Whatever happened to personal contact?

Not long ago, I attended a retirement party for a former colleague. He had been a surgeon for 43 years at a hospital where I was once chairman of surgery. A number of old friends and colleagues whom I hadn’t seen for a long time were there. The event was so enjoyable that I said to the guest of honor, “This is a great party. You should retire more often.”

Later that evening, my wife, who is noted for profound observations, remarked that it is too bad that we don’t see people in the same way anymore. She pointed out that although we interact electronically in so many ways, we aren’t as personally connected to many of our friends and acquaintances as we once were.

That led to a discussion of the atmosphere permeating medicine today. Back in the day, physicians used to socialize more. In most hospitals, there were doctors’ dining rooms or designated tables in the cafeteria where a rolling group of docs from many disciplines would have lunch and chat about difficult cases, the hospital administration, politics and many other topics.

There’s no longer a need for such things since no one has time for lunch nowadays and the hospitalist movement has succeeded in eliminating the primary care doctors from the hospital environment. I have been practicing at the same hospital for over three years and have never even met 95% of the local primary care docs.

Something is lacking when you aren’t able to attach a face to a name.

Are these are just the ramblings of an older doctor longing for “the good old days”? Or is this another reason why a lot of us don’t enjoy practicing medicine as much as we used to?

Reflections on retirement

As I contemplate retirement from clinical practice as a general surgeon, something I've been doing for over 41 years including residency, I've been having some unsettling thoughts.

Like many physicians, I've tried to stay somewhat emotionally detached from my patients. You must maintain some distance in order to be able to make tough decisions and to keep on doing surgery for so long.

I have written in a previous blog about the effect of complications on the psyche of a surgeon, realizing of course, the patients and their families suffer even far more than I do. I’ve always taken complications personally, but lately I’ve been more acutely aware of this issue.

As I reach the end of my career, I find myself empathizing more and more with the plight of my patients, especially since many of them have somehow become younger than I am.

 

There are things you don’t think about when you are 40 or even 50 years old. I find myself making a long mental list of diseases that I hope I never get. Lately, I've been pondering a real conundrum. Which is worse, growing old and becoming demented with a body that still has many miles left on the odometer, or having the body break down and remaining lucid enough to realize what a mess you are in?

 

I haven't settled that issue yet but I'm leaning toward dementia as long as I'm pleasant. Unfortunately having been a cranky bastard for pretty much my entire life, I think I'm more likely to be a disagreeable if dementia sets in, so maybe the sound mind/unsound body option would be a better deal for my family. Too bad they don’t get to choose. Nor do I.

I would prefer neither. In an attempt to postpone physical deterioration, I've been exercising regularly and am in the best shape I can ever recall, including when I was in high school.

If you’ve been following me, you know that for mental gymnastics, I've been blogging about three times a week for the last two years. I plan to continue writing for long as I can coherently put two sentences together.

Perhaps it is the end of summer that has made me melancholy. Or possibly it’s realizing that very soon the way I have defined myself for the last 41 years will no longer apply. Let’s look at the bright side. At cocktail parties, people who used to ask me for medical advice will probably think twice knowing that I’m retired. Instead maybe they’ll start asking when does “its” take an apostrophe.

A version of this post appeared on General Surgery News on 8/27/2012.

Hospital installs hand washing surveillance cameras

Doctors and nurses in the ICU at Long Island’s North Shore University Hospital are being watched by 39 video cameras in an effort to increase compliance with hand washing. According to a report hand washing compliance is up from less than 10% to 90% since the program started.

Cameras are positioned near the doors of patient rooms and at sinks Patients are not being videoed. The real-time feed is observed by workers in India. Staff failure to wash hands is noted, and the results are posted on electronic bulletin boards in the unit. So far, miscreants are simply talked to.

"No one's been fired, no one’s been written up but there have been one-on-ones," the news story says and, “Infections have decreased though an exact percentage was unavailable.” That raises the question of how they would know if infections have really decreased if the exact percentage is unavailable. And there’s another question, “Is the decrease statistically significant?”

