Friday, April 27, 2012

CME is a joke

I know it’s a good idea for us docs to participate in continuing education. What physician doesn’t understand that graduating from medical school/residency training is just the beginning of a life-long educational journey? And hospitals and states require CME for maintaining privileges and licenses.

But here’s the problem. With the possible exception of courses during which you learn a new technique [but be careful if they are industry sponsored], most CME activities are useless. A recent meta-analysis of the value of CME showed that physician effectiveness and patient outcomes are not influenced much by CME activities. Another two studies [here & here] showed that the didactic session, the most frequently used CME method, is the least effective at changing physician behavior. Samuel Johnson said it 200 years ago: “Lectures were once useful; but now, when all can read, and books are so numerous, lectures are unnecessary.”

There’s also the problem of assessing the knowledge acquired at a didactic session like a lecture or paper presented at a conference. Most society meetings or congresses just mandate that you sign in. You could be sleeping, daydreaming or surfing the Internet on your smart phone while sitting in the audience.

For an interesting take on the worthlessness of medical conferences, read an editorial by John Ioannidis in JAMA [subscription required for full text]. Another interesting [and free] link is to a blog by Richard Smith, former editor of the BMJ, who describes his adventures at a cardiology congress in Dubai with typical British humor.

What about so-called “tested” CME as required by many boards for maintenance of certification? The American Board of Surgery requires the completion of 90 hours of CME every three years, and as of July 1, 2012, 60 of those hours must include a “self-assessment activity,” otherwise known as a test.

You can obtain 48 hours of tested CME per year by answering questions found at the back of the Journal of the American College of Surgeons. That sounds challenging until you realize that of the four articles that the CME test encompasses, two sets of questions are accompanied by the answers. For the last issue, I was able to answer the questions for the other two topics without having read the papers.

The topics of papers chosen for the CME test [transplantation, hepatectomy, rat surgery, etc] are not what the average general surgeon is interested in. The principles of question construction are not followed. The questions appear to be made up as an afterthought. The exercise satisfies the letter of the law, but that’s about all.

The current state of the art in CME serves to do two things.

1. Placate the general public and regulators, both of whom assume that CME must be beneficial.
2. Make a lot of money for the conference sponsors and the travel and hotel industries.

What do you think of CME?

Thursday, April 26, 2012

Docs are not happy: Medscape’s survey of physicians

MedScape recently surveyed over 24,000 US physicians regarding their compensation. In general, incomes are down somewhat since the 2011 survey. Most news outlets focused on the finding that only 11% of doctors considered themselves “rich,” which was not defined. Many docs pointed out that although their incomes were high, they had many expenses and debts.

Not receiving any notice were some other interesting results.

Only 54% of the respondents said that they would choose medicine as a career if they had a chance to “do it all over again.” Think about that. How sad. Anecdotally, I know a lot of unhappy doctors, but for almost half to admit that they made a poor career choice is shocking. Only 41% would choose the same specialty, and a mere 23% would practice in the same setting.

Another outcome of note is that of satisfaction by specialty. With 64% saying they were satisfied, dermatologists led the list. Specialties which had fewer than 50% of their ranks expressing satisfaction were the core groups, family medicine, internal medicine, obstetrics/gynecology and my own specialty, general surgery. Fewer than half of the general surgeons would choose medicine as a career again or general surgery as a specialty.

These findings will likely not be cited by medical schools looking to recruit applicants, who apparently don’t read surveys like this anyway. It’s not very flattering for most specialties either. How bad is it when even one-third of the dermatologists aren’t satisfied? So-called “organized medicine” will ignore all of this as they have done for years. The government will continue to put the squeeze on.

I’ve said it before; the future of medicine is indeed bleak.

Tuesday, April 24, 2012

TSA “Security Theater” becomes “Theater of the Absurd”

Three recent events serve as stark examples of the ridiculous level to which the Transportation Security Administration has sunk in its elaborate charade in the name of stopping terrorism.

Let’s start with a visual. This photo shows a TSA security pat down being conducted on an unlikely terrorist [Syriana notwithstanding], actor George Clooney. How silly can it get?

The next two episodes aren’t silly.

