Patient Complications & Surgeon Collateral Damage

"Collateral damage: the effect of patient complications on the surgeon's psyche" was a brief but interesting paper that probably went unnoticed by many. Using the results of a survey completed by only 123 of the 403 surgeons who received it, the paper studied the effect of complications on the emotional well-being of surgeons. You could argue that the response rate of 30.5% renders the conclusions suspect. But that’s not the point.

The subject matter hits close to home for any surgeon who cares about his patients and what he does to them.

There are two types of complications—those that happen despite your best efforts, such as a postoperative MI in a seemingly healthy patient or an infection that develops after proper surgical technique and appropriate antibiotic prophylaxis were used.

Then there are the complications that occur because you made a mistake. Examples of this are sepsis due to an anastomotic leak due to your well-intended but erroneous judgment that the patient’s bowel wall would hold the staples or your failure to operate soon enough on a patient with a bowel obstruction.

Of course when any complication occurs, we feel bad for the patient and the family. But the latter type of complication can keep you awake at night, undermine your confidence and your ability to function and even effect your enjoyment of life in general. Eventually, you get over it and move on, but the next time is no easier. According to the survey, about two-thirds of the surgeons felt it was difficult to deal with the emotional aspect of  complications throughout their careers and experience did not seem to lessen the impact.

Not everyone is affected in the same way or to the same degree. I once had a surgeon tell me, “I’ve been in practice for 22 years, and I’ve never made a mistake.”

But for us mere mortals, mistakes happen and leave scars. A South African blogger named Bongi said it much better than I in a post he called “The Graveyard.” In it, he describes a case of his with a delayed diagnosis that resulted in a patient’s death. He said every surgeon has a graveyard in the “dark recesses of his mind” where “names engraved on the tombstones” can be recalled.

I have a graveyard. I think most doctors do.

Note: This post appeared on Sermo yesterday and generated some thoughtful comments.

Common sense lacking in schools

What is going on in schools today? No, I’m not talking about what seems to be an epidemic of teachers having sex with students. That’s old news.

Recently, there have been more examples of what I can only call an inexplicable lack of common sense on the part of teachers and others at schools. I have blogged about this before when school officials in New York attempted to ban words that might upset some students.

A six-year-old boy, accused of being a bully, was deemed by his teacher to need remediation. A second teacher was consulted. She had the perfect solution--have all the other students in the class repeatedly punch him. Another teacher reported the incident. The child’s mother was not happy. Here is the response of a school official from TV station KENS. “Steve Linscomb, a spokesperson for the district, confirms that the teacher will not be hired again within the school district, but suggests the incident was a result of a lack of experience. ‘This teacher is a relatively young teacher and just needs to be re-educated and reminded what needs to happen in the classroom in order for it to be a safe learning environment,’ he told KENS." No, It’s not about experience or re-education. This teacher has no common sense.

A 17-year-old student was allowed to lose consciousness during an asthmatic attack while the school nurse looked on. Why? His mother had not signed a form authorizing use of an inhaler. It gets worse. The the story says the nurse not only failed to call an ambulance, she locked the door of the office with the boy inside. The school’s response? “Deltona High School and Verona County officials stand by the nurse's decision.” The kid would have been better off had he been in the street. Bystanders would have at least called 911.

At a school field day, two girls were sunburned to the extent that their mother took them to a hospital that evening. It was raining that morning and their mother did not apply sunscreen. When the sun came out later that day, the girls were not permitted to use sunscreen. Why not? According to a published report, “The school district's sunscreen policy, which forbids teachers from applying sunscreen to students, and only allows students to apply it to their own bodies if they have a doctor's note authorizing it, is based on a statewide law.” No one thought to take the children out of the sun or call their mother to come to apply sunscreen. Oh by the way, one of the girls has a type of albinism. Tell me please, how easy do you think it is to obtain a doctor’s note authorizing the application of sunscreen, a non-prescription substance?

In case you think that this is a uniquely American phenomenon, here’s a similar story from England. Pupils in a creative writing class were told to write a note to their mothers as if they had only a few hours to live. When he got home from school, one 14-year-old boy handed the essay to his mother who thought it was a suicide note and was understandably upset. The school apologized "for any distress."

What is going on here? A six-year-old is beaten up by his classmates at the direction of a teacher. What is the lesson for the “bully” and the other students? A nurse watches a child try to die from an asthma attack and does nothing. Two children are sunburned because a doctor’s note is required for the application of sunscreen. A suicide note as a creative writing exercise is understandably of great concern to a child's mother.

These teachers and administrators are supposed to be educating our young. And people ask me why one of my daughters has chosen to homeschool (or rather “unschool”) her two children.

