The Internet Clouds Your Mind, Even If You’re a Doctor

A Sermo post on March 5, 2012 concerned a paper from the Archives of Surgery stating that over 15% of surgeons either abused or were dependent on alcohol. The results were obtained using the Alcohol Use Disorders Identification Test (AUDIT-C), a survey that has been widely employed as a screening tool for alcoholism.

The post generated 58 comments, many of which were highly critical of the AUDIT-C survey. Several commenters were critical of the first of the three questions on the survey, which is reproduced below.

1. How often do you have a drink containing alcohol?

a. Never     b. Monthly or less     c. 2-4 times a month    d. 2-3 times a week     e. 4 or more times a week

According to the points linked to each answer, a man who answered “e” or a woman who answered “d” would appear to be categorized as a problem drinker. Commenters correctly stated that having a drink 4 or more times a week does not make one a problem drinker. They then said this question not only invalidated the AUDIT-C  but also the paper itself.

But wait. Those who interpreted the question that way did not notice the explanation of the scoring system which clearly states the following:

“However, when the points are all from Question #1 alone (#2 & #3 are zero), it can be assumed that the patient is drinking below recommended limits and it is suggested that the provider review the patient’s alcohol intake over the past few months to conform accuracy.”

Why did several people, all of whom are physicians who you would expect to be more careful, overlook the above explanation of how the AUDIT-C scores are calculated?

I blame the Internet, which like the radio hero of the 1930s known as “The Shadow,” apparently has the ability “to cloud men’s minds.”

Technology expert Nicholas Carr has written extensively on this topic. In a 2010 piece for Wired magazine entitled “The Web Shatters Focus, Rewires Brains,” he wrote, “We start to read faster and less thoroughly as soon as we go online.”

Is it only the Internet or is this phenomenon common to all documents displayed on a computer screen? Does this problem spill over into the sometimes mind-numbing task of wading through a consultant’s report taking up five screens of an electronic medical record?

What do you think?

Note: I am now writing a column for Sermo, a physician community on the Internet, every Thursday. This blog was published on Sermo yesterday.

Research finds that air contains bacteria!

In the quest for the ultimate environmental contamination paper comes one from Yale via Science Daily stating “A person's mere presence in a room can add 37 million bacteria to the air every hour.” Let that sink in—37 million bacteria EVERY HOUR! The story was picked up by several news organizations. Google “37 million Propionibacterineae” and see for yourself.

Before you reach for your gas mask and “boy-in-the-bubble” protective gear, let’s read on.

The researchers measured the air in a classroom at Yale, when it was both occupied and vacant. They found that "human occupancy was associated with substantially increased airborne concentrations" of bacteria and fungi of various sizes. [Insert your own “toxic air at Yale” joke here.]

Only 18% of the bacteria found came from humans with the most common being Propionibacterineae, skin organisms not generally considered pathogens.

Down at the end of the article is the disappointing news that “Extremely few of the microorganisms commonly found indoors—less than 0.1 percent—are infectious.”

But the study’s lead author is quoted, "All those infectious diseases we get, we get indoors." He pointed out that Americans spend more than 90 percent of their time inside.

If you want to learn more, the paper was published in Indoor Air, The International Journal of Indoor Environment and Health.

I’m going to pass on that and mention that I’ve written several blogs about this type of study. If you want to read them, click on the “Infection” label to your right. The point I make in these blogs is that many different environmental surfaces have been shown to harbor bacteria, but very few have been linked to outbreaks of disease.

I am happy to report that although contaminated with 37 million [!] bacteria per hour, air is still OK to breathe. This remains true even with people in the room.

Things you need to know about an open ankle dislocation, bleeding and the media

Joba Chamberlain, a pitcher for the New York Yankees, suffered an open dislocation of his right ankle a few days ago. He was playing with his son at an indoor children’s gym. Exactly how he was injured is not clear, but it appears he was on a trampoline when it happened. Also not clear is the extent of his injury. We know the injury involved open skin and bleeding. Whether a fracture occurred was not mentioned at first. He underwent surgery immediately to control the bleeding, debride and close the wound and reduce the dislocation.

Some accounts of the injury reported that Chamberlain suffered “life-threatening” bleeding at the scene.