A 4-year-old child was fingered as possibly smuggling a gun to her grandmother, who needed a pat down after setting off the metal detector twice. The child had passed through the detector without incident. She went to where her grandmother was sitting and gave her a hug. Because of that, the child was identified as a “high-security” threat and frisked while sobbing hysterically. Remember, she had already gone through the metal detector. She was wearing leggings and a short-sleeved shirt. I suppose she could have been hiding a non-metallic gun in her rectum, but how big a gun could it have been? She was already inside the secure zone anyway. At least a body cavity search was not done.

The third case involves a 95-year-old retired Air Force officer and his 85-year-old friend, who both set off the metal detector due to joint replacements. Pat downs were deemed necessary. The man had $300.00 in bills and potentially incendiary Kleenex in his pocket and was asked to put the items in a bin so they could go through the X-ray scanner. After he was thoroughly searched, the money had gone missing. The entire scenario took over an hour and the pair nearly missed their flight. The TSA has yet to provide an explanation for what happened to the two travelers and their money. Oh, the security tapes were “too blurry” to be of use.

Is there no end to the madness? Couldn’t the personnel and resources wasted on these embarrassing incidents be put to better use?

Here's a similar rant of mine about the TSA from 18 months ago. Nothing has changed.

Acknowledgement: Thanks to @drval and @David_Dobbs for alerting me to the third case.

Monday, April 23, 2012

Read the entire paper not just the abstract

Here is a paper touching on two of my favorite subjects, robotic surgery and misleading abstracts.

It is entitled “Overcoming the challenges of single-incision cholecystectomy with robotic single-site technology” was just published ahead of print in Archives of Surgery. It is a study of 100 robotic single-incision cholecystectomies done by five Italian surgeons.

The conclusion of the abstract:

Da Vinci single-site cholecystectomy is an easy and safe procedure for expert robotic surgeons. It allows the quick overcoming of the learning curve typical of single-incision laparoscopic surgery and may potentially increase the safety of this approach.”

From the full text of the paper, here is a summary of the results of a survey of the five surgeons who participated in the study.

Rating single port insertion technical issues using a scale of 1 to 5 with 1 being easy and 5 being difficult, one surgeon rated it a 2, two said 3 and two said 4.

Regarding the ergonomics of robotic single-site vs. standard laparoscopic 4-port cholecystectomy, two surgeons rated robotic worse and three said equal.

Comparing robotic to standard laparoscopic 4-port cholecystectomy, all five surgeons said robotic surgery was more difficult.

All five surgeons said the robotic procedure was safe based on their having performed a mean of 18 cases with a range of 12 to 42 cases.

The mean duration of the surgery was 71 minutes, which does not compare favorably to an operative time of 40 minutes from series of 238 single incision non-robotic laparoscopic cholecystectomies reported in the Journal of the American Collegeof Surgeons in 2010.

The authors state, “None of the considered [operative] times (total time and each of its main components) appeared to significantly decrease with the number of patients operated on." How is this statement reconciled with the “quick overcoming of the learning curve typical of single-incision laparoscopic surgery” mentioned in the conclusion of the abstract? No such comparison was included in the paper.

This abstract of this paper, much of which is a survey of only five surgeons with a modest experience in robotic single-incision cholecystectomy, is misleading. The paper itself suggests that compared to standard laparoscopic surgery, robotic single-incision cholecystectomy is less ergonomically comfortable, more difficult and takes longer. To say it is safe based on a series of 100 cases is premature at best.

For previous posts on robotic surgery, see the label to the right of this post.

Here is a previous post on misleading abstracts: "Reading an abstract vs. reading an entire paper."

Friday, April 20, 2012

Jury duty? I'll gladly serve

Not long ago, I was called for jury duty. Although I was busy, I consider jury duty to be part of my civic responsibility and I did not try to avoid it. Well, another reason is that in my state, it is just about impossible to get out of at least appearing for a day of jury selection.

I was interviewed for three potential cases. Two were malpractice cases for which I regret I was excused from serving on faster than you can say, “I object.” The third case involved a lawyer whom I knew personally. That turns out to be an automatic exclusion.

I’ve decided that in order to fulfill my obligation, I am going to volunteer to serve. Here are three cases that have yet to be tried. I would be happy to sit on a jury for any of them.

