of the study which included years before and after the institution of the Universal Protocol. Providers either ignored the protocol or failed to execute it properly.

The factor that will prevent the total elimination of wrong-patient and wrong-site procedures is us. As long as humans are in the equation, human errors will persist.

A recent paper from the British Journal of Surgery entitled “Nature, causes and consequences of unintended events in surgical units,” described 881 self-reported unintended events in 10 hospitals in the Netherlands over a one year period. Human error was the root cause in over 70% of instances, with system errors comprising only 16%. Similarly, an article from San Diego by the leaders of one of the most mature trauma systems in the country, noted a stable rate of complication ocver a 12-year period. While human errors decreased over time, they could not be entirely eliminated. Lack of adherence to guidelines, fatigue, inexperience and other human issues were cited as continuing problems.

Finally, no less an authority than Donald M. Berwick himself has stated “The search for zero error rates is doomed from the start.” [Quoted in Graber M, Gordon R, Franklin N. Reducing diagnostic errors in medicine: what's the goal? Acad Med. 2002;77:981-92.]

Medicolegal Musings: Physician Posting on Social Media & the Internet

You are in the middle of a deposition. Plaintiff’s lawyer asks, “Do you blog or tweet?” Before you answer, consider this. If you blog or tweet and respond in the affirmative, I believe anything you have ever posted would be subject to discovery by the plaintiff. Oh, you post anonymously? Would you then lie under oath and say you do not blog or tweet? For many physicians, admitting that you blog or tweet might not be a problem. But in my short career as a blogger/tweeter, I have read some things that frankly would not enhance a malpractice defense if projected on a large screen in front of a jury.

I will allow that I am skeptical and sarcastic, but I do not think I have posted anything that is derogatory to a patient, either generally or specifically. There are some very popular anonymous doctor-tweeters who post some scathingly negative comments about patients. Even if a patient could not be identified, the tone of some of these posts implies a deep-seated resentment of patients and their problems, not to mention many are vulgar, sophomoric or both. OK, some of them are funny as well, but the humor would be lost in a courtroom. Some of these tweeters disseminate prodigious numbers of posts per day perhaps suggesting that they are not always focused on their work.

I have followed several medical bloggers who post clinical anecdotes, which are essentially case reports. Despite disclaimers stating they are not about real patients, it seems obvious that they are. If the subject of one of these case report blogs decides to sue, it might be difficult to convince a jury that the blog was about a fictitious case. And this type of publication might be considered a HIPAA violation especially because it is unlikely that a blogger would have obtained institutional review board permission to publish the case report.

By the way, if you blog or tweet anonymously and answer falsely that you don’t, you better never have told anyone that you do. A lie under oath that is discovered tends to undermine your credibility quite a bit. [Defense lawyer, “Your honor, may we have a short recess while I talk to my client.”]

As far as I know from an attempt to search for medicolegal references to Twitter and blogging, this perspective has not been brought up before. What do you think?

“Body Size Misperception” May Be a Factor Contributing to the Obesity Epidemic

Did you ever wonder, as I often have, what obese people are thinking as they keep putting on weight? Why doesn’t it occur to them as they pass, say 250 lbs., that maybe they should stop eating so much? As published two weeks ago in Archives of Internal Medicine*, researchers in Dallas suggest that a substantial number of obese people have what they term “Body Size Misperception.” More than 2000 obese adults were shown drawings of human figures on a 9 point scale, ranging from very thin to very obese. They then were told to pick both a figure that they felt would be ideal and a figure that represented how they thought they appeared. Body size misperception existed if the subject chose an ideal body size that was the same or larger than his/her actual size.

Some 8% of the group exhibited body size misperception. In other words, these people did not recognize that they were obese. Further examples of denial were that the body size misperception cohort felt they had a low lifetime risk of heart attack, high blood pressure and diabetes. The most amazing revelation is that a full two-thirds of these already obese individuals considered themselves at low risk for developing obesity. The authors of the paper think this issue is under-publicized and generally not dealt with well by physicians.