This venture, while well-intended, seems like a bad idea to me. I suppose you are thinking, “Could Skeptical Scalpel really be against hand washing?” Well, I’m not. But what seems logical and correct sometimes may not be. For example, everyone knows that sinks with faucets that have electronic eye sensors are cleaner and better to use in hospitals than sinks with manual faucets, right?

A study presented at a meeting of the Society for Healthcare Epidemiology of America last year by a group from Johns Hopkins concluded the following: Electronic faucets were more likely to become contaminated with Legionella spp. (species) and other bacteria after water system disruption. Electronic faucets were less likely to be disinfected after chlorine dioxide remediation. Electronic faucet components may provide points of concentrated bacterial growth. These findings led to removal of all electronic faucets from clinical areas in our institution. [Emphasis added.]

Washing hands with soap and water may cause dryness and irritation resulting in skin breakdown. It may be that constant, obsessive hand washing and use of gels could promote the emergence of resistant organisms.

Another potential issue with the video observation is a false accusation of failure to wash. Patient rooms and patients themselves are not being watched. Let’s say a nurse went into a patient’s room to tell him something and didn’t touch anything. A person in India watching a video from a camera focused on a door or sink would not be able to tell that. If the nurse doesn’t wash her hands when she leaves the room, is she going to be cross-examined?

And what about cost? How much does it cost to install and maintain 39 video cameras, stream the video to India and pay people there to watch the monitors and feed back the information 24 hours per day? Remember, they have no proof that video surveillance reduces infections.

What does this scheme say about the relationship of the professional staff to the hospital’s administration? More problematic is the fact that even though they know they should, doctors and nurses at a major medical center apparently cannot be trusted to wash their hands unless they are spied upon. What else do they not do?

Instead of issuing press releases about this ill-advised program, hospital management might want to consider investigating why their staff is non-compliant.

Civility is Disappearing. Why?

A while back, USA Today reported on the declining civility on college campuses citing numerous anecdotes such as Yale women taking offense at frat boys shouting sexist slogans, the online video resulting in a Rutgers student's suicide and a UCLA student's YouTube rant against Asians.

There is a bigger issue which is the decline of civility in general. For example, political discourse is at an all time low on the civility scale.

It may not have started on the Internet, but it certainly serves as a convenient platform for incivility.

Take the USA Today story mentioned above. If you look at it on-line, you will find numerous malevolent comments, many of which have nothing to do with the story itself but rather are directed toward previous commenters, including the following:

What's it like to go through life with no IQ like you do?

Would it be asking too much to put a verb or semicolon in a sentence?

The best thing these idiotic "scholars" can do for America is volunteer to go to Afghanistan and clear minefields by walking across them. Of course, in that they're not patriotic, they won't...

These sissy-chicks (all liberals, of course) make real women look bad. Go back to your mommies and leave normal people alone.

Encourage respect and tolerance? Why is it these LEFTIST professors NEVER encourage respect and tolerance towards individuals promoting a CONSERVATIVE viewpoint. Instead, they try to CENSOR any political viewpoint that is not in LOCKSTEP with their LEFTIST AGENDA. HYPOCRITES!!!!!

WELL, IN THE NAME OF FREE SPEECH I WILL FIGHT BACK IF SOMEONE START TELLING ME UGLY OR RACIST NAMES. I HAVE PLENTY OF AMMUNITIONS SO WE'LL SEE WHO GAVE UP FIRST.

I agree with many who say it is about the anonymity that the Internet provides. As one of the more coherent commenters pointed out, many of the rants would not have been made if real names had to be used. As a by-product of the decline in civility comes a decline in grammar, spelling and punctuation.

This trend has infected Sermo, a doctors only on-line community, as well.

Here are two excerpts from comments on a post of mine on Sermo from three weeks ago:

A surgeon: Also no need for me to see the film or examine the patient, although of course I did both, you ass.

A radiologist: Well, it seems, surgeon, if you have a radiologist who cannot tell "worsening bilateral pneumonia" from atelectasis, you are working in a hospital with perhaps suboptimal radiologists. As for the "you ass" part, FUCK OFF pissant.

I doubt that exchange would have taken place in the cafeteria or the doctors' lounge.

