The Surgical Coach

By now, most medical people have read or heard about Dr. Atul Gawande’s latest New Yorker piece. After taking a tennis lesson which improved his game, he decided to see if acquiring a “surgical coach” would improve his “surgical game." He wanted to continue to reduce his—[self-described] already lower than the national average but level for a few years—complication rate. He enlisted a retired surgeon, who was a mentor during his residency training, as a “coach,” and his complication rate is falling again.

I was asked to comment by Dan Diamond, Managing Editor of The Advisory Board’s Daily Briefing. He quoted me in his commentary on Gawande’s concept: 

But not all think that Gawande's article heralds a viable model.

The blogger known as Skeptical Scalpel—a longtime surgeon and former surgical department chair who writes under a pseudonym—told the Briefing that he's, well, skeptical about the ideas that Gawande raises.

"I would accept a coach but doubt I could find one," according to Skeptical Scalpel, particularly a coach as talented, experienced, and available as Osteen. He adds that surgeons often are challenged by issues outside of the operating room, such as in areas like diagnosis, communication, and bedside manner. Skeptical Scalpel also wonders whether the coach would be liable if the patient experienced complications and elected to sue.

Medicine's cultural barriers may present the most significant barrier. As Gawande acknowledges, many surgeons are happy to prescribe a coach for others—but few would acknowledge the benefits of finding a coach of their own. Skeptical Scalpel told the Briefing that a successful surgeon needs a healthy ego; "most of us feel we are the best surgeon we know. If you didn’t feel that way, you probably can’t do some of the things we do."

I’d like to further explore my issues with Gawande’s surgical coach.

Where would the average surgeon find a suitable coach? There aren’t many retired surgeons who would have the necessary skills, the time or the motivation to do it. Gawande practices in a major teaching hospital in Boston. Very few surgeons would have access to people like the coach he chose.

The coach is apparently only involved with what goes on in the OR. Many complications arise due to patient co-morbidities, timing of the operation, postoperative care, supervision of residents and many other factors. Should the coach make floor rounds or see patients in the surgeon’s office too?

The liability question is real. You can bet that if a patient has a serious complication or dies in the OR, everyone in the room, including the coach, will be sued. And the coach, a retired surgeon, is not likely to have malpractice insurance. 

The patient has a right to know who is in the operating room. How does one explain the presence of a coach to the patient? At the end of his article, Gawande shares a vignette depicting his rather awkward attempt to introduce his coach to a patient on the operating room table:

“He’s a colleague,” I said. “I asked him along to observe and see if he saw things I could improve.”

The patient gave me a look that was somewhere between puzzlement and alarm.

“He’s like a coach,” I finally said.

She did not seem reassured. 

That is not surprising since only the most enlightened patient would see the value of a coach in that situation. I think a more typical reaction would be to think, “Maybe the coach should operate on me instead of the trainee.”

From an ivory tower in Boston, the idea of a surgical coach is a lovely one. Too bad it has little to do with the average surgeon in the United States.

Things that bother me about Twitter

Disclaimers. Doctors put in their profiles, “Tweets not intended to be medical advice.” Who gets their medical advice from Twitter? Has there ever been a lawsuit based on someone interpreting a tweet as medical advice? Who thinks of these things?

Followers and Following. Here are two examples which seem absurd to me. Last week a self-described “internet marketer” may or may not have had a “ghost tweeter” say some unkind things about him after having been fired. Or he may have done it all himself to get attention. What was lost in the mild dustup about it was that he had over 59,000 followers [down to 56,000] on the day the alleged ghost tweets occurred. He was, and still is, following over 37,000 people. I doubt that he actually follows 37,000 tweeters and many of his followers did not react to the controversy. Maybe they don’t really follow him either.

Here’s another one from a different perspective.

He announces to all that he does not tweet, yet he has 172 followers. I don’t get it. Why would anyone follow him?

Influence. I blogged about this before but now I have more data. According to PeerIndex, I have a score of 54. This places me well into the top 10% of my “topic community,” since a score of over 40 means one is in the top 10%. This sounds great until one realizes that I have about 975 followers, many of whom do not react to anything I tweet. I have seen some increased traffic to my blog after a good tweet with some retweets from more influential people than I. But again remember that there are about 7 billion people in the world. That means I might be influencing 0.0001% of the world’s population.