Lesson #1

No one with an extremity injury should ever “bleed out.” For many years, it has been widely known in medical circles that just about all external bleeding can be controlled by direct pressure on the bleeding site.

If direct pressure fails, a tourniquet should be applied. Yes, that’s right—a tourniquet. Long thought to be harmful, tourniquets have made a full comeback and are now considered a first-line method of controlling hemorrhage. [See research here.]

In fact, every soldier in the US Army is issued a personal first-aid kit containing two Combat Application Tourniquets® which can be employed with one hand.

Lesson #2

Depending on the exact nature of the injury that Chamberlain suffered, his prognosis varies from possibly returning to baseball late this season to never playing baseball again. The lesson here is not to speculate until all the information is available. That did not stopping various media outlets from contacting “experts” who weighed in with opinions about Chamberlain’s future.

The latest news is that no bones were broken and if he does not develop an infection [the risk is higher because the dislocation was “open”], he could pitch as early as July [New York Times] or not at all this season [CBS New York]. He was released from the hospital on March 25th, 3 days after the injury occurred.

Lesson #3

The New York tabloid newspapers are every bit as sleazy as their English counterparts. A column in the New York Daily News equates Chamberlain’s injury to that of a former Yankee prospect Brien Taylor whose pitching shoulder was injured in a fight and who recently was arrested for alleged drug dealing. Playing with one’s 5-year-old son is not the same as brawling with someone.

Chamberlain suffered a severe injury. Can we cut him a little slack please?

Update on the “Cholecystectomy via penis” story

I thought the mild interest in my "Removal of the gallbladder via the penis" blog was over but last night a commenter wrote the following on the blog:

Anonymous said ...

The link to the Austrian Newspaper is not working.
I also found this following link discrediting the whole story
http://urologieisoveral.blogspot.co.uk/2012/03/removing-gallbladder-through-penis.html

The link takes you to the blog of a Dutch urologist who, without attribution, posted my entire “SurgeryWatch” blog, wherein I explain that the original story about Austrian surgeons removing the gallbladder through the penis was a fabrication.

An anonymous comment on the Dutch blog reads ...

Sceptical Scalpel should be notified to the authorities to spread hoax news articles.

@goingtomedschool ‏tweeted

To elude the authorities, I have gone to a safe house [with Internet access].

Anesthesia fees for routine endoscopy/colonoscopy are expensive and may be unnecessary. Why are anesthesiologists used?

Using data from Medicare and private insurers, analysts at the RAND Corporation found that rate of involvement of anesthesiologists for upper GI endoscopy and colonoscopy in low-risk patients had risen steadily over the last few years and is estimated to add $1.1 billion in what may be unnecessary health care costs. There was wide regional variation in the use of anesthesiologists which suggests that some or most of the practice is discretionary and could be eliminated without harm to patients.

From the abstract: In both populations, the proportion of procedures using anesthesia services increased from approximately 14% in 2003 to more than 30% in 2009, and more than two-thirds of anesthesia services were delivered to low-risk patients. There was substantial regional variation in the proportion of procedures using anesthesia services in both populations (ranging from 13% in the West to 59% in the Northeast).

From the paper itself: However, prior literature has demonstrated that in low risk patients, sedation administered by nonanesthesiologists is safe or offers patient satisfaction comparable with sedation administered by an anesthesiologist or nurse anesthetist. In fact, the only published randomized clinical trial on the topic shows that endoscopist administered sedation during colonoscopies results in higher patient satisfaction and fewer adverse effects than anesthetist-administered sedation.

The paper and its accompanying editorial can be found in the March 21, 2012 issue of JAMA or you can read a summary of it in this Reuters Health article.

I am surprised that the percentage is only 59% in the Northeast as in just about every hospital I am familiar with, nearly every patient undergoing these procedures has general anesthesia administered by an anesthesiologist or nurse anesthetist.

The authors and the editorialist speculated on the causes of this citing medicolegal issues, the fact that anesthesiologist can offer deeper sedation than what a gastroenterologist or procedure nurse can give, the study can be completed more quickly and more thoroughly, patient preference and even financial gain for physicians.

I can think of other reasons.

In the name of patient safety, certain state health departments and national regulatory groups have mandated strict rules for the administering of moderate sedation to patients undergoing procedures. Passing an examination to be credentialed to give moderate sedation and the amount of documentation needed are seen by some as excessive. Ironically, this sometimes results in patients simply not receiving sedation for some types of other operations done under local anesthesia.

