My “most-read” blog posts of 2011

I want to thank everyone who has taken the time to read my blog and follow me on Twitter. The blog has seen significant growth over the last few months, averaging over 400 page views per day. I also appreciate all the comments agreeing or disagreeing with what I have written. And I now have over 1565 followers on Twitter.

Here are the seven most-viewed posts of the year:

Statistical vs. clinical significance: They are not the same

Choosing a medical specialty is difficult

Hospital politics, patient care and a doctor’s suicide

Harvard says train residents and medical student like Navy SEALS

What is most important to residents looking for a practice setting?

Surgery at the end of life: Reality check

Is robotic surgery all hype and no substance?

Robotic gastrectomy: Is it better?

Here is yet another paper, this time from Archives of Surgery, extolling the virtues of robotic surgery. Thus time the subject is gastrectomy for cancer. Surgeons in Korea retrospectively looked at 827 gastrectomies for cancer; 591 of which were done with standard laparoscopic technique and 236 were done robotically. Preoperative co-morbidities were similar but the robotic patients were an average of 4 years younger, which was statistically significant, p < 0.001.

The main results were that the complications, deaths, extent of lymph nodes removed were not significantly different between the two groups. The robotic surgery took significantly longer (49 minutes) to perform, p < 0.001. The average estimated blood loss was statistically significantly less in the robotic patients, (91.6 mL vs 147.9 mL, p = 0.002). Hospital length of stay (LOS) was significantly shorter for the standard laparoscopic group, 7.0 vs. 7.7 days, p= 0.004.

The authors concluded “robotic gastrectomy [has] better short-term and comparable oncologic outcomes compared with laparoscopic gastrectomy.”

Is this conclusion valid? Let’s take a closer look.

The study was not randomized nor was it prospective. Despite the similar number of patients with co-morbidities in both groups, patients chosen for robotic surgery were obviously selected for suitability. Other confounding factors may not have been unaccounted for. The only short-term advantage for robotic surgery was in the estimated blood loss. The authors themselves admit, “The statistically significant difference in 56.3 mL of blood loss between the robotic and laparoscopic groups may not translate into much clinical benefit for every individual patient.” This is certainly true. In addition, estimated operative blood loss is notoriously inaccurate. A study involving spine surgery showed that estimated blood loss exceeded measured blood loss by a mean of 248 mL (p = 0.0001). And since the study was not blinded, the blood loss estimates could easily have been biased.

Hospital LOS was actually longer for the robotic patients, amounting to 0.7 of a day or 17 hours. The authors tried to explain away the difference in LOS by pointing out that the robotic group had a couple of outliers who had really long LOSs. As I have blogged before, LOS is a soft endpoint which can be affected by many things other than the clinical state of the patient.

The study did not mention readmission rates for either group. Long-term follow-up was not included in the study, meaning that the oncologic outcome has yet to be determined. The issue of cost was neatly avoided by a convoluted explanation of the uniqueness of the Korean national insurance program and individual hospital differences. However, the methods section of the paper did note that the patients would have to pay for the extra costs of robotic surgery themselves. This suggests that the robotic patients may have been from a higher socioeconomic group. Robotic surgery is unquestionably more expensive as the robot itself costs $1.5-2.0M with an annual service contract of at least $150K and disposable instrument costs of about $2K per case. A New England Journal article estimated the actual additional cost of each robotic procedure at $3.2K.

So you tell me, does robotic gastrectomy have better short-term results than standard laparoscopic gastrectomy?

What if doctors could charge like airlines?

Say you want to book a trip to Amsterdam in the next few months. You know that Delta flies there. You go to Delta’s web site to see what the fares are like.

Here is the first screen after you insert your dates.

Wow! $368.60 one way. Looks good, right?

Oh, but what’s this (arrow)? The total price is $901.60? They apparently did not have a smaller font for the total price figure.

So you click on that number and here’s what you see.

Whoop-de-damn-do, the base fare includes US tax. But what on earth are all the other charges? The “International Surcharge” is a mere $470.00. In medicine, this is called “unbundling.”

I wish doctors could charge like this. Of course, we can’t because our fees are heavily regulated and discounted by the government and other third party payers while expenses steadily rise.

But I can dream. Here is a sample bill.

In case you are wondering, for an appendectomy Medicare's average reimbursement to the surgeon is $586.00.

Should Medical School Be Fun?

In the New York Times, Pauline Chen reports that Vanderbilt University is making an effort to relieve the stress of medical school with games and crafts. I read the piece with mixed feelings. It’s great that the school recognizes the problems faced by med students and is trying to help. And what Vanderbilt is doing seems more appropriate than importing puppies as some law schools have done.

I was struck by this sentence in the article, “[T]here is something toxic about the medical education process.” It amazes me that we still teach medical students the same way we did when I was in school some 40+ years ago. Memorize a lot of material that a) is available in electronic media that you can carry with you and b) is useless to the everyday physician [e.g., the Krebs cycle].

Oh, and don’t teach synthesis of ideas or decision-making. While you’re at it, smother the students and even residents with supervision so they never have an opportunity to make an independent decision anyway.

Then I thought, what’s up with the medical students? You’d think by now they might have heard that medical school was difficult and occasionally stressful.

