A “rule” without foundation

The practice of medicine often involves “rules” that are not based on fact or evidence. Many of them are justified in a manner similar to that which we use with our children—“because.” The rationale for some rules is “that’s the way we’ve always done it.”

How about a rule prohibiting the clipping of hair in the operating room? My hospital has decided that if hair is to be clipped, it must be done before the patient arrives in the OR. One reason for this is said to be prevention of infection by loose hair.

Wait a second. It is generally agreed that the fewest wound infections result when patients are not shaved or clipped at all. If that is so (and the evidence is convincing), then why would hair cause a problem if loose? I am not aware of any data that supports the claim that clipping hair in the OR causes wound infections.

After asking about the source for this rule, I find it originates in standards promulgated by the Association of periOperative Registered Nurses (AORN). On page 367, the AORN 2011 Perioperative Standards and Recommended Practices states “Hair removal should be performed the day of the surgery, in a location outside the operating or procedure room.” The justification is said to be “Clipping the hair outside of the operating room minimizes the dispersal of loose hair and the potential for contamination of the surgical field and surgical wound.” No reference is cited.

Other sources such as the Association of Surgical Technologists’ Standards (I.3.B.) say the “shave prep should be performed in the preoperative holding area where the privacy of the patient can be maintained.” I don’t know about your OR holding area, but every holding area I’ve ever seen is far less private than the operating room itself.

The AST apparently hasn’t received the memo that “shave” is not the correct term and has not been for many years. So it’s not infection that’s the problem; it’s privacy?

In addition to not being evidence-based, the recommendation would be difficult to follow because clipping in an area outside of the OR itself will delay the case. If clipping is necessary for the purpose of applying tape after the operation, I prefer to do it myself because 1) I know it will be done without inflicting injury and 2) it will encompass only the area that I want clipped.

I performed a thorough literature search and found nothing to justify this rule regarding infection or privacy.

The problem with rules like these is that, as is the case with the 55 MPH speed limit, rules without reason are often not followed. This breeds mistrust of authority leading to failure to abide by reasonable rules too. General anarchy follows and civilization as we know it will be destroyed.

Do you know of any other "made up" rules like this?

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Pregnancy among women surgical residents

A paper reporting the results of a survey of women surgeons on the topic of pregnancy appears in Archives of Surgery online ahead of print.

Responses were received from 1937 female surgeons, which was 49.6% of those who were sent surveys. Not surprisingly, the findings were that women surgeons feel stigmatized about pregnancy during surgical residency training.

Things are improving, but slowly. The percentage of women reporting that pregnancy during training is stigmatized fell from 76% for women who graduated more than 30 years ago, all the way down to 67% for women who graduated less than 10 years ago. The difference was statistically significant [p = 0.001] but hardly significant in the real world. At this rate, pregnancy among female surgical residents should be no longer stigmatized by about the year 2127.

According to Table 3 of the paper, the cumulative rate of pregnancy of female surgery residents who graduated fewer than 30 years ago is 32.2%. To put it another way, 1/3 of all female surgery residents became pregnant at least once during their five years of training.

The most interesting finding was that even women faculty and women residents were perceived as having a negative influence on women surgeons contemplating childbearing and this negativity has not abated over the years. Meanwhile, the percentage of both residents who are women and those who become pregnant is increasing.

Male residents can get sick or be injured and miss time. Should there be any reason to deal with pregnancy differently?

What do you think about this?

This blog appeared on Sermo [registration free for physicians] yesterday and 38% of the 26 doctors who voted felt that female surgical residents should feel stigmatized about pregnancy.

An error occurred. Suspend all surgery in the US?

Here is an extreme “system error” type of response to an event which seems to have been a human error.

According to CBS News: “Mowing at all national parks has been suspended indefinitely because of safety concerns after a maintenance worker cutting grass along the Blue Ridge Parkway in North Carolina fell to his death.”

The unfortunate victim was killed when the mower he was riding on fell down a 140 foot embankment. The report says, “He was trimming a 12- to 15-feet-wide area between a wooden guardrail and a cliff when he lost control of the zero-turn riding lawnmower and went over the edge.”

