Discrediting the paper about discredited practices

According to a study in the August 2013 issue of the Mayo Clinic Proceedings, 146 papers appearing in the New England Journal of Medicine over the first decade of this century contradicted medical practices previously thought to be effective.

The paper's findings were widely publicized. There was talk in the New York Times of inertia hindering change and allowing ineffective treatments to continue for years.

The full text of the paper and a supplement containing a brief summary of all 146 discredited practices are available on line.

I decided to see for myself if any practices relating to general surgery were included in the paper and found 11.

Two of them seemed somewhat debatable to me.

Number 43 on the list was a comparison of open mesh to laparoscopic mesh inguinal hernia repair that appeared in NEJM on 4/29/04. This was the critique:

"A laparoscopic approach to repair inguinal hernias with mesh was thought to have lower hernia recurrence rates and less post-operative pain. This multicenter, randomized trial in a VA population found that the laparoscopic approach led to a higher rate of complications and a higher rate of recurrences when repairing primary inguinal hernias."

It definitively closed the door on laparoscopic inguinal hernia repair. Or did it?

In the 4/30/04 issue of NEJM, letters to the editor pointed out that the laparoscopic recurrence rate of 10% in the VA study was much higher than in other reported series, and the size of the mesh (~8.0 cm) used in the laparoscopic cohort was much smaller than the 10 cm x 15 cm that most experts recommended.

How has the VA paper affected surgeons' choice of technique for hernia repair?

A report from the American Journal of Surgery in 2012 found that as of 2008 at the Mayo Clinic, 41% of inguinal herniorrhaphies were performed laparoscopically.

Looking at national resident case logs data for 2012 from the ACGME, 35% of all groin hernia repairs were done laparoscopically.

Despite having been "discredited" in NEJM, laparoscopic inguinal hernia repair is quite alive and well.

The Mayo Clinic Proceedings paper also stated that preoperative biliary drainage for patients with cancer of the head of the pancreas was discredited by another NEJM paper for 1/14/10. Here is what they said about number 131 on their list:

"Jaundice in surgical patients is postulated to increase the rate of postoperative complications. Many surgical centers have employed biliary drainage prior to surgical intervention for cancer of the head of the pancreas, but there is conflicting evidence regarding its effect on morbidity and mortality. This multicenter, randomized trial found that routine preoperative biliary drainage increases the rate of serious complications without a mortality benefit."

Subsequent letters in the 4/8/10 issue criticized the study because patients were drained for 6 weeks prior to surgery which was not the norm of 2 weeks, patients with bilirubin levels above 14.6 gm/dL who were most likely to benefit from preop drainage had been excluded, the wrong type of stent was used and prophylactic antibiotics for ERCP were not uniformly administered.

Is preop biliary drainage still being used?

A randomized trial from South Korea in the July 2013 American Journal of Surgery showed that preoperative biliary drainage for longer than 2 weeks resulted in twice as many complications as drainage for less than 2 weeks, 25.9% vs. 9.1% respectively. This compares favorably to the 74% complication rate of 6 weeks of drainage found in the 2010 NEJM study.

In the July 2013 American Journal of Gastroenterology, a group from Memorial Sloan Kettering Cancer Center published a retrospective review of over 500 pancreaticoduodenectomy patients, 220 of whom had preop stents. The overall complication rates did not differ whether a stent was used or not.

Again despite being "discredited," the use of preoperative biliary drainage continues to be very common.

So what happened here?

The only surgeon among the authors of the 146 discredited practices paper is a third-year general surgery resident. Maybe he did not have enough experience to evaluate these papers and their impact.

Or maybe one should not necessarily base an opinion about whether a practice has been discredited or not on a single paper in one journal.

The findings about these two topics, hernia repair and biliary drainage, lead me to question just how many of the other discredited practices are really no longer indicated or used.

Surgeons behaving badly

An orthopedic surgeon from New York reportedly has 261 malpractice suits against him. He has been accused of performing "phantom" and unnecessary operations. In one case, he supposedly performed a knee reconstruction, and the patient died of a pulmonary embolism the same day. A post-mortem examination allegedly showed no evidence of a reconstructed knee.