Maybe the concept of body size misperception, an entity that I certainly was not aware of before, can explain the apparent lack of self-recognition that one might be obese. And lacking the ability to see this obviously explains not only why some people become morbidly obese but also why they don’t seem inclined to correct the situation.

*Powell TM, et al. Body size misperception: a novel determinant in the obesity epidemic. Arch Intern Med. 2010 Oct 11;170:1695-7. [No abstract available]

Hospital Ratings Revisited

A recent press release from HealthGrades claims that some 232,442 Medicare patients’ lives could have been saved over a three-year period if all hospitals performed at the level of a HealthGrades five-star hospital. While this is a laudable premise, can it be true? Let’s see.

First you need to know something about HealthGrades and its rating system. Using a large Medicare administrative database (that is, the data are submitted by hospitals for billing purposes), HealthGrades compares hospitals on an observed vs. expected outcomes basis. For some reason, hospitals are rated as five-star (best), three-star (as expected or average) or one star (poor). There is no mention of four- or two-star. And according to their methodology, “…70% to 80% of hospitals in each procedure/diagnosis were classified as three stars, with actual results not significantly different from predicted results. Approximately 10% to 15% were 1-starhospitals and 10% to 15% were 5-star hospitals.” For non-statisticians, that would be classified as a normal distribution.

Now what would happen if every hospital in the U. S. performed at the level of a five-star hospital? Well, the observed rate of complications and deaths would go down but as long as one compares observed vs. expected outcomes, the distribution of hospital ratings would still be normal with 10%-15% being above average, 70%-80% average and 10%-15% below average.

Therefore, with the possible exception of hospitals in Lake Wobegon (“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]), all hospitals cannot be above average.

Then there is the problem of using administrative databases to judge clinical outcomes. By this passage from HealthGrades’ own description of its methodology the following disclaimers are listed.

“Limitations of the Data Models
It must be understood that while these models may be valuable in identifying hospitals that perform better than others, one should not use this information alone to determine the quality of care provided at each hospital. The models are limited by the following factors:

“Cases may have been coded incorrectly or incompletely by the hospital.
The models can only account for risk factors that are coded into the billing data–if a particular risk factor was not coded into the billing data, such as a patient’s socioeconomic status and health behavior, then it was not accounted for with these models.
Although Health Grades, Inc. has taken steps to carefully compile these data using its methodology, no techniques are infallible, and therefore some information may be missing, outdated or incorrect.”

There are a number of peer-reviewed articles questioning the validity of using administrative databases in clinical outcomes research. A study of patients with cerebral aneurysms, from the Bloomberg School of Public Health at Johns Hopkins University, found many large discrepancies between the Maryland state administrative database and the clinical records of the patients at their institution. A paper from Harvard and Tufts concluded “Cardiac surgery report cards using administrative data are problematic compared with those derived from audited and validated clinical data, primarily because of case misclassification and non-standardized end points.” A systematic review of papers on infectious diseases found that administrative databases have “limited validity” for the evaluation of co-morbidities, a key factor in risk adjustment.

Try this for some hospitals that you might be familiar with. Compare HealthGrades ratings with “Medicare Hospital Compare,” which one must assume is using the same outcome data since HealthGrades uses Medicare’s data for its ratings. Here are the results for heart attack outcomes for three hospitals in New York City. (See Table.) The rating scales are the same, three possible grades.


I don’t know which one to believe. Do you?

Note: A previous blog post of mine pointed out a few other issues with HealthGrades that everyone should be aware of.

Why Reporters (And Hospital Administrators) Should Learn Statistics

Interesting article on amednews.com about the pros and cons of publically posting emergency department waiting times. The pros are that patients can self-triage to the least busy ED, and it might be good for a hospital’s business. The cons are that patients who are really sick might be discouraged from going to any ED if the waiting times are long, and ED doctors might cut corners to speed patient throughput.

One paragraph of the article caught my eye.