[Digression: Once upon a time, an outpatient surgical procedure not requiring the presence of an anesthesiologist could be documented on a single page of the medical record. Now such a procedure generates 20-25 pages of BS. And that is in hospitals with mature electronic medical records, so-called “paperless” hospitals!]

The other reason is related to the term “medicolegal,” but put more bluntly is known as “Cover Your Ass,” otherwise known as defensive medicine. I don’t perform endoscopy or colonoscopy, but I can tell you that if you are a patient and you have airway problems or vomit during a colonoscopy, you will be glad that your gastroenterologist is not the only doctor in the room.

If there is no anesthesiologist and the outcome is bad, you can bet that the plaintiff’s lawyer will conveniently ignore all the evidence that outcomes are just as good whether an anesthesiologist is present or not.

Amazing breakthrough in minimally invasive robotic surgery

You have probably read about natural orifice cholecystectomy and appendectomy or removal of the gallbladder or appendix without an abdominal wall incision. These procedures have been limited to women because the natural orifice through which the surgery is performed and the diseased organ is removed has heretofore been the vagina.

The author of the first large study of transvaginal appendectomy, Dr. Kurt E. Roberts of Yale Medical School said men would need to have surgery through the stomach or rectum and quipped, “Finally, an advantage for women"

But now via Presse-Agentur Österreich (Austrian Press Agency) comes a report from the Schweinsteiger Institut für Experten-Chirurgie (Institute for Expert-Surgery) in Vienna of minimally invasive gallbladder surgery in three men. The natural orifice employed was the urinary bladder via the penis.

The men had elective surgery for chronic symptoms of right upper abdominal pain and gallstones. They are said to have tolerated the operations well and were discharged home within three hours of completion of their cases.

At a hastily called press conference, lead author of the research team and his eponymous institute, Professor Herr Doctor Bastien Schweinsteiger, explained how the revolutionary procedure was accomplished:“Using miniature instruments machined especially for the institute’s proprietary robot, called Michelangelo, the penis is cannulated and the bladder entered. A small enterotomy is made in the dome of the bladder and the gallbladder is grasped. A metallic grid is deployed and attached to the gallbladder. A powerful electromagnet is placed on the skin of the upper abdomen. When activated, the magnet lifts the gallbladder into a suitable position for dissection. After the cystic duct and artery are divided, the gallbladder is dissected free of the liver.

According to Dr. Schweinsteiger:“The most challenging part of the procedure was devising a method of extracting the gallbladder and stones through the penis. We finally realzed that we could place the gallbladder into a bag inside the abdomen and emusify the contents of the bag using the same type of sound waves used for lithotripsy of kidney stones thus allowing the gallbladder and bag to be drawn out through the penile urethra.“

Study co-author Dr. Miroslav Klose told the throng of curious reporters that an unexpected but welcome consequence of the surgery was improvement in urination in all three men presumably due to the dilatory effect of the gallbladder and bag traversing the prostate gland.

The researchers expect to launch a full-scale Phase II trial of this latest advance in minimally invasive robotic surgery sometime in late summer of this year.

Drs. Schweinsteiger and Klose disclosed that they are officers and stockholders in Scherz Roboter, the company that manufactures the Michelangelo robot.

Link to Presse-Agentur Österreich article here.

“America Is Stealing the World’s Doctors.”

According to the New York Times “America Is Stealing the World’s Doctors.”

Is this really true? The article included interviews with a few foreign doctors. The ones who came to America appear to have done so of their own volition. As far as I could tell, they were not recruited. To the best of my knowledge, there is no concerted effort by any person or institution in the United States to coerce, shanghai, kidnap, seduce or otherwise lure physicians here.

How big a problem is this? According to 2010 data from the Educational Commission for Foreign Medical Graduates [ECFMG], 9399 physician graduates of foreign medical schools were certified as eligible for training in the US. Of those, 2287 were US citizens. Most of the rest were from India [1848], Pakistan [526], Canada [410], China [304], Nigeria [216], The Philippines [211], Egypt [209]. Libya [107] and Ethiopia [51]. For the geographically challenged, Nigeria, Egypt, Libya and Ethiopia are African countries.