What bothers you about Twitter?

Do you tell people you are a doctor?

An interesting post appeared on the physician website Sermo the other day.

A woman said that she hides the fact that she is a doctor for fear of being overcharged for goods and services and that she hates being asked medical questions in social situations. Read the entire post plus comments here. [Free registration required.]

Over 100 comments were received and at least 95% concurred with the idea that one should not reveal that one is a doctor even if directly asked what one does for a living. Some of the comments echoed the post and others brought up issues such as the feeling that doctors are no longer liked or respected.

How far we have fallen.

It is a shame that most MDs don't want to admit what they do. But I do the same thing. I do not tell trades people or car salesmen what I do. I keep a low profile when meeting new people. When I am forced to reveal this dark secret, I hate having to explain what a general surgeon does. Yes, it’s a specialty. I take out appendices, gallbladders and most of whatever else ails you. Try explaining what a surgical hospitalist does.

I also don’t like to be presented with acquaintances’ symptoms and asked to give advice. And I don’t have a CT scanner in my house or car so how can I possibly make an accurate diagnosis? [Joke]

I especially hate it when someone tells me that they are all set to have a procedure done by Dr. Stonehands and what do I think? It is a “no win” situation. If I tell you the guy is no good, then you might tell him I said so. If I don’t and you have a complication, I’ll feel bad. How about asking me for advice before you are already scheduled? But better yet—don’t ask me at all.

The Sermo sample of 100 is obviously not definitive. I wonder how most doctors feel about this issue.

ICD-10 Codes: V97.33XS Sucked into jet engine, sequela

In an effort to expand the International Classification of Diseases [ICD] codes to be all-encompassing, the new ICD-10 list includes many new diseases and injuries. We have already reviewed code "V9027XA Drowning and submersion due to falling or jumping from burning water-skis, initial encounter" and found it difficult to imagine a scenario in which water-skis ignite.

Here is another code that at first seems to be a bit of a stretch, "V97.33XS Sucked into jet engine, sequela." One would think that the only sequela of someone being sucked into a jet engine would be hamburger. 

However, here is video evidence of one of the luckiest guys on earth. A Navy crewman was preparing an attack jet for take-off from an aircraft carrier when he was ingested by one of its jet engines. Miraculously, he survived with only a few scratches.

On the other hand, surviving having been sucked into a jet engine is a relatively rare event. Do we really need a code for this?

Training Surgeons and Informed Consent

A rather bold new survey reveals that patients are willing to let residents operate as long as they operate on someone else. The study, published on line in Archives of Surgery, queried 316 patients at a tertiary care US Army hospital.

There were some positives. When given generic questions on resident participation in their surgery, 94% of all respondents said they would “consent to the involvement” of a resident in their operation. Of those respondents who had a preference, 91% felt that their care would be as good or better in a teaching vs. a non-teaching hospital. 

However, when presented with specific descriptions of the degree of resident participation in an operation, patients’ enthusiasm waned significantly. Just over half (57%) said they would consent to a junior resident assisting the staff surgeon; 32% would agree to having the staff surgeon assist the resident; 25% would consent to having the resident perform the surgery with the staff surgeon observing; only 18% would allow the resident to operate without the staff surgeon in the room. This survey clearly shows that if given a choice, most patients would not allow surgical residents to perform any part of their surgery.

This research is bold because it addresses a topic that most surgeons in teaching hospitals would rather not talk about.

You see, to learn how to be a surgeon, one must actually perform surgery. It can’t be learned by watching and regardless of what you may have read or heard, it can’t be learned on simulators alone.

With the pressure on to reduce work hours and alleged fatigue, surgical residents already are grappling with their levels of confidence upon graduation from training. The American College of Surgeons is so concerned about this that it is surveying its members to assess their opinions on whether today’s residents are adequately trained [Survey Regarding Competency and Confidence of Current General Surgical Trainees, link not available].

 

Since everyone likes the surgeons/pilots analogy, are you aware that co-pilots, some with far less experience than senior pilots, often are at the controls during take-offs and landings without the knowledge or consent of the passengers? The airline industry knows that flying is another skill that has to be learned by doing.