“Scottsdale Healthcare began posting wait times in April 2008 at its four EDs, all of which are within about 15 minutes' driving time of one another in the city (two -- a general ED and a pediatrics ED -- are housed at the same center). Its patient satisfaction scores have improved by 2 percentage points [emphasis added], said Nancy Hicks-Arsenault, RN, the organization's systems director of emergency services.”

I can’t be sure but knowing what I do about patient satisfaction scores [a good subject for future blog], I would bet that a 2% increase in patient satisfaction is not statistically significant. In my experience, fluctuations in patient satisfaction scores of 2% are common and well within one standard deviation of the average for these rather crude measures. One of the most popular patient satisfaction survey companies uses a rating scale of 1 through 5 and then converts the responses into percentages. This means that if a patient rates an ED service as a “4” instead of a “3”, that is a 20% increase in satisfaction when the patient may not really have been 20% happier with his experience. The response rate of most patient satisfaction surveys is usually below 10% which further diminishes their validity.

I would have asked to see the raw numbers, performed a statistical test and determined if a 2% increase in patient satisfaction was real or not.

Reporting Wrong-Site “Surgery”: Errors and Omissions

This morning, four health-reporting websites [New York Times, MedPage Today, CNN Health, Science Daily] reviewed a paper that appears in the October issue of the journal Archives of Surgery entitled “Wrong-Site and Wrong-Patient Procedures in the Universal Protocol Era.” The paper documents a number of wrong-site and wrong-procedure incidents from a medical liability insurer’s database in Colorado. The incidents were self-reported by physicians without penalty. It is an interesting study that bears reading but the full on-line version is only available by subscription. So at this time, we only have the abstract of the paper and the reports from the four news organizations to go by.

What strikes me is the manner in which the story is reported. Although the study clearly states that these adverse events were caused by surgeons and non-surgical specialists in equal numbers, three of the four websites headlined the story as follows:

“Wrong Surgery on Wrong Patient Still Happening”
“Surgical Errors Continue Despite Protocols”
“Surgery Mix-Ups Surprisingly Common”

Only one site, Science Daily, used a headline consistent with the title and content of the paper, “Study Documents Wrong-Site, Wrong-Patient Procedure Errors.” That outlet also went into some detail about the percentages of specialists report errors, mentioning that internists were responsible for 24% of the wrong-patient procedures.

A casual reader of one of these articles might assume that these incidents are happening every day. The paper recorded only the submitted events, not the denominator, which would be the number of opportunities to experience an adverse event. The use of a self-reported database is not the same as an epidemiologic study, but only two of the four reports [MedPage Today and NY Times] took the trouble to point this out. The NY Times cited a previous estimate that adverse events such as those documented in the paper occur about once in every 110,000 procedures. This is a serious topic and one which deserves the coverage it is receiving but more accurate reporting and more thoughtful analysis would inform the public better.

There are some other questions about the paper such as how many of these adverse events pre-dated the institution of the universal protocol, which calls for a “time out” and other measures to prevent such incidents. The paper covered the years 2002-2008 and the Universal Protocol was mandated by the Joint Commission in 2004.

I will review the paper in depth for you when I get the full version.

Proof That Our Country’s Education System Is in Serious Trouble

Here is an actual problem from a fourth grader’s math workbook. [See photo.] Since the photo is a little dark, I have transcribed it below.

“Reasoning Hwong can fit 12 packets of coffee in a small box and 50 packets of coffee in a large box. Hwong has 10 small boxes and would like to reorganize them into large boxes. Which boxes should he use? Explain.”

Speculation has ranged from the Stonehenge and pyramids lining up with Orion to Fermat’s last theorem to just chalking it up as an inscrutable mystery of the Orient.

If you can deduce the answer, please explain it to me so I can explain it to a 10 year old.

Brain Trauma Blood Test Shows Promise But Report of Findings Is Flawed

USA Today reports that US Army doctors have discovered a blood test that can reveal whether a trauma victim has had a concussion. The test measures the level of proteins released when brain cells are damaged. If these findings are confirmed in a larger study, it would be a major advance in the treatment of traumatic brain injury [TBI]. However, the article is mostly an uncritical look at the subject.