The National Park Service investigation of the accident is already complete but the findings will not be released for months. It is not clear why it will take so long. [That’s a subject for another post.]

If you have been following my blog, you know that I have consistently questioned the tendency of organizations, including hospitals, to blame adverse events that seem to have been human errors on “system errors.” Once a problem is deemed a system error, policy changes must be made. New protocols are written. It gives the appearance that the organization is “doing something” about the perceived system error. In my experience, most of the time the changes are soon forgotten and everyone moves on.

Pending the results of the investigation, I could possibly understand suspending the use of all riding mowers of the type used by the victim or suspending the mowing of grass along the edges of cliffs, but to suspend all mowing of grass at all 397 national parks seems a bit excessive.

I had tweeted a brief mention of the CBS News story and one of my followers, @dockj, responded, “What if we stopped all surgery for the entire country every time there was an error?”

What a great question. I tweeted back that I wished I had thought of that. I hope the patient safety gurus don’t hear about this or it might be the next step.

Meanwhile, watch out for snakes in the tall grass when you visit a national park.

More of my blogs about system error here, here, here, and here.

Wide disparity found in hospital charges for appendicitis. Why?

If you wonder why hospitals are under fire for outrageous and often baffling accounting practices, look no further than a brief paper published last month in Archives of Internal Medicine.

 

Hospital charges for straightforward appendectomies done for acute appendicitis in California in 2009 were examined with the following inclusion criteria:

• Patients between the ages of 18 and 59
• Hospital stays fewer than 4 days
• Discharged home

For the more than 19,000 records reviewed, the median hospital charge was $33,611 with a low of $1,529 and a high of $182,955. Not included in the article but mentioned in news stories about the paper were more details about the care of the two patients at the extremes of charges.

From the Huffington Post: “The costliest bill, totaling $182,955, involved a woman who also had cancer. She was treated at a hospital in California's Silicon Valley. Her bill didn't show any cancer-related treatment. The smallest bill, $1,529, involved a patient who had her appendix removed in rural Northern California. Otherwise, the cases were similar: Both patients were hospitalized for one day, had minimally invasive surgery, and had similar numbers of procedures and tests on their bills.”

A California Healthline story about this clarifies the issue. It said,“Dave Glyer, CFO for Community Memorial Health System, said that the study ‘assumed that hospital charges matter when they don't,’ making it ‘completely off base.’ He said that insured patients pay rates negotiated by health insurers and that certain uninsured patients are aided by assistance programs.”

It’s all clear to me now. Hospital charges don’t matter.

What if you have no insurance and are not one of the “certain uninsured patients” who are aided by assistance programs? You are on the hook for the entire bill unless you can negotiate too.

What’s not clear is how the median hospital charge for a simple procedure such as an appendectomy can be $36,611 with such a large variation. 

May we see an itemized bill for the $182,955 please?

I Missed My Calling: Hospital Execs’ Pay Astronomical

This is probably not news to many but according to data recently published by the Connecticut Health I-Team, hospital executives are being paid handsomely .

Figures from 2009-10 reveal that 18 executives in Connecticut, a state with only 30 hospitals, made over $1 million per year.

Some of these figures include retirement packages. The top earner was the outgoing president of Hartford Hospital, who made nearly $7 million, with “all but $1.1 million of it nontaxable and retirement benefits.”

Below is a table from the Connecticut Health I-Team showing the top 15 highest paid executives.

Some of the hospitals, Yale-New Haven, St. Raphael's and Hartford, are large. Most are between 300-400 beds, but #13 New Milford is only 85 beds.

I realize that hospital executives have a lot of responsibility, but usually when they make a mistake, no one dies. I doubt they are sued very often either.

When I am reincarnated, I thought I wanted to be a weatherman [See my blog about this here] or maybe a consultant (both jobs with good pay and no accountability), but perhaps hospital executive is the best choice.

Oh, and how’s your retirement package looking these days?

[This blog appeared on Sermo yesterday and 95% of doctors who voted felt that hospital execs were paid too much (surprise) and only 13% of doctors felt that their retirement situation was "all set."]