Horace Greeley: “Common sense is uncommon.”

Skeptical Scalpel: “Common sense cannot be taught.”

Dictations can be tricky, Part 2

A while back I wrote a blog about a resident’s operative dictation that was incoherent and the pitfalls of dictating. Here is another example.

The switch to electronic medical records has brought some unintended consequences. We now have rapid turnaround of dictations at my hospital. They appear in the electronic record within a couple of hours and require verification by electronic signature. As is true of many documents that appear on computers and the Internet, they sometimes are not read carefully.

It was electronically signed by the physician who dictated it. I’m guessing that he did not proofread it. At least I hope not.

The name was changed to protect the innocent.

Dr. Balotelli found on endoscopy a stomach full liquid with esophagitis. There was a 3 orifices in the distal esophagus. There is a hiatal hernia sac, actually 2 of them; 1 led to the antrum. Pylorus and duodenum of the hernia sacs are full with dark liquid which were suctioned. The third compartment led to the small bowel. It did not contain any contents.  The hernia sacs were friable and ulcerated. The mucosa in the antrum and pylorus were widely open. The duodenum appeared normal. Since then, the patient is no longer nauseated or vomiting. His NG output is minimal.

As far as I know, I am the only person who has actually read this note. The entry was made a while ago and has not been corrected.

I used to use Dragon dictation. You must take great care when proofreading because you tend to read what you meant to say, rather than what Dragon thought it heard. I once dictated a letter of recommendation for a student. Instead of Dragon typing "she is confident and poised," it came out "she is confident and moist."

Does anyone really read electronic progress notes?

Do you know of any examples of dictations gone astray like this? If so, please describe.

A slightly different version of this post appeared on Sermo yesterday. Most of the comments suggested that the EMR would be the downfall of society as we know it.

Unprofessional behavior by medical hospitalists

By their own admission, medical hospitalists are guilty of many types of unprofessional behavior says a recent paper published ahead of print in the Journal of Hospital Medicine. A group of researchers from the University of Chicago surveyed medical hospitalists from three major Chicago area teaching institutions. The respondents themselves rated each listed behavior on a professionalism scale. There were 77 responses from pool of 101 hospitalists who were sent the questionnaires. The study asked respondents to state whether they had either engaged in and/or observed unprofessional conduct.

The key findings were as follows:

• Most of the respondents had engaged in at least one unprofessional behavior.
• The most common unprofessional behavior was [I hope you are sitting down.] having non-medical/personal conversations, such as discussing plans for the evening, in hospital corridors. [Gasp!]
• Over 60% of these doctors admitted that they ordered a routine test as “urgent” as a way of obtaining results more quickly. [Can you believe it?]
• My favorite is that 40% confessed that they had made fun of or disparaged the emergency department team for missing findings. [Unreported but very likely true is that 60% of those questioned committed another unprofessional act, which was lying by claiming they had never made fun of or disparaged any ED MDs. The only physicians I know who do not routinely make fun of the ED staff are pathologists because they never deal directly with the ED. Before all you ED docs get your panties in a knot, I am certain all of you disparage all of us too.]
• Other alleged unprofessional behaviors were celebrating a blocked admission, going to working when ill and texting during conferences.

Another interesting finding was that for every one of the over 30 unprofessional behaviors listed in the questionnaire, hospitalists said they had observed many more such behaviors than they admitted to participating in.

Despite what many surgeons may have believed, this survey shows that medical hospitalists are really pretty normal. 

But I suspect there will be corrective actions for these doctors at the three hospitals. A curriculum will be developed and monitoring metrics will be established. Maybe listening devices will be placed in hallways. These scandalous behaviors must be stopped.

A final note—this study was supported by grants from two different sources.

Words mean what I say they mean

Apparently a few years ago someone decreed that “non-compliant” was no longer a politically correct term to describe patients who did not take their medicines or follow instructions. The newspeak to use is now “non-adherent.” This was recently brought to my attention by cardiologist-blogger Dr. John Mandrola, who humorously blogged about his own non-compliant-adherent behavior after a hand injury.

I googled “non-adherent vs. non-compliant” and found references to the former used in medicine from as far back as 1998 but most hits were from this century. I could not identify the origination of the switch or why the term non-compliant was perceived to be judgmental.

I suppose compliant has a more submissive connotation, and God knows, we should not consider patients as subjugated, but adherent really means sticky as an adjective and follower as a noun. Is a patient who takes his meds “sticky” or a “follower”? The difference between the two definitions, compliant and adherent, is minor at best.

Who decides these things anyway? I don’t remember this being discussed anywhere.