A major question not answered is how was the blood test validated? A quote from the report “Doctors can miss these injuries because the damage does not show up on imaging scans…” is correct, but how then did they verify that a patient with a positive blood test indeed had a concussion? In medicine, before a new diagnostic test can be accepted for general use, it must be compared to a so-called “gold standard.” If the new blood test was not measured against the results of head CT scanning, then what was the gold standard used?

Only 34 subjects were included in this apparent pilot study, which has not been subjected to the peer review process. I would like to call the new blood test by the name of the protein or proteins being investigated, but the article did not provide that information.

The article referred (without a link) to a Rand Corporation study that, according to the USA Today article, stated “About 300,000 troops in Iraq and Afghanistan have suffered concussions…” I accessed that study and found that what it actually said was

“A telephone study of 1,965 previously deployed individuals sampled from 24 geographic areas [found that] 19 percent reported a probable [emphasis added] TBI during deployment...”

The author of the USA Today piece apparently then assumed that 300,000 or 19% of the 1.64 million deployed troops had in fact experienced concussions, a rather large leap of faith on three levels. The following assumptions are invalid: one, a “probable” TBI is the same as an actual concussion; two, a telephone interview is an accurate way to acquire clinical information; three, the results of a telephone sample of 1,965 people, which is 0.1% of those deployed, can be extrapolated to represent the experience of the entire population of troops.

A larger study of the unnamed protein is planned. Let’s hope it does prove to be an effective test. As the article points out, a TBI blood test would be useful in many areas such as sports, child abuse and others.

Resident Work Hours: The Solution

I don’t know why I didn’t think of it sooner. Or like many great ideas, why didn’t someone else come up with it? This morning at 4:30 as I lay awake having just received a consult from infernal medicine for an elderly lady being admitted with gallstones, atrial fibrillation and acute dehydration which could have waited until 7:00 a.m. today or even tomorrow, it hit me. I have the solution to the resident work hours controversy.

A few years ago, I was in the Navy and served on a ship. Crew members “stood watch” which consisted of a rotations of four hours on duty and eight hours off duty. Thus, each crew member worked eight hours per day but the work time was divided into two four hour shifts. To me this would be the perfect solution to the resident work hours dilemma.

I know, you are saying, “But Skeptical Scalpel, wouldn’t that mean six patient hand-offs per day?” Yes, of course it would. But according to the proponents of reduced work hours for residents, hand-offs are not a problem for continuity of care or patient safety. So if two or three hand-offs per day are OK, why not six?

There are a few issues that need to be worked out. For example, surgical residency training would have to be increased to 8 or 9 years duration. Operations would have to be scheduled carefully to enable a resident to participate from start to finish. All operations would have to last fewer than four hours. Each residency position currently filled by a single individual would require three people. Who is going to pay for that? Well, no one is concerned about who is going to pay for the newly adopted regulations limiting first-year trainees to 16 hour days. Then there are weekends, vacations and holidays which would mean that extra residents would be needed to cover.

Since I wrote this rather hurriedly, I may have overlooked something. I will give you 45 days to comment and then I will implement these new and improved work hours as stated.

Medical Student Whining and Resident Work Hours

For those of you who may not have heard, the Accreditation Council for Graduate Medical Education [ACGME] recently approved further restrictions on the number of hours that residents can work. The rules take effect in July of 2011. While many appreciate the fact that the ACGME was forced to do something to at least appear to rein in what has been portrayed as draconian working conditions for trainees lest Congress or OSHA or the ACLU enact even more onerous rules, the ACGME changes were met with mixed responses. Directors of residency training programs were most upset about the rule that restricts first-year residents to a maximum of 16 consecutive hours worked followed by a minimum of 10 hours off.