What do you think? A version of this post appeared on Sermo yesterday and the few who commented all felt that civility is declining and most agreed that the Internet was fueling that decline.

Plastic surgeon in trouble for aggressive billing practices

There’s a big Internet dustup about a California plastic surgeon who is being sued by the state to stop her aggressive billing practices. The state medical board is investigating her for possible illegal balance billing and may remove her medical license.

The LA Times ran a story documenting the plight of a patient who cut off the tip of a finger. In the emergency department, he requested the services of a plastic surgeon. The doctor saw the patient and had him sign an agreement to pay for what she was about to do.

It is not clear exactly what was done in this case, but apparently, all the work took place in the ED. The surgeon billed the patient $12,630.00 and received $3500.00 from the patient’s insurance carrier, which she refused to accept. She billed the patient for the entire amount and sued him when he didn’t pay. She also started a process to force the patient to sell his house in order to pay her.

Some doctors are defending the surgeon. For example, the blog White Coat Call Room said, “Suing a doctor and trying to revoke her license because she wants to get paid the asking price for her services? If people don’t want to pay her price, then don’t use her. Go see another ‘professional.’”

The LA Times article was posted on Sermo [free registration required & restricted to licensed MDs] and has yielded over 280 comments, a large majority of which are sympathetic to the surgeon.

There’s a lot more to this than you think.

Some have pointed out that patients often request a plastic surgeon unnecessarily. I agree with that. But such consults are often instigated by the ED staff and no discussion of costs or fees ever takes place. I spent 24 years as a surgical department chairman fielding complaints about this sort of case from both patients and surgeons.

Although the patient may have agreed to pay the surgeon, it is not clear from the LA Times account that he was made aware of what the fee would be before signing.

Some have suggested that because the surgeon was “out of network,” she could bill whatever she wanted to. Nonsense. She was covering the ED. She had an obligation to treat emergencies. Fees must be reasonable.

The fee of over $12,000.00 is outrageous for any procedure done in an ED and particularly for what seems to have been a simple fingertip repair. The $3500.00 payment from the patient’s insurance company seems quite generous to me.

The surgeon has a pattern of this behavior having filed more than 50 breach of contract lawsuits since 2010.

Most damning of all, the LA Times notes, “She attended law school at UC Berkeley, though she is not licensed to practice law in California.” Too bad. She would be a great lawyer.

To me, the plastic surgeon is simply greedy.

These are the kinds of stories that make all doctors look bad. Is it any wonder that people resent us and don’t respect us as much as they once did?

Evidence-Based Surgery: What Evidence?

Here is a study that illustrates everything that is wrong with the current status of evidence-based surgical practice.

Many of the standard procedures we perform in general surgery are based on observational studies, expert opinion or my favorite “That’s the way I was trained,” and not randomized controlled trials. Although some such research has been done, subjecting patients to sham operations raises ethical issues and would expose patients to anesthesia unnecessarily.

But some topics could be studied prospectively. A recent paper [Variation in the use of intraoperative cholangiography during cholecystectomy. Sheffield KM et al. J Am Coll Surg. 2012;214:668-79] highlights the problem of insufficient evidence in some areas of surgery.

A group from the University of Texas Medical Branch in Galveston looked at differences in the rates of operative cholangiography in their state. They analyzed data from 212 hospitals in which more than 160 cholecystectomies had been done including almost 177,000 such operations over the 8 years from 2001-2008. The surgeon was identifiable in 89% of cases.

Despite the known pitfalls of basing clinical research on administrative data, several interesting findings of this paper are worth discussing.

Operative cholangiograms were done on 44.6% of the total cohort. By hospital, the operative cholangiogram rates ranged from 6.0% to 98.2%. The breakdown by surgeon was limited to the 706 who had done at least 40 cases. The range of operative cholangiogram use by individual surgeons was 0% to 100% with a median of 39%. Medians were higher for patients with gallstone pancreatitis (69%) and lower for those with acute cholecystitis (25%).

Uninsured patients were only slightly less likely to have operative cholangiography than those who were insured. A puzzling finding was that of those patients who had both ERCP and operative cholangiography, 37% had undergone the ERCP before the cholecystectomy and operative cholangiogram. Why would an operative cholangiogram be necessary after an ERCP had already been done?