There is also said to be evidence showing that in one day he was doing as many as 22 cases, some apparently lasting less than 8 minutes. Details can be found in a lengthy story in the Poughkeepsie Journal.

If you've been following my blog, you know that I am not a big fan of lawyers. But I have to admit that one lawyer's questions about what the hospital knew about all this and why the surgeon wasn't scrutinized sooner are good ones.

Surely the operating room staffs of the two hospitals he worked in must have had a hint that something was wrong. If he said he reconstructed a knee and didn't really do it, wouldn't the OR nurses, techs and anesthesiologists have noticed? Were there no quality assurance or risk management policies in place?

And what about the other orthopedists in town or members of his multispecialty group? They must have seen some of his patients who were dissatisfied. How could they not have spoken up?

What about the company providing his malpractice insurance. How do you get to 261 cases? I once sat on a committee of a malpractice insurance company run by a state medical society. We interviewed a surgeon who had about 10 active or closed suits against him.

When we spoke to him, he could not explain why he had so many suits other than that he had a high-volume practice. His record keeping was poor and his communication skills were lacking.

We terminated his policy on the spot. No other company would insure him. Without malpractice insurance, he could not work.

The orthopedist in question has surrendered his New York medical license as of September 2, 2013 but still has a license to practice medicine in Virginia. Another Poughkeepsie Journal article describes his work history since he left Poughkeepsie, a non-medical incident in Virginia and the transfer of assets to his wife's name. By the way, that might not work since it was probably done after the problems surfaced.

Of note is the fact that he has excellent patient satisfaction scores. Based on 51 responses, he gets 4½ of 5 stars from HealthGrades.    

A spine surgeon in Ohio has been indicted by a federal grand jury on 10 counts of performing unnecessary spine surgery, 5 of which involve health care fraud.

He is said to have told some patients that surgery was urgently needed, including that their heads would fall off if they were in an automobile accident "because there was almost nothing attaching the head to the patient's body."

A lawyer filed a malpractice suit against the surgeon claiming he did unnecessary operations on over 100 patients.

Although he apparently has no current hospital privileges, he still can operate at a surgical center that he owns.

His HealthGrades scores are a bit more modest at 3 stars.

I realize that only one side of both of these stories has been told. These are allegations. Nothing has been judged in court yet.

Finally, we go from the serious to the silly. A New York City eye surgeon has gone public with an offer to trade his services as rewards for dates with women. He has exacting standards however.

According to the New York Post, he went to three Ivy League schools (Dartmouth, Columbia and Harvard), Emory and has an MBA from NYU. "He wants a woman with a graduate degree or Ivy League undergraduate degree."

Police have been stationed outside his office to control the hordes of Ivy League women who are queuing up.

These are isolated stories and not representative of all surgeons. But they are disturbing to me.

What do you think?

Electronic charting, tracking and malpractice lawsuits

A recent article on amednews.com called "Medical charting errors can drive patient liability suits" led with a case involving a bad outcome after coronary artery bypass surgery. The plaintiff's attorney alleged that the doctors did not review the patient's lab results or x-rays because they did not specifically say so in the medical record.

The article quoted a defense attorney who said, "By the time [the doctors] are deposed, it's three years later and they say, 'I'm sure I looked at that,' but there's no charting to back it up.” 

Unless there is something very unusual about the electronic medical record (EMR) used by the doctors in that case, there should be a very easy way to determine if they viewed the results in question.

A feature of every EMR that I am aware of is that each time a chart is accessed, the EMR records who accessed the record, where they accessed the record from, what they looked at and for how long they stayed on a page down to the second. It is like an electronic fingerprint with time included.

When I was a surgical department chairman, I had many opportunities to see how this worked. 

For example, I was asked to review a situation in which a resident failed to call for help with a patient who was crashing in the ICU. An arterial blood gas showing severe metabolic acidosis was not acted upon on a timely way. The resident said that the nurse did not report the critical blood gas result to him after the lab phoned it to her. This could not be verified, but the EMR showed that he had seen the result some 30 minutes before calling his senior resident.

Another case centered on an allegation by a gynecologist that a consultant surgeon failed to respond promptly to a call to assist with a bleeding patient in the operating room. The EMR revealed that four days after the case, the gynecologist had altered her operative dictation to make it appear that she had called for the consultation much earlier in the course of the surgery than what actually had occurred.