Even the mathematically challenged can see that 16 + 10 = 26, which will make scheduling interesting since last time I checked [I love that cliché], a day consists of 24 hours. The new trainees also are mandated to receive more supervision. What is not spelled out is how these new doctors are to learn to work independently the following year when they will be less supervised and stay awake for 24 hours never having done it before. As a practicing surgeon, I am here to testify that after working a full day, I am often called to see patients in the middle of the night. So far, we don’t have a mandatory 10 hours off, although it wouldn’t shock me if that is on someone’s agenda. Also, someone will have to take care of the patients when the first-year residents go home after 16 hours. Who that will be and how they will be funded is not clear.

The American Medical Student Association [AMSA] Thinks the restrictions did not go far enough. "We're going to keep pushing" for stronger limits "because it involves both patient safety and our safety and well-being," Sonia Lazreg, the group's health justice fellow [Wow!*], told The Associated Press. "The fight for safer work hours is not over."

Never mind that the jury is still out regarding the effect of the current work hours restrictions on patient safety, whether more frequent “hand-offs” of patients leads to more errors in patient care than tired doctors, what the long-term impact of these restrictions will be and many other aspects of the issue.

To the AMSA I say, stop whining about work hours. Why did you apply to medical school if you didn’t want to work hard? No one said it was going to be easy. Don’t tell me you didn’t know that doctors work long hours. This reminds me of the type of complaining that people do when they buy a house near an airport and then bitch about the noise. So AMSA members, get over yourselves. If you don’t like it, go to law school.

*(Comment by Skeptical Scalpel, who has applied for a health justice fellowship)

The “Straw Man” Is Back

A rather breathless posting on Science Daily today extols the virtues of the “scarless” or single incision laparoscopic cholecystectomy compared to the standard four small incision technique. Single incision, or laparoendoscopic single-site surgery [abbreviated LESS (a catchy acronym is mandatory)], utilizes one incision in the navel through which the entire surgical dissection and removal of the gallbladder are done. LESS cannot usually be done when the surgery is for an acute gallbladder attack or if the patient has had previous upper abdominal surgery. The study was done at Mt. Sinai Hospital in New York.

According to the article “The Mt. Sinai group did find two advantages to the LESS procedure: these patients required less pain medicine after the operation than their counterparts who had the traditional minimally invasive operation; and LESS patients typically reported higher satisfaction scores: —4.7 on a scale of 1 to 5 (5 equals highest score) versus 3.6 for the conventional laparoscopic surgery group.”

Available in the abstract of the paper but not reported by Science Daily were the following: the study was retrospective and involved only 26 LESS patients and 50 conventional laparoscopic cholecystectomy patients; 31% of the LESS patients required additional incisions; the average age of the LESS patients was significantly younger than the conventional group [37 vs. 49 years respectively]; follow-up data were unavailable for over half of the conventional group.

The Science Daily piece quotes one of the authors. "What's really exciting is how these patients would recommend the procedure to a friend or family member," Dr. Chin said. "Seventy-four percent of the patients who had the single-incision operation would strongly recommend the procedure to someone else versus 36 percent of those who had laparoscopic surgery."

Here is where the “straw man” is introduced. A “straw man” is defined [see The Skeptic's Dictionary] as creating a fallacious argument and then refuting it with one’s own position. If you believe this article, only 36% of those who had standard four-incision laparoscopic surgery would recommend it to someone else. However, in the early days of laparoscopic cholecystectomy, papers reported patient satisfaction rates of 94-95% after conventional laparoscopic cholecystectomy.

Patients in both groups had obviously undergone only one of the two procedures making the recommendation data rather difficult to interpret. If 64% of patients who had undergone conventional laparoscopic cholecystectomy would not recommend it to someone else, what then would they recommend? Keep your gallbladder despite the pain? Old fashioned large incision open surgery? Suicide?

The straw man is an old friend. It’s good to see that he is still around.

Stretching Before Exercise: The Facts

Despite evidence dating back over a decade indicating that pre-exercise stretching has no value, I continue to observe joggers in my neighborhood and people in the gym going through elaborate stretching routines.