The authors found that the variation in rates of operative cholangiography was attributed much more strongly to the surgeon and the hospital rather than the indication for surgery. They concluded that the likelihood that a patient would undergo operative cholangiography depended on the hospital she arrived at and who the surgeons was.

The extent of the variation in the use of operative cholangiography could hardly be greater. It is difficult to believe that there is no agreement on the indications. I don’t think this is unique to Texas either.

The literature is conflicting. One can find multiple papers to support any position. Some claim that operative cholangiography helps prevent common bile duct injuries and reveals unsuspected stones. Others say false positive operative cholangiograms result in more procedures and that most asymptomatic stones discovered by cholangiography never cause symptoms. Surgeons who routinely perform operative cholangiography say it does not waste time while those who don’t do them say it does.

False negatives can occur. I have seen patients with negative operative cholangiograms readmitted within a few weeks because of symptomatic common bile duct stones.

I firmly reside on the low end of the operative cholangiography spectrum. I never perform one unless there is a specific indication as dictated by the liver function tests or a significant question involving the anatomy in the operating room.

A large, well-designed randomized controlled trial would help settle the issue, but it will probably never be done.

Who would sponsor such a study? The companies that manufacture the equipment for cholangiography certainly would have no incentive to fund it. Maybe the best we can hope for is a consensus statement from a group of expert surgeons.

Will it ever be forthcoming?

A version of this post appeared in General Surgery News in June of 2012.

What do interns do when they're on call?

You may be surprised and dismayed when you find out.

A study in the Journal of General Internal Medicine from a VA hospital affiliated with the University of Wisconsin reveals some startling facts.

During a 14-hour call period of 3 pm to 5 am, medical interns spent 40% of their time on computer work and 30% on “non-patient communication,” such as clinical conversations with team members, other physicians and nurses among other things. Direct patient care accounted for a whopping 12% of their time.

What about teaching and learning? Would you believe 2% of the time?

The study was conducted using observers trained in time-motion research. They followed the 25 interns who volunteered for the project, but did not interact with them or influence them in any way. The study was likely much more accurate than most previous research on this topic, which was based on self-reported surveys of house staff.

Other interesting tidbits from the paper were that the on-call intern cross-covered an average of 27 patients per night, which seems like a lot to me. The amount of time spent on “sign out” or “hand offs” was not stated. They averaged 4 admissions per night. Only 93 minutes [11% of the total time on call] were devoted to “downtime,” that is sleeping, eating and recreational computer time.

So it looks like internal medicine interns at the VA in Wisconsin do a lot of “scut work” and don’t have much time for learning or sleeping. With only 4 admissions per night, you would think there might be more opportunity for sleep, but since this was internal medicine, each admission probably took two hours.

The interns in the study worked every fourth night. Ironically, in the good old days when we worked every second or third night, we cross-covered far fewer patients because there were more of us on call each night. Therefore, we got more sleep and were less tired the next day.

When one looks at the small amount of time allotted to patient care and teaching and learning, one is not shocked that many graduates of residency these days are not confident about starting independent practice.

I suspect the results would be similar if surgical residents were observed.

What do you think about this?

A version of this appeared on Sermo yesterday and most agreed that interns are not being properly trained.

Cancer fears raised by newspaper stories

It’s bad enough that every week there’s another study finding germs everywhere. Now it’s chemicals. Here are two recent alarms sounded by reputable newspapers about the problem of toxic substances found on commonly used items.

The LA Times says that Samsonite is recalling 250,000 suitcases because a Hong Kong consumer group found a sample from a side handle “had levels of polycyclic aromatic hydrocarbons higher than recommended in voluntary guidelines.” The substance is apparently a carcinogen.

Deeper in the story is the finding that the consumer group found levels of the chemical that were 1000 times higher than tests run by Samsonite. The company recalled the items “to allay consumer concerns.”

The model in question, called “Tokyo Chic,” [shown above] has a pull-out end handle that is much more likely to be used than the side handle. Also, the story says the high levels of polycyclic aromatic hydrocarbons were found in “a sample.” Really? Was it just one sample? 