This phenomenon is not unique to the US. Public health workers in the UK were recently informed that the use of the word “obese” could be viewed as derogatory by obese people. The workers were told “that patients may respond better if they are encouraged to achieve a ‘healthier weight.’” The full story is here and is worth reading if only for this amusing mixed metaphor uttered by an opponent of the UK advice, “If you beat around the bush then you muddy the water."

There is research on this subject. A 2012 paper from the journal Obesity [soon to be renamed “Healthier Weight,” I guess] describes a survey of a lot of people whose weight formerly would have been termed obese but now should properly be called unhealthily weighted. The term fatness was rated as significantly more undesirable than all others and excess fat, large size, obesity and heaviness were rated as significantly more objectionable than the remaining terms, such as weight problem, BMI, excess weight and the best of all, weight.

It’s not clear how just describing someone as “BMI” or “weight” will get the message across, but then I didn’t perform the study.

Question: what do you do with a person who needs to achieve a healthier weight but is non-adherent?

This post appeared on Sermo yesterday and attracted 28 comments. As you might expect, most did not like the idea of politically correct terminology.

Proposed ban on large sized sweet drinks in New York is hypocritical & likely to fail

New York City’s Mayor Bloomberg has proposed a ban on the selling of sugar-containing drinks in containers larger than 16 ounces in all types of eating establishments including street vendors, movie theaters, delicatessens and even stadiums. The purpose is to limit sugar intake and theoretically help people lose weight by saving them from themselves.

The plan has received mixed reviews with some calling it a “nanny state” action. Also since a consumer can buy more than one 16 ounce bottle at a time, detractors point out that the truly motivated sugar addict will not be deterred. Supporters say that anything that limits sugar consumption is good. A recent poll shows that slightly more than half of New Yorkers think the idea is bad.

I don’t think it will have any impact on the general public at all. There is no proof that obesity is related to the size of a drink container. One wonders if the mayor is simply grandstanding.

But more importantly, the mayor could have far more influence if he addressed something he can control. That is the selling of sweetened sodas and junk food at the 11 acute care hospitals owned and run by the city serving mostly indigent New Yorkers.

On nearly every floor of the city owned hospitals, vending machines are stocked with mostly non-nutritious snacks and sodas containing sugar. Cafeterias and coffee shops feature similar fare.

If the mayor wants to do something constructive about obesity, he should mandate that his hospitals lead the way and stop giving obese patients and those with diabetes access to products that are not good for them. It makes no sense to counsel a hospital patient about a diabetic or weight-loss diet and then provide that same patient a vending machine full of junk 100 feet from his hospital room.

While he’s at it, the mayor should ban the sale of junk food and sodas in the more than 40 other private and not-for-profit hospitals in the city’s five boroughs.

That would be a real obesity prevention program, not a publicity stunt.

Why is the attrition rate of general surgery residents so high?

The cumulative attrition rate of general surgery residents has been holding at about 20%, a figure that has been steady for nearly 20 years. This figure is higher than that of most other medical and surgical specialties.

The institution of the 80 hour work week was heralded as a solution to the problem of attrition. Students who in the past wanted to be surgeons but had shied away from surgery were thought to be more likely to enter the field. The presumption was that in the old days, surgery was considered daunting due to the excessive number of hours worked.

If the attrition problem was just about the hours worked, one would expect the attrition rate to be less now; so far, it is not so.

The latest study of this problem points out that attrition occurs early in the course of training and is not related to the gender of the resident or any other specific factor.

So why do so many surgical residents drop out or wash out?

I believe a major cause is that medical students do not understand what surgical residency training is really like. In some schools, third-year clerkships are as short as 4 to 6 weeks, and part of that time may be devoted to clinic or subspecialty rotations.

Many medical schools limit the amount of night call that a student is required to take to one night per week with the proviso that the student is only to be awakened if something interesting is happening on the service. Some schools define night call as ending at 11:00 p.m.

Limited exposure such as this gives the students an unrealistic picture of what a surgical residency is like. This can result in disillusionment when the prospect of 4 years of real general surgery residency hits home. [I am counting only 4 years because the new Accreditation Council for Graduate Medical rule limiting first-year trainees to a maximum of 16 consecutive hours of work will simply postpone the problem for a year.]

An interesting paper from 2006 noted that a significant number of applicants to general surgery residency programs were “relatively uncommitted” to the field of general surgery compared to applicants to other surgical disciplines.

The combination of unrealistic expectations and lack of commitment leads to residents resigning or performing poorly.

This problem has implications for both the program and the departing resident. When a resident leaves a program, a competent replacement may not be easy to find, and the departing resident often finds he has wasted a year or more of his life because he often ends up in a non-surgical specialty.

True to my style, I am good at pointing out problems but not so good at finding solutions.

What do you think?