Case 1. An 83-year-old woman is suing for $1 million because she walked into a glass door at an Apple store and broke her nose. You read it correctly. She’s 83 and thinks her nose is worth $1 million. [LINK]

Case 2. A woman is suing McDonald’s and one of its franchisees because she says the company forced her into prostitution. She blames low wages and the fact that the franchise owner, now her ex-husband, coerced her into becoming a prostitute at the Chicken Ranch in Nevada. She says McDonald’s didn’t have a proper grievance policy and "failed to conduct a due diligence into the moral character of [the franchisee] when it sold franchises to him." By the way, this all occurred in the 1980s. [LINK]

Case 3. A 28-year-old prison inmate is suing the hospital in which he was born for circumcising him. According to the article about this, he just found out he was circumcised and says that the procedure “robbed him of his sexual prowess.” In addition to monetary damages to the tune of $1000, he is asking that his foreskin be replaced. [LINK]

I am hoping to be picked for the third case as it involves surgery.

Are there any other cases for which you would like to be among the jurors?

Thursday, April 19, 2012

Helicopters & trauma patients: JAMA paper deconstructed

Twitter and the media were abuzz with reports of the paper in this week’s JAMA that found a 1.5% survival advantage if trauma patients were transported by helicopters rather than ground ambulances. The headlines were sensational and misleading.

LA Times: Trauma patients more likely to survive if rescued by helicopter
MSNBC: Helicopter beats ambulance for trauma patients
US News: Helicopter Beats Ground Transport for Trauma Victims: Study
Scientific American: Helicopters Save Lives for Serious Trauma Victims

What I am going to do is point out the many flaws in the paper and give you some information about the other side of the story. As is true of nearly all papers, you should read the full text, not just the abstract.

The paper looked at outcomes for 61,909 trauma patients transported by helicopter and 161,566 patients were transported by ground ambulances. Although the unadjusted results showed a higher mortality rate for those transported by helicopter, they were also more seriously injured. The adjusted mortality rates favored the helicopter by a statistically significant but small 1.5%. The number needed to treat was 65 to save 1 life and the cost for saving 1 life was estimated at $325,000, the same figure as heart surgery.

The authors used the National Trauma Data Bank [NTDB] as their source. More than 900 of the 6000 or so hospitals in the US voluntarily contribute data. Although the NTDB is said to contain more complete data than in prior years, some issues remain.

For example, the paper started with records of more than 1.8 million patients. Various appropriate exclusions, such as restricting the analysis to seriously injured patients, whittled the number down to 978,000. Over 115,000 records were then excluded because information about their method of transportation was not reported. More than 102,000 patients not treated at Level I or II trauma centers were omitted too. Of the patients included, some 38% were missing more than 40% of the data that was supposed to have been submitted. Remember, this is the so-called “improved quality” NTDB data.

This was a retrospective study and the authors point out that no accepted nationwide guidelines for first responders on the ground to call in a helicopter exist.

The cost analysis was done using information from the state of Maryland, which uses state police helicopters. At $5000 per flight, it is one of the least expensive medical helicopter services in the nation. Other cost estimates range from $5000 to well over $15,000 per flight. And some studies have shown that nearly half of all patients transported by helicopter are not even admitted to the hospital. The costs of those flights, had they to be included in the calculation, would certainly increase the cost per life saved.

There is also the issue of medical helicopter safety. Many crashes occur every year with several resulting in the deaths of patients and crew. [National Transportation Safety Board Report, page 32].

Should the safety record and the number of patients unnecessarily transported by helicopter be considered in the number needed to treat?

The authors mentioned several limitations of their study including the following:

They imputed [translation: made up] data for variables where data was missing in no more than 20% of the records. There is selection bias because hospitals submitting data to the NTDB are likely doing better than those which do not submit data. It is unknown whether the modest survival improvement is due to the helicopter or the fact that helicopters are usually staffed with MDs, nurses and advanced paramedics as opposed to paramedics and EMTs on ground ambulances.

The literature is replete with papers stating that helicopters do not increase survival rates. In fact one that was presented at the American Association for the Surgery of Trauma just appeared last month in the Journal of Trauma. Other than prehospital time which is significant longer for helicopter patients, there were no differences in any parameters including survival.