Closer to home, the Washington Post headline reads “Don’t Drink The Water: Study Warns Drinking From Garden Hose.” Researchers from an outfit called “Healthy Stuff” studied 90 garden hoses and found high levels of lead and phthalates as well as “PVC plastic additives, which can cause birth defects, liver toxicity, and cancer.” 

The article closes with the suggestion that you shouldn’t drink water from a hose, but if you do, you should let the water run for a few seconds first.

Now, people, with everything we have to worry about in today’s world, are these real problems? Unless you are a member of an airline flight crew, how often do you travel and come in intimate contact with the side handle of a suitcase?

And how often do you feel the need to drink from a garden hose? If you have ever tried drinking from a hose, you know you always let the water run for a few seconds because water that is standing in the hose is usually warm. By the way, that headline “Don’t Drink The Water: Study Warns Drinking From Garden Hose” doesn’t make any sense to me.

Let’s just say that I was able to get to sleep without much worry about these two cancer threats.

Institute of Medicine: Obesity is not caused by lack of willpower

In a 48-page report, the Institute of Medicine “refutes the idea that obesity is largely the result of a lack of willpower on the part of individuals.” [You know the IOM, the same folks who brought you the “98,000 people are killed each year by medical errors” report, the accuracy of which has been challenged.]

According to a spokesman for the IOM, “"When you see the increase in obesity you ask, what changed? And the answer is, the environment. The average person cannot maintain a healthy weight in this obesity-promoting environment."

The report goes on to say, “People cannot truly exercise ‘personal choice’ because their options are severely limited, and biased toward the unhealthy end of the continuum."

Quoting further from an article about this revelation from the IOM, “The panel recommended tax incentives for developers to build sidewalks and trails in new housing developments, zoning changes to require pedestrian access and policies to promote bicycle commuting.”

"We've taken fat and sugar, put it in everything everywhere, and made it socially acceptable to eat all the time. We're living in a food carnival, constantly bombarded by food cues, almost all of them unhealthy," said David Kessler, former head of the U.S. Food and Drug Administration. Maybe Kessler should have done something about this when he was in charge of the FDA.

Are they serious?

Things like this really aggravate me. [Lots of things aggravate me.]

Everyone who drinks alcohol doesn’t become an alcoholic. The IOM says it's not willpower. How is it then that some who are exposed to the same environmental factors and food cues as obese people manage to maintain a normal weight?

How much did the IOM’s 48-page report cost and who paid for it?

Do you think building sidewalks and promoting bicycle commuting will really decrease obesity?

What do you think of the IOM report?

A version of this post appeared on Sermo yesterday. Most of those who commented felt that the IOM was out of touch with reality or al least, mistaken.

Overused Words

While reading the iconic New York Times the other day, I happened to notice that the word “iconic” was used in a few different articles.

The world-wide resources of the Skeptical Scalpel Institute for Evidence-Based Outcomes and Advanced Research were mobilized. Fact checkers swarmed over the Times and discovered that in the last 30 days, the word iconic has appeared 87 times in the paper for an average of 2.9 times per day.

The range of occurrences was 0 (on July 20, July 30 and August 6) to 8 (on August 1, a truly iconic day). The mode, or most frequent number of occurrences per day, was 1, which happened on 10 separate days.

By comparison, the previously unchallenged overused word of the century “artisanal” has only appeared 52 times in the Times during the last 30 days or about 1.7 times per day.

Now I am a mere blogger and am admitted somewhat (artis)anal retentive, but it seems to me that iconic just may have achieved cliché status.

May I suggest that the Times consider removing Iconic from its style book? In my opinion, doing so would increase its iconicity and help to maintain the artisanality of its writers.

Reduced Rate of Infections in Colorectal Surgery: Real or Hawthorne Effect?