A surgical resident looked at a chart of a patient who did not have a surgical problem and was not on his service. She denied having accessed the record. When it was reviewed, the EMR showed that she had looked at 9 separate sections of the chart and had spent more than 10 minutes doing so.

As is true of many reports about malpractice trials, important details about the heart surgery patient's case are lacking. But surely the defense attorneys must have known that the EMR could be searched to see if and when the doctors in question looked at certain portions of the chart.

If all medical, nursing and ancillary staff members are not aware of the tracking features of EMRs, they should be. This is the same type of tracking that catches unauthorized personnel who peek at the chart of a celebrity or other prominent patient in the hospital. 

Note the example of the recent Boston Marathon bomber who was hospitalized. Staff who were not involved in treating him were repeatedly warned not access his EMR. 

Consider yourselves informed. Big brother is watching.

Employers, health insurance coverage and PSA testing

Help me with this please.

A 56-year-old man just got a new job. As part of the pre-employment process and in order to be covered by his new company's health insurance, he had to undergo a physical examination and some blood tests. A digital rectal exam was not done.

He has no risk factors for prostate cancer or urinary symptoms and by most guidelines is not a candidate for PSA screening.

He was not told of the possible harms of the test, nor was he told to abstain from ejaculation within 48 hours of the blood being drawn.

Of course, his PSA is 5.9 ng/mL.

The cost of the repeat PSA test will be borne by the patient. There is already talk of biopsies.

Not only will the patient have to deal with the anxiety generated by the test, he is being pro-rated by his health insurance carrier. He will be paying $200 per month extra for his coverage.

Does anyone have any thoughts about this?

More baffling stuff about ICD-10 codes

The ICD-10 list may be inadequate.

ABC News reports an actor was hospitalized after his foot became caught in an elevator raising the stage during a performance of the Broadway show "Spider-Man: Turn Off The Dark."

As a connoisseur of ICD-10 codes, I decided to see if I could classify this injury correctly.

To my surprise, I could not.

The only codes having to do with elevators are the W303XXs Contact with grain storage elevator.

Since I had once read that the codes were originally developed in Europe, I even searched for "lift." But all I got were Y93F2 Activity, caregiving, lifting and W240XXs Contact with lifting devices, not elsewhere classified.

Contact with lifting devices, not elsewhere classified hardly seems appropriate for elevators, which are so common. People are frequently hurt on them or by falling down their shafts. All you get when you search "shaft" are hundreds of codes dealing with bones.

We know that ICD-10 has given us such gems as

V9027XA Drowning/submersion due to falling or jumping from burning water-skis, 

V982XXA Accident to, on or involving ice yacht,

W5609XA Other contact with dolphin,

V9542XA Forced landing of spacecraft injuring occupant and

V9733XD Sucked into jet engine subsequent encounter.

[Click on the links to read my comments about those codes.]

So how is it that there's no code for contact with an elevator? For that matter, what about injury during a Broadway show? Surely both elevator and Broadway show injuries are much more common than say V8022XA Occupant of animal-drawn vehicle injured in collision with pedal cycle.

Filippe Vasconcellos ‏(@fvguima), a Twitter follower, suggested W230XXA Caught, crushed, jammed, or pinched between moving objects, initial encounter, but it is not clear that there was more than one moving object. And the stated aim of ICD-10 is to introduce much more specificity into the codes for better tracking of things like injuries.

What we need is even more codes. Maybe we need to get going on ICD-11 sooner than we thought.

What is the purpose of research?

There a number of excellent answers to this question. Here are a few—exploration, description, and explanation; to learn something; to gather evidence; documentation, discovery, and interpretation; the advancement of human knowledge

Here’s a nice one from TheLancet about why medical research is done: "to advance knowledge for the good of society; to improve the health of people worldwide; or to find better ways to treat and prevent disease."

I’m sure you could come up with a few responses to the question yourself.

But I don’t think you would get it, nor do I think the lofty answers I listed above are correct either.

What's the real reason to do research?

To get published.