In the discussion of this paper, a well-known trauma thought leader, Dr. Ken Mattox, said, “So my question is, is it time for the ROC [Resuscitation Outcome Consortium] or this organization [AAST] or organized medicine to take the power of our convictions and our evidence and make a policy statement on this very expensive advertising mode that does not really alter outcomes?

Bottom line. The study left out almost as many patients [mode of transport unknown and those not taken to a level I or II trauma center] as it included. Many of the patient records include in the study had missing data. The cost per life saved was calculated to be as favorable as possible and did not include the substantial costs of unnecessary flights. The abysmal safety record of medical helicopters was not mentioned. The helicopter may not be the factor leading to the modest [1.5%] increase in survival rate, but rather it may be the way they are staffed.

How do the headlines look now?

Wednesday, April 18, 2012

More robotic surgery overkill (with video proof)

Symptomatic sialoliths, or salivary duct stones, are relatively uncommon, occurring at a rate of 27 to 59 cases per year per million population. Most can easily be treated with hydration, local heat, “milking” the duct, and sialogogues [things that increase secretion of saliva] such as lemon drops.

When stones require intervention for removal, many choices are available such as lithotripsy, wire basket retrieval via fluoroscopic- or endoscopic-guidance or operative stone removal through the mouth.

Surgery is remarkably successful. One study from 2001 found that utilizing operative trans-oral surgery, over 90% of patients were rendered asymptomatic with few complications including a < 1% rate of lingual nerve injury. Another study showed that this surgery was curative 85% of the time.

Here’s a case report in the journal Laryngoscope that describes extracting a large sialolith using the da Vinci robot. It has an accompanying video [found under the “Supporting Information" tab] which shows the robot in action along with a regular [non-robotic] forceps and suction. Human fingers are seen placing a stent into the duct. The duct is then sutured closed using the robot again.

Since the standard surgery is done via the mouth, there is no scar. Standard surgery is  nearly always successful and has a low complication rate.

It’s difficult to appreciate just how the robot makes this simple surgery better.

Similarly, a hospital in Iowa live tweeted its first robotic cholecystectomy. They didn’t live stream the video of the surgery [that takes guts] but posted a heavily edited video on its website. [Update 9/27/12: the link has been removed by the hospital.]

A new link features a 1 minute video on the benefits of single incision robotic cholecystectomy with a claim by a surgeon that there are fewer hernias using this technique. This has not been supported by the literature which has suggests that the opposite is true.

The surgery took about 50 minutes, not counting the docking time for the robot. Two surgeons were engaged for the entire procedure. Surgery for a small gallbladder like this with no inflammation should have taken 30-35 minutes and could have been done by a surgeon assisted by a physician assistant, a scrub tech or a nurse.

Again, it’s hard to see how this is progress, since standard laparoscopic surgery is so routine now.

Friday, April 13, 2012

Questions on my mind

These things have been bothering me lately.

Why do you have to be at the airport two hours before an international flight? It shouldn’t take two hours to check to see if you’re on the “No Fly” list. Do the baggage handlers need that much time to steal the valuables from your suitcase?

Why can pilots, who sit right next to the avionics, use iPads on planes during takeoff and landing and I can’t? If iPads cause disruptions to sensitive airplane systems from Row 38, they must really wreak havoc from the pilot’s seat.

What does Microsoft do with the error reports they receive? I think the programmers at Microsoft sit around and laugh at the fools who send in these reports.

Why does the “Alternative Minimum Tax” sound like a good thing but actually is not so good? Having just paid it, the “minimum” part doesn’t seem so minimal to me.

Will the “Affordable Care Act” be affordable? I don’t think so.

Who made the rule that says a multicenter randomized controlled trial has to have a catchy acronym? If I see one more cutesy study acronym that is the result of a forced, artificially awkward series of words, I’m going to scream (or blog).

Why is it called “Meaningful Use”? Is it really meaningful? Or useful?

Why is gasoline the only item priced in 9/10 cent increments? I have no idea. It has been this way as long as I can remember.

How is it possible that someone could have a 2-inch long hair growing out of a nostril and not notice it?

Do you have any questions? Or answers?

Wednesday, April 11, 2012

Robots attack America, but Canada not so much

As of December 2011, 1548 surgical robots have been sold and installed in the United States as opposed to 16 in Canada.

The estimated population of the U.S is 313,388,000 and for Canada, 34,764, 600.