There was some buzz last week on medical news sites like MedPage Today, Fierce Healthcare and Science Codex, about a paper from Johns Hopkins describing how the institution reduced its surgical site infection (SSI) rate for colorectal surgery. A multidisciplinary project called the Comprehensive Unit-Based Safety Program (CUSP), involving 36 people including a “team coach” and a hospital executive, began when the SSI rate was 27.3%. After meetings and suggestions for change, they came up with six interventions that they felt would make a difference. They were

• Standardization of skin preparation with chlorhexidine
• Administration of preoperative chlorhexidine showers
• Selective elimination of mechanical bowel preparation
• Warming of patients in the preanesthesia area
• Adoption of enhanced sterile techniques for skin and fascial closure
• Addressing previously unrecognized lapses in antibiotic prophylaxis

In the year following the implementation of the changes, the SSI rate dropped to 18.2%.

Sounds great, doesn’t it? Let’s take a closer look at a few of the interventions.

The issue of chlorhexidine for skin preparation is not quite settled. One of this paper’s own references cites a study which says that povidone iodine use leads to significantly fewer SSIs than did chlorhexidine.

The bowel prep intervention is very confusing. To quote the paper, “In December 2011, the CUSP group reviewed the literature again and decided to change from no mechanical bowel preparation to mechanical bowel preparation with oral antibiotics beginning in February 2012.” This is interesting since the paper was submitted to the journal in January of 2012.

Regarding enhanced sterile techniques for skin and fascial closure (which means they changed gloves and some instruments after the intestinal anastomosis was completed), there is no evidence that doing so prevents wound infections. The only reference they provided was to a book of standards from the Association of periOperative Registered Nurses (AORN), a notoriously non-evidence-based document. [See my previous blog on rules without foundations.]

The lapses in antibiotic prophylaxis involved patients who were allergic to penicillin, a condition that affects only about 10% of the population. There were 602 patients in the study of whom about 60 would probably have been allergic to penicillin. That’s hardly enough to make a big difference in the infection rate.

These policy changes reduced the infection rate of colon surgery from 27.3% to 18.2%. A quick search reveals that in 2010, the colon surgery SSI rate for all hospitals in the state of New York was 5.3%. That’s all hospitals, not just university medical centers. The respected medical resource UpToDate also says the expected SSI rate for colon surgery is 5%.

Despite the well-known effectiveness of 36-person committees (and wouldn’t you have liked to have attended those meetings?), I think there is another explanation for these results. It’s called the Hawthorne effect, which is the name given to the fact that the behavior of experimental subjects changes if they know they are being watched. For example, if you tell the staff of an ICU that there will be changes to the hand washing protocol and compliance will be monitored, whatever the changes are, the rate of compliance with hand washing will increase.

In summary, the authors have turned an abysmal colon surgery SSI rate into a merely bad one by observing it. Medical news sites reported the findings without questioning any of the conclusions. One wonders why the paper is receiving any attention at all or even why it was published.

Vague radiology reports: Can anything be done?

Possible mild peri-appendiceal inflammation. So states a CT scan reading I received the other night.

Here’s another. The findings are concerning for appendicitis.

And another. The appendix is dilated and mildly thick walled with suggestion of mild surrounding inflammatory change, although there is air within the lumen. There is an appendicolith at the base of the cecum. The findings are suspicious for mild acute appendicitis. Clinical and laboratory correlation are recommended. [Digression: You can't diagnose appendicitis with lab tests.]

Even radiologists are questioning the way their colleagues dictate reports. From an editorial in the journal Applied Radiology: The report might say “there appears to be a nodule in the right lower lobe.” If you’re wrong, and there isn’t a nodule in the right lower lobe, you’re covered because you never actually said there was a nodule, only that there appeared to be a nodule, and we all know that nothing is ever as it appears.

Some Stanford researchers looked at radiology reports and found that the most frequent terms used to modify conclusions were probable, consistent with, consider, likely, suggestive, no definite evidence, suspicious, cannot exclude, not likely, maybe and possible. They surveyed radiologists and clinicians and found wide variations in what these words meant to each physician regarding the specifics of whether a hypothetical lesion should be biopsied.

An editorial in the journal Radiology scorned the use of the often-seen phrase if clinically indicated.

I could go on.

Do you know of similar examples of radiologic ambiguity?

Is there a solution to this problem?

A version of this post appeared on Sermo yesterday with interesting comments. About 2/3 of those who voted said there is no solution to the problem. Some commenters said the radiologists are just describing what they see.