Radioactive man? Milford resident pulled over by state police

A few days ago, a 42-year-old man was stopped by a state policeman because radiation coming from his vehicle was detected by a device in the patrol car. Earlier that day, he had undergone a cardiac stress test which involved the injection of a small amount of radioactive isotope into his body. He was released when he produced a doctor’s note stating he had undergone the test. [Full story here.]

Two things make this story interesting.

One, the report reveals the fact that many police cars have radiation detectors that are so sensitive that a man emitting a small amount of radiation while driving could be fingered as a possible terrorist. Despite my being a news junkie, I did not know that such detectors were deployed. Did you?

Now the terrorists know too. What is to stop them from bringing a nuclear weapon into a city now that they are aware of the existence of these detectors and that a note from a doctor can get one off the hook?

The second interesting point involves the stress test. The story says the man had what seems to have been a transient hypertension. There was no mention of any cardiac symptoms or a family history of heart disease. The man is employed as a fireman, a strenuous occupation.

Why was a nuclear stress test ordered?

I am a mere, “non-cognitive” surgeon, but I believe that an asymptomatic 42-year-old fireman with hypertension, episodic or not, does not need a cardiac stress test.

Do you wonder why we spend so much on health care in the United States?

Are you afraid to be wrong?

Richard Smith, a former editor of the British Medical Journal, wrote a thoughtful essay offering guidance for new medical students. Full text here. Although it was published in 2003, someone just brought it to my attention via Twitter.

Dr. Smith lists many pearls of wisdom in a scholarly and lightly humorous way. I disagree with only one of his statements:

“Do not be afraid to be wrong.”

It is not that this is bad advice. To me, a timid doctor is prone to failure. Sometimes you have to take your best shot based on the information at hand. The problem is that in today’s medical world, we are expected to be perfect. If you make a wrong diagnosis and the patient suffers a poor outcome, you have a good chance of being sued and a better chance of experiencing an inquisition by emissaries from the quality improvement and/or risk management departments, AKA the “thought police.”

I once did some expert witness work for a malpractice insurance company. There is rarely a case that does not have many opportunities for second-guessing. When you know the outcome, you can always find something in the medical record that could have been done differently.

The current medicolegal and patient safety climate creates a feeling among physicians that any error is going to be extensively scrutinized. This results in a situation analogous to an athlete trying not to lose a game instead of trying to win. For those of you not familiar with sports, that strategy usually fails. Fear of being wrong can lead to excessive testing too.

Many say that medicine should have a blame-free or “just culture” like the airline industry, where reporting of near-miss and other events does not result in sanctions to pilots or air traffic controllers. It would be nice, but I know of no hospital that has achieved that state of nirvana in this country. For more on the pitfalls of just culture, see a recent blog I wrote.

This reminds me of the comic strip where the pointy haired boss says to Dilbert: “According to the anonymous online survey, you don’t trust management. What’s up with that?”

Single-incision laparoscopic surgery: What are the indications?

My answer is “None.”

There is no compelling reason to perform single-incision laparoscopic surgery (SILS).

Take cholecystectomy, for example. The three 5 mm incisions in the upper abdomen done for standard laparoscopic cholecystectomy are nearly painless and, after a few months, almost always become invisible. The umbilical incision is larger and does cause pain, but the incision for SILS is generally 50% larger than that of standard laparoscopic cholecystectomy and likely to be just as painful if not more so.

For appendectomy, the same reasoning applies regarding the two 5 mm incisions and the umbilical incision. Not only is the umbilical SILS incision larger, one recent paper reports that it results in more postoperative pain too.

The ergonomics of SILS leave a lot to be desired as well. Since the instruments enter the abdomen so close to each other, it is difficult to triangulate them. Obtaining the critical view of the structures in Calot’s triangle is more difficult. It certainly is hard to imagine that SILS is safer for the patient.

There has not been one study convincingly showing superiority of SILS over conventional surgery for any outcome. It will be a challenge to show that compared with multiple-port surgery, SILS shortens length of stay, decreases pain or even has a better cosmetic result after six months.