Canada has a population that is 11.1% of the U.S. population but Canada has only about 1% as many robots. Or put another way, Canada has 1 surgical robot for every 97 robots in the U.S.

California’s population is 37,691,912, which is about 3 million more than the population of Canada, but California, with 114 robots, has seven times as many robots as Canada.

Here are some more numbers.

Price of the surgical robot: $1.0-2.3 million
Cost of instruments and accessories per procedure: $1300-2200
Annual service agreement: $100,000-170,000 per year.

As the saying goes, “You do the math.”

Data and figures available here.

Tuesday, April 10, 2012

Medical school tuition. Follow the money?

You may have missed this New York Times story from the other day. For several years, St. George’s University Medical School has been paying New York City’s public hospitals to teach its third- and fourth-year students. Now the school has established a scholarship fund that it will use to try to entice its students to train as primary care physicians and work in the city hospital system.

St. George’s also is offering the public hospitals more money if they will allow more St. George’s students to do their clerkships at those institutions.

So, you say, what’s the problem? It seems that New York City’s medical schools are upset about all this.

Here’s an excerpt from the Times article: “The deal seemed likely to increase friction with the New York City area’s medical schools, which have already complained that St. George’s is squeezing out their own students because it is willing to pay for clinical training. That training has traditionally been perceived as part of the mission of teaching hospitals, to be offered without charge.”

To clarify this. Medical schools like Cornell, Columbia, New York University and Mount Sinai must farm students out to other hospitals because their main medical school hospitals cannot provide enough clinical material for the number of students they have in each class. These venerable schools, with tuitions & fees of nearly $50,000/year, do not pay a single penny to the affiliated hospitals or their teaching physicians. In fact, the hospitals actually pay for the privilege. It’s about the prestige.

We are talking about 50% of a medical student’s tuition over four years. Let’s do some math. Let’s say 150 students at $50,000/year. That’s $7,500,000/year or $15,000,000 for the two years. That does not count the fees that the affiliated hospitals pay the schools.

Note please that this situation is not limited to New York City. To the best of my knowledge, almost all U.S. medical schools have similar arrangements with affiliated hospitals.

A recent editorial in JAMA called for shortening the length of medical school by a year. Somehow I don’t see that happening soon.

Question: Where does that tuition money go?

Monday, April 9, 2012

Paying for medical care

While we anxiously await the decision of the Supreme Court on the Affordable Care Act, let me offer you three thoughts.

1. Health care for all is only possible if those of us who have money and jobs pay for those who do not.

I love it when people say, “Let the federal government pay for it.” Who do they think funds the federal government? Ditto for “Let the states pay for it.”

What about “cost shifting”? Put a surcharge on health insurance so that the extra money can go to those who cannot afford to buy health insurance. Don’t look now, but that means that those who have the money to buy health insurance will be paying for those who do not.

How about mandating that corporations contribute a percentage of their profits to a fund that supports health insurance for the needy? That will make the price of everything that corporations sell rise, shifting the burden back to those who have money to buy those things.

2. An old axiom in business is appropriate for health care too. It goes like this, “You can have affordable health care, access for all and high quality, but you can only have two of the three.” There is no way that everyone can have every test for every disease.

For example, many guidelines suggest that everyone over the age of 50 should have a colonoscopy. According to the last census, there are 40 million people in the US over the age of 65. Can Medicare pay for 40 million colonoscopies? Even if it could, there are not nearly enough qualified colonoscopists to do the job.

3. According to Supreme Court Justice Elena Kagan, “You are entitled to health care when you go to an emergency room, when you go to a doctor, even if you can't pay for it.” [See page 74.] If you want to have a little fun, mention this in a roomful of physicians.

Maybe Justice Kagan can tell us how we are supposed to pay our rent, malpractice insurance, office staff, workers’ comp, other benefits etc, if we see patients who can’t pay? Oh, universal health insurance? See #1 above.

What do you think of my three thoughts?

Friday, April 6, 2012

Antibiotics instead of surgery for appendicitis? I don’t think so.

Like the villain in a bad horror movie, the idea of treating appendicitis with antibiotics refuses to die.

A meta-analysis published yesterday on line in the British Medical Journal claims that treating uncomplicated appendicitis with antibiotics is better than surgical appendectomy. Four studies involving 900 patients were included in the paper. [Full text here.]