Of the remaining 3914, all other African countries accounted for [presumably] far fewer than 960, which is how many countries had fewer than 50 doctors certified. In addition, possession of an ECFMG certificate does not guarantee a foreign doctor a residency position in the US.

The NY Times piece said, “The managing director of University Teaching Hospital in Lusaka [Zambia], Lackson Kasonka, suggested to me [the author] that doctors who received government financing for their educations and then left exhibited ‘a show of dishonesty and betrayal.’”

Interestingly, the surgeon featured in the article, although from Zambia, went to medical school in India. His tuition was paid by his parents. I am not sure that he was the best example one could find of “stealing” a doctor. Speaking of India, the country has a population of 1.2 billion, with about 320 medical schools.

From Wikipedia: “India is one of the few countries which produces many medical graduates from its medical schools who work not only in India but in many other countries all over the world, especially [the] Middle East, UK and USA.” Apparently, those other areas are “stealing” doctors too. It also said, “Most of the [Indian] graduates do not like to practice in rural areas due to under staffed hospitals & lack of facilities.”

While sipping a beer in his apartment in a gated complex in New Jersey, the surgical resident from Zambia did not give the impression that he will be returning to the bush any time soon.

I do not see how we could possibly deny qualified people who want to come here for training the right to do so. If this is such a big problem, perhaps the affected countries should not issue exit visas to selected citizens or otherwise detain them.

What do you think? Are we actually “stealing” the world’s doctors?

Overhyped research on prostate cancer & circumcision link

Yesterday Twitter was abuzz with tweets about a new study that showed an association between circumcision and a lower risk for prostate cancer. You wouldn’t know that it was just an association by the headlines.Here are but a few.

Circumcision Cuts Prostate Cancer Risk Scientific American
Circumcision reduces prostate cancer risk UPI
Circumcision Linked to Lower Risk for Prostate Cancer, Study Finds Yahoo News

And my favorite,

Males of the Mideast Rejoice: Circumcision Reduces Prostate Cancer Asian News International

In fact, not only is it just an association, it is a very weak association at best.

The research was a retrospective case-control study of men who self-reported their circumcision status, sexual histories and other information. There were 1754 men with and 1645 without prostate cancer in the study. The numbers of circumcised men differed by only 2.7% [1207 (68.8%) with cancer vs. 1176 (71.5%) without cancer.}

The relative risk of developing prostate cancer was not significantly different in circumcised and uncircumcised men until the authors looked at those who had been circumcised after their first episode of sexual intercourse. The numbers of men who had been circumcised after their first sexual encounter was only 68 (3.9%) of the men with prostate cancer and 41 (2.5%) of those without. Although the relative risk reduction was 15%, the confidence intervals were wide (73% to 99%) and were just barely significant.

And don’t forget, this is a relative, not an absolute, risk reduction of only 15%.

Most of the paper’s discussion involved circumstantial evidence that because infection has been linked to some cancers, infection of the prostate or penile skin may possibly play a role in the development of prostate cancer.

So does circumcision actually reduce the risk of contracting prostate cancer?

It shouldn’t surprise anyone, but I am skeptical. Do you really believe that one act of sexual intercourse before a man is circumcised would really have an impact? What if the man did not develop an infection after that episode or any subsequent episodes?

Don’t believe me? Here is a quote from Internal Medicine News, which not only had a more subdued headline, it published one of the few articles that featured the opinion of an outside expert, Dr. Stephen J. Freedland, a urologist at Duke. He said:

"This study provides modest evidence: a 15% reduction. It’s not as if we should recommend that every baby be circumcised because it can reduce prostate cancer by 15%. This is more of a research finding,"

Those males of the Mideast should probably temper their rejoicing until some more solid evidence appears. Meanwhile, they may want to consider a study from 2003 suggesting that masturbating may prevent prostate cancer.

Student and resident training needs radical change

If you’ve followed my blog, you know that I have been concerned about the state of surgical residency programs and other issues involving medical education. For more on these topics, browse the labels “surgical residency training” and "medical education" in my blog.

Here is more food for thought.

While the impending shortage of general surgeons has prompted calls for increases in the number of general surgery training programs and expansion of existing programs, there are some questions about quality.