In the old days, surgeons learned by doing. Yes, we made some mistakes. And we still do. We are human. But how is the next generation of surgeons to be trained if they cannot operate under supervision?

ICD-10 Codes: "Drowning and submersion due to falling or jumping from burning water-skis"

The Centers for Medicare and Medicaid Services [CMS] have just released the updated version of the medical coders’ bible, the International Classification of Disease, 10^th Revison [ICD-10]. The long-awaited revision is much more detailed than previous versions, going from 18,000 codes in ICD-9 to 140,000 codes in the new release.

In an attempt to achieve greater specificity for describing diseases and injuries, the authors came up with some curious items. There are probably some other howlers, but so far, the winner is “V9027XA Drowning and submersion due to falling or jumping from burning water-skis, initial encounter.” There are also codes for subsequent encounters and sequela of drowning and submersion due to falling or jumping from burning water-skis.

I have been wracking my brain all weekend to come up with a plausible scenario in which a person could drown and  be submerged while falling or jumping from burning water-skis.

Can water-skis be set afire? It’s hard to say. According to Trails.com, they are most commonly made of a combination of fiberglass and graphite. I suppose they could be burn under certain conditions but I really don’t see how they could be ignited during normal use because, of course, they would be in the water.

One way that I could envision anyone falling or jumping from burning water skis is if that person were to water-ski through a burning oil slick. And even then, it’s hard to see how the skis would catch fire as the skier would be moving fairly quickly. Furthermore, why would one deliberately water-ski through a burning oil slick? Not only would he have to fall or jump off, he would also have to drown and be submerged.

I have come up with an answer. Someone, possibly an actor from the Jackass series of movies, sets up his water skis on milk crates in the back yard. The skis are positioned over a kiddie pool. He mounts the water skis while an accomplice sprays them with gasoline. The skis are lit, and the man jumps or falls from the burning skis, submerging and drowning himself in the process. Luckily there is an ICD-10 code for that.

While we’re on the subject, how does one have subsequent visits after drowning? Once one drowns, he is dead. I believe charging for subsequent visits would possibly be considered fraud. The only sequela of drowning that I am aware of is a funeral.

I wonder if there are codes for jumping or falling from burning snow skis?

Adherence to Process Measures Does Not Equal Better Care

Another paper recently published in Annals of Surgery confirms my previous blog on the subject of one of the more popular process measures, the Surgical Care Improvement Project (SCIP). The main components of SCIP are selection of the proper antibiotic(s) and proper timing of and discontinuation of the the antibiotic(s). Even a year ago it was apparent that although it seemed like a good idea, SCIP didn't lower the surgical wound infection rate.

The new paper reports that there is no correlation between a hospital's level of adherence to the SCIP protocol and the incidence of wound infection in surgical patients.

This also calls into question the Joint Commission's selection of "top performing hospitals" based on their rates of compliance with processes such as SCIP. To read more about the absurdity of the Joint Commission's list, see the blog I posted yesterday.

Joint Commission Proves It's as Irrelevant As HealthGrades

The New York Times reports that the Joint Commission has just published a list of its 405 "Top Performing Hospitals." As is typical of these types of evaluations, most of the large, well-known teaching hospitals where knowledgeable folks [like doctors] go for care when they are really sick didn't make the list.

Similar to the HealthGrades list of "top" hospitals [which I have commented about in the past], the JC's list is dominated by small community hospitals without teaching programs. These institutions know how to play the game and have figured out that compliance with process measures results in high marks from the likes of HealthGrades and the JC. For a related post on why process measures don't mean better care, click here.

At least the Times article pointed out that no hospital in New York City made the JC list. What about Chicago? Sorry, just a children's hospital and a VA hospital. Philadelphia? No university hospital but one community hospital. Surely University of Pittsburgh Medical Center? No, not the main hospital but several of its suburban affiliates made the list. St. Louis? Nope, no good hospitals there. Pick any major city. See the list for yourself.

Guess which state had the most top performing hospitals by far? It's a state that immediately comes to mind when one thinks of quality medical care. Of course, Florida with 51, not one of which was a university hospital unless you want to count the University Hospital & Medical Center of Tamarac. A visit to its website fails to reveal the name of the university it is affiliated with. However, Don Shula, former Miami Dolphins coach, endorses the emergency department in a short video.