How to overcome a low USMLE Step I score and become a surgeon

On my companion blog "Ask Skeptical Scalpel," a medical student asks how he can overcome a low USMLE Step I score and obtain a residency position in general surgery. Click here to view that post.

Why send letters containing ricin to public figures?

You probably heard about the Texas woman who was indicted for sending letters containing the deadly poison ricin to President Obama and New York's Mayor Bloomberg.

What goes through the mind of someone who would try to send the president ricin? Did this individual really think that presidents open their own mail?

She might have thought it was something like this.

Barack Obama: "Michelle, did you get the mail today?"

Michelle Obama: "No, I didn't, honey. Would you mind doing it?

BO: "OK. I'll be right back." [Goes out the front door of the White House, goes to the end of the driveway, greets tourists through the fence, opens mailbox, grabs mail and walks back.]

MO: "Anything important in the mail?"

BO: "Not much. A bill for the healthcare of everyone in the United States, a coupon for 20% off from Bed, Bath and Beyond, some credit card offers … wait, here's something interesting. It's a letter. Hmmm, no return address, but it's postmarked 'Boston, Texas,' so it might be worth reading. I'll open it and see what it says."

Not likely. In fact, inconceivable.

Why on earth would someone in their wildest dreams think that poison sent to any prominent person would reach them?

If you think that was bad, how about the two Upstate New York men who were charged with conspiracy to support terrorism? Using an x-ray machine, they constructed a "death ray" for targeting certain groups and possibly the president.

ABC News reported the story uncritically, but the Huffington Post quoted a radiologist as saying the device was unlikely to have been effective because it would have required a large amount of electricity, would not have been very portable and any potential victim would have had to remain stationary for a long time.

One of the plotters was an industrial mechanic for General Electric, a company that makes x-ray machines.

Despite that background, he and his henchman apparently didn't consider all the details.

Neither did the ricin lady. There wasn't enough ricin in the envelopes to harm anyone.

Ricin? Death ray? What were they thinking?

In my next life, I want to be a management consultant

I once blogged that in my next life, I wanted to be reincarnated as a weatherman. You get to make predictions and have no accountability when they are wrong (except for one Washington, DC weatherman who was given a "time out" after an erroneous forecast).

I know it can be stressful when you have to stand on the beach in front of a TV camera and try to keep your cap on during a hurricane.

But even so, it seems a bit easier than being a surgeon, a job which is very stressful and carries strong penalties for errors—especially for the patients.

Another occupation that is similar in circumstances and results to meteorology is that of management consultant. They advise, and they leave. They don't see the aftermath of their actions nor do they suffer the consequences. They also make a lot of money.

The ultimate hospital rating system

Finding out which hospitals are best is like "a riddle, wrapped in a mystery, inside an enigma."

Are you tired of seeing conflicting ratings from such once respected sources as Leapfrog, Medicare Compare, HealthGrades and Yelp?

Does it confuse you when a hospital is ranked in the top 10 by US News and World Report, but is "god-awful" according to Consumer Reports?

The Skeptical Scalpel Institute for Advanced Outcomes Research is proud to unveil a new rating system for hospitals.

Advanced metrics and creative statistics are linked with secret Bayesian methodologies, patient surveys and publically available databases to yield the most powerful and accurate hospital ratings ever imagined.

Just kidding.

Based on word of mouth, innuendo and rumors that have come to our attention through the back channels of the Internets, Skeptical Scalpel Ratings Plus offers unparalleled accuracy in hospital ratings.

For the low, low price of only $29.99, you will receive the Skeptical Scalpel Hospital Ratings Guide.

But wait, there's more. Here's the plus. At no extra charge, we will send you information about a weird trick that will enable you to undergo open heart surgery for just $8.00. Insurance companies are furious.

That's not all. The first 127 people to buy the guide will get a set of the sharpest kitchen knives known to mankind as our gift.

Are you a hospital administrator? Be advised of some special features of our ratings just for you.

If your hospital's ranking is not what you think it deserves, don't do what all the others do and waste time with in-house task forces or ad hoc committees. And don't claim we used bad data. Since we don't use data, that won't work.

Instead, try an on-site consultation from the Skeptical Scalpel Institute. We can show you ways to improve your standing without the need for expensive new patient safety programs.

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