Treatment with antibiotics was said to have resulted in fewer complications [relative risk reduction of 31%] and similar hospital lengths of stay of just over 3 days for each group.

Medical news outlets such as MedPage Today “Antibiotics May Be Enough for Appendicitis,”  Eurekalert “Antibiotics a safe and viable alternative to surgery for uncomplicated appendicitis, say experts” and the BBC “Appendicitis: Antibiotics may be better than surgery” touted the study without much criticism. That will not be the case here.

The authors state, “Diagnosis of acute appendicitis at admission was confirmed by ultrasonography in one study and by computed tomography in two studies, although this was done only in some patients in the study by Hansson et al.” In the fourth study, the diagnosis was based on clinical factors only. Translation: An unknown number of patients in the group treated with antibiotics may not have actually had appendicitis.

There were issues concerning the methods of randomization in the four studies. The paper says, “Randomisation methods were reported as computer generated, external randomization [not explained, my comment], and by date of birth. The randomisation method was not clear in one study.” Date of birth is a notoriously poor way to randomize subjects in a study because the treating physicians can know which group the subject is assigned to before entering him in the experiment. This means that two of the four studies had questionable randomization schemes.

In one of the four studies, almost half of the patients [96/202] in the antibiotic group required appendectomy. And 20% of all patients treated with antibiotics required appendectomy within one year of entry into their respective studies.

The mean length of stay for both treatments was just over 3 days for both antibiotics and surgery. Maybe that is true in Europe where these four studies were done. Only one of those four studies included patients with complicated appendicitis. But here in the US, the median length of stay for almost 17,000 appendectomy patients with uncomplicated appendicitis is 1 day [Advani et al, Am J Surg]. In my personal series of 171 appendectomies during 2009-2011, the mean length of stay for all patients, including those with complicated appendicitis, was 2.4 days with a median of 1 day.

The complication rate comparison raises a “straw man.” The 25% rate of complications for the appendectomy group in the meta-analysis is more than twice that quoted in the series by Advani. Laparoscopic appendectomy results in fewer complications than open appendectomy. One of the studies used in the meta-analysis is from 1995, when very few laparoscopic appendectomies were being done.

The success rates for the two treatments are compared. According to the paper’s Table 2, 58.3% patients were successfully treated with antibiotics vs 92.6% successfully treated with surgery. Unsuccessful surgical treatment is defined as removal of a normal appendix.

The recurrence rate of appendicitis in those who underwent surgery was 0.

If I proposed treating you with drugs that had a 58.3% rate of success in curing your illness for one year with the possibility that you could still suffer another attack of the illness two or twenty years later, would you choose that treatment? Or would you opt for a treatment which would keep you in the hospital for less than 24 hours with no risk of recurrence of the problem?

Sticks and stones ...

The New York City Department of Education wants to ban some 50 words from appearing on standardized tests because the words might upset some students. The story apparently first came to light via the New York Post, but Google “New York banned words” and you’ll see lots of coverage and comment.

You can see the complete list here. To give you an idea, I’ve selected a few of the more interesting entries for comment.

Alcohol, tobacco, or drugs—I suppose they get enough about those topics after school anyway.
Birthday celebrations and birthdays—On the list because some religious groups do not celebrate birthdays. Being of a certain age, I don’t like these words either.
Celebrities—Is just the word “celebrities” to be banned or is it about mentioning the names of specific celebrities? Either way, I’m all for it.
Dinosaurs—We wouldn’t want them to learn about that subject or be tested on it now, would we?
Disease—Said to be banned because it might upset students who have family members who are sick.
Evolution—See Dinosaurs
Halloween—A dangerous topic for young minds.
Junk food—Interesting in light of all the talk about an epidemic of obesity.
In-depth discussions of sports that require prior knowledge—How would one ask about this on a standardized test anyway?
Sex—Take care of that on your own time.
War and bloodshed—So students can’t be asked about war on a test? That’s going to shorten history class a lot. And how are the kids going to learn about stuff like when the Germans bombed Pearl Harbor?
Weapons (guns, knives, etc.)—See sex

It looks like New York City has taken the “Nanny State” concept to new heights. What do you think?

This post appeared on Sermo yesterday.