I’ve got bad news for medical students. Hodie peius [Latin: This day worse] Medical school and residency training are not even remotely as stressful as actually practicing medicine. Wait until you are the one responsible for all the decisions you make, some of which will be wrong and result in complications or deaths.

Do these people, who are at least 22 years old, really need the school to generate extra-curricular activities for them? What are they going to do when they start practicing medicine for real? According to amednews.com, a recent survey revealed that 87% of doctors “said they feel moderately or severely stressed or burned out” EVERY DAY.

Who is going to arrange their cooking competitions and variety shows then?

Electronic devices distract doctors. So do other things.

Another hand-wringing piece about the dangers of distraction by electronic devices, this time from The New York Times, prompts these comments.

According to the article, Dr. Peter J. Papadakos, an anesthesiologist and director of critical care at the University of Rochester Medical Center reportedly said he had seen nurses, doctors and other staff members glued to their phones, computers and iPads. It goes on to say the following:

“My gut feeling is lives are in danger,” said Dr. Papadakos, who recently published an article on “electronic distraction” in Anesthesiology News, a journal. [Anesthesiology News, a journal? Since when?]

This is interesting coming from an anesthesiologist, whose colleagues were notorious in the analog age for doing crossword puzzles and reading the [print] Wall Street Journal during cases.

Here, via the AHRQ, is a nice example of an adverse event that occurred because of a distraction. A resident forgot to place an order to stop warfarin because she was interrupted by a text. Curiously, the electronic computer order entry program, while described as being “robust,” did not alert anyone. When his INR reached 8.5 three days later, the patient developed a hemopericardium requiring surgery. It’s a little disingenuous to blame a text for this complication when a team of doctors apparently forgot that a patient was receiving one of the most dangerous drugs around.

The Times article described a malpractice case from Colorado. It involved a neurosurgeon who was making personal phone calls during an operation which left the patient partially paralyzed. Where were the OR staff and the anesthesiologist while all these calls were being made? I doubt that I could even make one personal phone call during a case in my OR without the supervisor, the medical director and risk management being notified.

There is no question that electronic devices can be addicting and distracting if you let them. So can many other things like thinking of sex, which men apparently do at least 19 times a day or so a recent study says.

I will admit that it annoys me when I am talking to a resident or PA and she pulls out her phone to read an incoming text. And I certainly agree that 99.9% of all emails do not need to be viewed immediately.

That does not mean we should electronic devices from hospitals. I think the ability to look up a drug instantly or review management of a problem on UpToDate at a patient’s bedside far outweighs the potential for distraction.

I wonder if the same debate took place when radios were first placed in automobiles?

iPads approved by FAA for use by airline pilots, not passengers

As reported by The New York Times and ZDNet last week, iPads are now approved by the FAA for use by pilots. iPad flight charts replace about 35 pounds of paper charts. Another story says that the iPads, which weigh about 1.5 pounds, will save some $1.2 million worth of fuel a year.

Supposedly fearing disruption of avionics equipment, the FAA has yet to approve iPad use for passengers when the planes are below 10,000 feet. Yet if I interpret the FAA correctly, pilots, using iPads while sitting directly next to the avionics, present no threat.

This reminds me of the still on-going controversy about the use of cell phones in hospital intensive care units. Cell phones have been said to interfere with monitors and ventilators. Many hospitals still have signs prohibiting cell phone use.

Research (e.g., here, here and here) shows that cell phones do not cause clinically important interference with medical devises unless placed within a minimum of about 3 feet, although a Dutch study claimed otherwise. However, that study used certain European cell phones which emit three times the energy of American phones. It is likely that iPads and other tablets do not cause problems either.

Yes, I realize that being unable to use one’s iPad for 30 minutes of an airplane flight is not really that big a sacrifice. And I would hate to be subjected to three hours of 200 people talking on their phones in a space as confined as an airliner. But one could make the same argument as that use regarding the replacing of paper flight charts with iPads. Let’s say 200 passengers brought iPads, Kindles or Nooks aboard instead of books. Wouldn’t that save a lot of weight and fuel too?

If it’s about being distracted during critical take-off and landing sequences, then the flight attendants should make all passengers put down their non-electronic books during those times too.

Bottom line: Rules that are irrational cause people to lose faith in authority. If this rule is not rational, people think maybe other rules [e.g., the 55 mph speed limit] are not rational either. As respect for authority decreases, chaos ensues.

UPDATE 12/26/2011:
New York Times reports electronic devices do not emit significant energy and are highly unlikely to affect avionics.

More on System Failure and Human Error

The South Florida Sun-Sentinel reported that an investigation revealed a police officer who was killed in a car crash was late for work, was not wearing his seat belt, had just turned on the police cruiser’s on-board computer and was speeding. It was a tragic loss of what the story depicts as a good cop, husband and father of four children

What caught my eye in the story was another example of what I blogged about two days ago, which is the increasing trend of invoking system failure as the root of all evil. With all due respect to the late officer, one can only conclude that human error, not system failure, was the cause of this man’s death. Yet the response of the department was this:

“Following the crash, Delray Beach police instituted additional driver training for their officers, police spokeswoman Nicole Guerriero said.”

The department must have decided that a system failure had occurred. The corrective action was to make its officers take further driver training.

I think the photograph of the car wrapped around a palm tree and the description of the actions of the deceased officer that appeared in the newspaper account would have been adequate reinforcement of good driving habits.