Here is a paragraph from the Residency Review Committee for Surgery program requirements:

V.C.3. The performance of program graduates on the certification examination
should be used as one measure of evaluating program effectiveness. At
minimum, for the most recent five-year period, 65% of the graduates must
pass each of the qualifying and certifying examinations on the first
attempt.

The American Board of Surgery publishes data on board passage rates by program. According to the 2011 figures, 82 (34.3%) of the 239 accredited general surgery residency programs in the US have first-attempt board passage rates of <65% for the most recent five years and 30 of those programs (12.6% of the 239 programs) have rates of 50% or less.

In the March, 2012 issue of Archives of Surgery, Dr. Leigh Neumayer cited a decline in the in the rate of individual residents passing their boards. In 2010, 75.1% passed the written and 76.8% passed the oral examinations. These percentages are remarkably consistent with the 25% of surveyed surgical residents who feel that they are not adequately prepared to practice independently. She mentioned the trend of graduating residents taking fellowships because they are not ready to practice by themselves.

She also discussed the need to change the way surgeons are trained, pointing out that the amount of knowledge to be acquired by trainees is increasing exponentially while the time available to learn is decreasing.

She said that every surgeon should not necessarily be trained to perform every procedure. This is actually sorting itself out with the volume and outcomes debate, which despite a few discrepancies, favors surgeons who perform large numbers of certain procedures.

She made some other interesting suggestions which, because they are sensible, are unlikely to be adopted by those in power. Others have called for reforms in medical education such as reducing the amount of useless material memorized in the first two years of medical school, also unlikely to change.

Now that a resident can carry a computer in her pocket and access everything there is to know instantly, why should she have to memorize formulas, chemical reactions and other minutia? With the exception of the rules limiting work hours, medical school and resident curricula have changed very little since I was a student and resident some 40 years ago.

To summarize: We are trying to cram much more information, which is also more complex, into less time using the same methods we did in the middle of the Twentieth Century.

My suggestion: Let’s teach them to think instead of memorize.

I wonder what it will take to get the people in charge of medical education [American Association of Medical Colleges, American Board of Medical Specialties, Accreditation Council for Graduate Medical Education (parent organization of the Residency Review Committee for Surgery) and others] to wake up and notice that the system is not working very well.

Why I am I so grumpy?

Patient information and situations have been slightly altered for privacy reasons, but the essence of the stories is true.

A middle-aged woman was admitted to the medical service for symptoms of alcohol withdrawal. Her liver function tests were abnormal. Despite the fact that she had no abdominal pain, an ultrasound was ordered and showed a gallstone. The cognitive doctor called me and said he didn't think the gallstones were significant but would like me to see the patient and confirm his feeling. Asymptomatic gallstones do not require surgical intervention. Why can’t a cognitive doctor deal with this himself?

An emergency physician had a woman in the ED who had fallen down some steps and fractured her right humerus, clavicle and a rib. There was no history of loss of consciousness. Her total body CT scans were otherwise negative. He consulted me to "clear" her regarding possible other injuries before deciding on her disposition. Are ED MDs capable of assessing and "clearing" trauma patients or not?

A man was admitted to the medical service with gallstone pancreatitis. [Whether such patients should be admitted to medicine or surgery will be the subject of another discussion.] I was called for a consult at 2:00 a.m. Think about it. How likely was it that I was going to operate on this patient in the middle of the night? Hint: Not very.

The answering service of a surgeon I was covering for called me at 5:00 on a Sunday morning to tell me that a woman had called to say her husband, who had undergone surgery a few weeks before, was having pain. I called the number I was given, and the call went straight to voice mail. Through clenched teeth, I left a message stating I was returning her call and that if she wanted to talk to me she should leave her phone on and call the service back. When she called back a while later, I learned that the pain had been going on for more than 24 hours. Why couldn’t they have waited two more hours to call? And how about leaving the phone on to receive the call-back?

A patient of another surgeon I was covering for called me at 6:00 p.m. on a Friday to tell me he had just run out of pain medication. Wouldn’t it make more sense to call the doctor for a refill when one was down to say, two or three pills? By the way, this happens all too frequently. It always makes me suspicious that the patient is drug-seeking. They get just enough pills to last the weekend.