Recent systematic reviews show that stretching before exercise neither prevents soreness nor injury. Regarding soreness, a Cochrane Review looked at 10 studies in young, healthy adults and found no significant difference in muscle soreness up to three days post-exercise in those who stretched before working out and those who did not. Similarly, another Cochrane group reviewed strategies for hamstring injury prevention and noted no difference in injury rates between those who did specific hamstring strengthening exercises or stretching and those who did neither. There is also some evidence that pre-exercise stretching may result in decreased muscle strength and power.

It appears that a few minutes of warm-up focusing on the same movements that will occur during the period of exercise is sufficient. So please stop with the ritualistic stretching and get on with the exercising.

Skeptical Scalpel’s Guaranteed Weight Loss Program

Every day you must burn more calories than you eat.

Suboptimal Outcomes for Medical School Matriculants

In the annual JAMA education issue of September 15, 2010, Drs. Andriole and Jeffe address the topic “Prematriculation variables associated with suboptimal outcomes for the 1994-1999 cohort of US medical school matriculants.” The paper is a comprehensive and scientifically sound look at what factors that existed prior to medical school enrollment were associated with students who achieved less than optimal outcomes. Poor outcomes were defined as failure to pass the United States Medical Licensing Examination (USMLE) Step 1 or 2 on the first attempt and withdrawal or dismissal from medical school for academic or non-academic reasons. The study involved over 84,000 matriculants from 1994-1999 with just over 11% falling into the suboptimal outcome category.

Major variables associated with first-time failure to pass the USMLE or academic withdrawal/dismissal were low Medical College Admission Test scores, race (Asian or Pacific islander), under-represented minority or debt of more than $50,000 before entering medical school.

But the most interesting part of this paper is that 178 matriculants in the group who started medical school from 1994-1999 had to be excluded from the study because they were still in medical school. In case you don’t get it, this means they had been in medical school for at least 10 years. [Medical school usually takes four years to complete.] I was apparently prescient in my blog post [rant] on medical education of August 10, 2010 in which I marveled that I once had received an application for a residency training position from a student who had been in medical school for 10 years, and I speculated that it must be very difficult to flunk out of medical school. This was confirmed by the prematriculation variables study which states that only 1049 (1.2%) of students withdrew or were dismissed from medical school for academic reasons.

To be fair, it is possible that some of the 178 long-term medical students could be taking 10 or more years to finish for reasons other than failure to advance because of academic difficulties. I asked Dr. Dorothy Andriole, the lead author of the study, if she knew why these individuals were in school for so long. She did not have specifics but speculated that “…some students enrolled in dual advanced-degree programs (such as MD/PhD, MD/JD, etc.) may be engaged in research-related or other degree-related activities that can substantially lengthen the time from medical school matriculation to medical school graduation [and] some students, unfortunately, experience very serious, life-threatening medical illnesses personally or within their families and must take a prolonged leave of absence from medical school.”

I hope to see a follow-up article on the fate of those 178 medical students. Maybe it could focus on such issues as how was the 10 or more years of tuition funded, how did these people perform on the USMLE, what specialties did they eventually wind up in and how competent were they?

Question: What do they call the person who finishes last in his/her class in medical school?
Answer: “Doctor”

Cancer Risk from CT Scan Exposure May Be Higher than You Think

According to two recent studies the cancer risk from radiation exposure may be higher than once thought. Berrington de Gonzalez and colleagues published two papers in the December 14/28, 2009 issue of Archives of Internal Medicine. One study postulates that CT scans in the U.S. in the year 2007 will lead to some 29,000 new cancers in the future. The largest number of cancers will result from CT scans of the abdomen.

The second paper investigated the variation in CT scan technique at four hospitals in the San Francisco area. The authors found wide variations in radiation dose due to different settings on the devices and the radiation exposure was much higher than previously published data suggested. For example, the median exposure from an abdominal CT scan was 31 millisieverts, a figure about four times higher than the usually quoted range.