Small pilot studies of robotic SILS are surfacing. The robotic method offers the possibility that triangulation is slightly improved. But increased costs and longer operative times negate that minor technical gain. What’s more, triangulation is even better with 4-port surgery.

I propose the following:

If SILS had been invented first, papers extolling the safety, ease and comfort of multiple-port surgery would be appearing and everyone would be jumping on the bandwagon to offer it to patients as a better procedure.

Feel free to comment. And don’t ask me if I’ve done a SILS case. The answer should be obvious.

For a more extensive review of single-port vs.standard laparoscopic cholecystectomy, read this paper. Thanks to @anblog84 for sending it to me via Twitter.

Note: This blog appeared yesterday on General Surgery News.

What happens when a doctor is paged

I dedicate this post to all nurses. National Nurses Week starts May 6th.

It’s 8:15 p.m. I am at home. My beeper goes off, and I check it instantly. It reads, “555-1212” [Number changed to comply with HIPAA regulations]. It’s the inpatient surgical floor. Within 10 seconds, I have dialed the number.

The unit secretary answers with the scripted and time-wasting response: “Hello, this is Blockley East, Jennifer, Unit Secretary speaking. How may I help you?”

“Skeptical Scalpel, returning a page.”

“Oh, yes. Hold on, I’ll get the nurse.”

Cue the recorded announcements extolling the virtues of the hospital’s world-class robotic surgery program, the revolutionary Cyberknife®, the wound care center, the award-winning maternity suite and blah, blah, blah. I have the spiel memorized. Give me elevator music any time over this.

I’m thinking about the patients I have on that floor. Is it about Mrs. Schweinsteiger’s urine output? Is Mr. Robben’s NG tube not working again? Has the lab work come back on Miss Ribery?

I look at my cell phone. It’s been 2 minutes and 37 seconds since I answered the page. I’m hearing the recording for the third time.

Hmmm. At 4½ minutes, I hang up.

The punch line? I was never paged again.

So, what happened here?

My theory is that immediately after a nurse pages you, she runs as fast as she can to get as far away from the nurses’ station as possible. Maybe she went off duty. Maybe she took a break. Or something. And it apparently wasn’t that important or she would have paged me again.

This kind of thing happens just about every day and drives me crazy.

Note: Yesterday, this blog was posted on Sermo, an on line physician community and 52/56 (93%) MDs who responded said they had experienced pages like the one I described.

Secret Service falls for “system error” myth

I have blogged before about the fact that many organizations tend to react to bad outcomes due to human error by somehow turning them into so-called “system problems.” Link is here.

For example, a hospital I am familiar with reacts to human errors such as a resident failing to call for help when confronted with a patient who is crashing as follows: Instead of doing remedial work with the resident, the incident is labeled a system error. A task force is convened and after several meetings, a new directive is issued stating that certain patient-related events mandate a call to an upper level resident or an attending physician. Of course the next time a crashing patient is seen at 3 a.m., the problem will not involve one of the listed events. Like the sentinel event, the real problem is a human failure to recognize that a patient is in trouble.

Now comes news that the Secret Service is sending its agents to an intensive ethics training course at Johns Hopkins University.

What this says to me is that married Secret Service agents, who are entrusted with the protection of the President, do not realize that getting drunk and frolicking with prostitutes in a foreign country is wrong. Apparently, the Secret Service feels their people need ethics training to help them with such knotty issues.

What would happen if you asked a group of high school boys this question, “If you were a married Secret Service agent with the presidential entourage in say, South America, would it be all right if you got drunk at a strip club and took a prostitute back to your hotel?” Despite lacking formal ethics training, I bet most of them would probably answer, “No.”

There could be a system problem involving the Secret Service, but it’s not about ethics. Maybe it's related to the way in which agents are selected.

Like prospective medical students, candidates for jobs with the Secret Service may need to pass a test that reveals their warm and fuzzy side.

No, I don't think it's about a system problem with ethics. I say it's a lack of both character and common sense.

PS: I hope the ethics class touches on the subject of “A Deal is a Deal.” If you agree to pay someone $800.00 for their services when you know you have only $225.00, that is truly unethical.