A survey I would like to see is what hospitals would the executives of HealthGrades and the JC choose if they or a family member had a serious illness? I'm guessing that list would be a lot shorter and would not include more than 400 of the 405 on the JC list of top performers.

Question for the 9/11 Conspiracy Theorists

As we approach the 10-year anniversary of the 9/11 terrorist attacks, I am hearing about the conspiracy theories again. Some say that the World Trade Center tower could not have collapsed that way simply due to airliners crashing into them. The conspiracy nuts say that demolition charges must have been placed in the buildings.

There is also talk that the building 7 collapse secondary to the WTC fires "could not have happened" because steel buildings blah, blah, blah. And despite that fact that some Jewish people we're killed in the attacks, there are those who say that Jews were told not to go to work that day because Israel was behind the attacks.

Forget about all the eyewitnesses who saw the planes crash into the towers and the Pentagon.

Here is my question. Over the last 10 years when absolutely no one, I mean no one, can keep a secret for even 30 seconds, how is it that all the guys who set the demolition charges in all the buildings and all the Jews who were called and the people who did the calling have never said one word about what happened?

Not bloody likely.

9/10/2011 ADDENDUM

Last night, @jordjonny tweeted this in reply to me:

"they've probaly [sic] been killed off."

He added a link to a video with the provocative title "911 Witnesses Murdered." The video lists a number of people indirectly or directly linked to the 9/11 attacks who died in "mysterious" and "unexplained" ways. If these deaths were part of a cover-up of the intricate conspiracy, then a number of local, state and federal police agencies as well as the Federal Aviation Administration [there were people who died in plane crashes] would have to be in on it. And all of these public officials would also have not said word one about all this in the last 10 years.

I don't see how that many people could keep such a monumental secret.

Night Call

What do you think about these two posts that mention diametrically opposite perspectives on night call that were published within the last few days?

On September 7, 2011, NPR posted a story about a trauma and burn surgeon named James Jeng, who was on duty at Washington Hospital Center on September 11, 2001. He cared for a number of seriously burned victims from the Pentagon. In discussing the intensity of the post-burn care of these patients, he said this:

I had fallen into an automatic rhythm of 36 hours on, 12 off in-house duty. Every other night, then, I would get home to be with my family.

This, of course, is against all the new rules but somehow Dr. Jeng and the patients got through it despite the potential detrimental effects of “decision fatigue” and sleep deprivation.

On September 3, 2011, the following from M. Schoen, MD appeared on Sermo, a website devoted to physician issues:

In my group most of the new docs joining in the past couple of years are refusing to take internal medicine night call. These are both docs who are subspecialists (but who also practice medicine) and docs who are only internists. Meanwhile the bulk of the night call is being taken by the older docs (of whom 7 of the 25 or so docs are over 60). The group refuses to consider what will happen in the future when there will be no one to do night call. Is it common for groups to allow this? And what will happen down the road? 

This has attracted 286 comments with most of them deploring the situation.

So where is this all going? I think I know, and it’s not a good place.

Aviation and Healthcare Compared in Review Article

In a paper* published ahead of print in the American Journal of Surgery (no abstract available), five cardiothoracic surgeons from the University of Miami compare both the similarities and differences between aviation and medicine.

Without simply reprinting the entire three pages of text and risking infringing on the AJS’s copyright, I can say that it is one of the most detailed and balanced analyses I have seen.

It includes some of the points I have made in previous blogs on the subject such as the heterogeneity of teams, simulators and systems in healthcare as compared to aviation and the lack of a true non-punitive culture regarding errors and near-errors in medicine.

The authors note that even checklists, which are relatively straightforward in aviation, can be much more complex in medicine. They also point out that protocols and practice guidelines are nether necessarily agreed upon or followed as commonly in medicine.

If you are interested in this subject, I urge you to obtain a copy of the paper from your medical library.

*Ricci, M et al. Is aviation a good model to study human errors in health care? Am J Surg. 2011 Sep 2. [Epub ahead of print]

Thanks to @DublinDoc for alerting me to this paper.

My previous blogs on this topic:

Surgeons vs. Pilots: There is no autopilot in the OR  
Surgeons are not pilots or long-distance truck drivers
Surgeons are not pilots
Patients are not airplanes