For comparison, a CT scan of the abdomen and pelvis with contrast has an estimated radiation exposure to the patient of some 234 routine chest x-rays. A CT coronary angiogram exposes a patient to the same dose of radiation as 309 chest x-rays.

Editorialists in both Archives of Internal Medicine and JAMA expressed great concern and call for tighter regulation. The radiologists are also considering measures to try to decrease the number of CT scans done in the U.S.

Delayed Appendectomy: A Different Kind of Peer Review

UPDATED MARCH 7, 2011

It seems that USA Today writer Rita Rubin is pushing an agenda which is that appendectomy for acute appendicitis should be delayed until it is convenient for the surgeon. The first article she wrote on this was in September of 2010. A similar article was published today. I blogged about this issue when the original article appeared. Here is my critique of the paper the articles were based on and why the concept of delaying appendectomy is not practical. I had entitled the post “A Different Kind of Peer Review” because the idea was reviewed by prospective patients in the form of comments on the USA Today website back in September.

The seemingly straightforward paper entitled “Effect of delay to operation on outcomes in adults with acute appendicitis” was published in a respected journal by a large and geographically diverse group of surgeons. The authors looked at almost 33,000 patients with appendicitis who underwent appendectomy at different time intervals after being admitted to a hospital. The data were collected from the American College of Surgeons National Surgical Quality Improvement Program [NSQIP] database over the four years from 2005 through 2008. They found no significant differences in risk-adjusted 30-day complication or mortality rates whether the patients underwent appendectomy within 6 hours of surgical service admission, 6 to 12 hours after admission or more than 12 hours after admission.

The authors acknowledged several limitations of the study. It was retrospective and therefore reasons for the delays to surgery for most patients could not be determined. The data were taken from a database with limited clinical information. Absent were data on antibiotic usage, fluids administered and reasons for choosing the laparoscopic or open approach to appendectomy. The authors and the accompanying editorialist suggested that since the outcomes were comparable it would be acceptable to delay appendectomy until daylight hours and have a well-rested surgeon perform the appendectomy. Allusions were made to possible money savings by not having operating room staffs and anesthesiologists awakened and called in at night, but no data were presented to support this theory.

Not mentioned by the authors but occurring to me are some other issues. The NSQIP database is contributed to on a voluntary basis by mostly academic tertiary care medical centers. I doubt the findings of this study are universally applicable. The three groups of patients based on the timing of the surgery were not really similar. In fact they were statistically significantly different and arguably clinically different in almost all respects. I don’t know about the authors’ practice patterns, but at every hospital I have ever worked in, including my present one, waiting to do an appendectomy until the morning means that someone’s elective surgery will have to be “bumped” [delayed] while I do my appendectomy. This causes the elective schedule to run late and staff has to work overtime [$$$$$] anyway. Also, most private practice surgeons need to get these cases done so they don’t interfere with office hours or their own elective surgery cases. Most patients with uncomplicated acute appendicitis can undergo laparoscopic appendectomy and be discharged home well within 24 hours of arriving at the hospital. Delaying the surgery for several hours will lead to increased lengths of stay and more costs and charges.

Then there is the little problem of the patients and their desires. Here is where the “Different Kind of Peer Review” comes in. Of the more than 40 comments about the September 2010 article posted online, the overwhelming majority expressed extreme negativity regarding waiting to have an appendectomy. Commenters railed against pain and suffering while waiting for surgery, government rationing of healthcare and lazy, avaricious doctors. Anecdotes about perforation of the appendix, peritonitis, near-death and veganism [yes, veganism] were offered. Similar sentiments are being expressed by the commenters on today's article. Finally, a surgeon would have a difficult time defending a lawsuit by someone who waited 12 hours for an appendectomy only to have a bad outcome due to perforation, sepsis, abscess and/or reoperation. That would emphatically negate any money saved by waiting, assuming such saving even exists.

I do not see delayed appendectomy catching on soon. What do you think?