I was called to the ED to see a morbidly obese woman with an incarcerated ventral hernia. While taking a history, I learned that she had diabetes, hypertension, asthma, sleep apnea, hypercholesterolemia, arthritis, atrial fibrillation and was taking prednisone and Coumadin, as well as 15 other medications. Her primary care physician, all of her specialists and the surgeon who had performed all of her previous operations practiced at another hospital. Why did she come to my hospital? She said she knew she wouldn’t be kept waiting as long in our ED.

Horace Greeley: “Common sense is uncommon.”
Skeptical Scalpel: “Common sense cannot be taught.”

Worst research study of the year (so far): America’s 10 most sleep-deprived jobs

Somehow this slipped by me a few days ago. And it was in the New York Times of all places. A column called “Economix” featured a report entitled “America’s 10 most sleep-deprived jobs.”

It seems the mattress company known as “Sleepy’s” commissioned a survey to find out which jobs were associated with the least and the most sleep. You could probably name a few of the occupations that cause people to be sleep-deprived. But some were surprising. Here they are with the amount of sleep claimed by people in those jobs.



Are you buying this? Home health aides? I can’t resist the urge to point out that they may occasionally catch a few winks on the job. Lawyers? Too many jokes to fit into a blog of fewer than 500 words.  Economists? If they’re up at night, what are they doing? Certainly not fixing the economy. Maybe they are talking to financial analysts or secretaries.

I think we may have a problem with methods here. I was unable to find much about the details of the study as the link provided by the Times went only to the National Health Interview Survey website and not the survey itself. The only other major news organization that carried the story was “MattressZine, The Premier On Line Mattress Magazine.” It had very little to add to the Times piece except for this shocking finding from the survey:

“Some workers also tend to oversleep or aren’t fully prepared to get up from bed, even as their alarms go off in the day.”

Alert the Nobel Prize for Economics Committee.

The Times report said that over 27,000 people were interviewed. They were asked about the average number of hours of sleep they got and what they did for a living. Could it be that the estimates of sleep were flawed? How many hours of sleep did you average last week?

The time difference between the amount of sleep stated by the #1 most sleep-deprived home health aides and that of #10 secretaries was 11 minutes. The statistical significance of the different times can’t be stated because we don’t know how many people were questioned in each job category, nor do we have the mean times and their standard deviations. Even if there was a statistically significant difference, is an 11 minute difference a clinically meaningful one?

Oh, there’s one other thing. Ranked at #8, #9 and #10 on the list of those who get the most sleep are engineers, aircraft pilots and teachers. Their average amount of sleep was 7 hours and 12 minutes, a whopping 4 minutes longer than secretaries, #10 on the list of the most sleep-deprived.

Bottom line. This survey is to research as hot pockets are to gourmet food.

Are medical students turning to prostitution to pay bills?

The answer is "No" but you wouldn’t know it if you read the headlines.

Here are a few:

Are med students turning to prostitution to pay tuition?-MSNBC
Sex Work Among Medical Students On the Rise?-ABCNews
Worrying rise in number of medical students in prostitution over last 10 years-Yahoo

And of course, not to be outdone, a London paper, the Metro, gets it all wrong.

Photo courtesy of Noorulann Shahid ‏(@NoorulannShahid)

Goggle “Medical Student Prostitution” and you will find many more, none of which give the reader any hint that US medical students are involved in the alleged practice..

The problem is that the article that these scandalous headlines are referring to says nothing of the kind. It was published in Student BMJ, a division of the formerly prestigious BMJ Group. Its flagship publication, the British Medical Journal, is one of the leading medical journals in the world.

The article is an opinion piece written by Jodi Dixon, a final year medical student at the University of Birmingham. She cites a previously published paper, which surveyed undergraduate students at a London university and stated that 10% of those students “knew of someone” who had worked as a prostitute or an escort. This is what is termed “hearsay” in legal circles. And isn’t it possible that many of the students knew the same person? Please note again that this study did not include medical students.

Ms. Dixon goes on to speculate that some medical students might have to consider prostitution as tuition in UK medical schools rises. She discusses the ethical and legal implications of medical students possibly becoming prostitutes.

The BMJ group apparently sent out a press release that conflates medical students and undergraduate students. This was reprinted as the Yahoo Groups “Research in Psychiatry” story.

Oh there is one bit of additional information, which does not exactly support the headlines. Student BMJ simultaneous published “Confessions of a student prostitute.” The author is anonymous and is a man.

The BMJ Group ought to be ashamed of this.