Thursday, January 31, 2013

Why I don’t watch medical TV shows

A new dramatic television show called “Do No Harm” debuted last night on NBC. It is touted as a modern version of Dr. Jekyll and Mr. Hyde. Its surgeon-hero is described in the network’s public relations material as “He’s twice the man you think he is.”

The pilot apparently aired a couple of weeks ago, and NBC posted it on line as a sample of what the series will be like. Against my better judgment, I decided to see what it was all about.

If the opening scene of the pilot is representative of the rest of the episodes, viewers are not only in for some drama, they might get a few laughs too.

In first three minutes, which was all I could take, the following events occurred:

Two doctors were scrubbing for surgery with their masks off.

When they entered the operating room, the masks had magically appeared in their correct positions.

The surgeon, who apparently had never met the patient, asked another doctor what the patient’s problem was.

The other doctor said the patient had a massive brain hemorrhage and had an ICP (intracranial pressure) of 40. Normal is less than 20. The blood pressure was 160/100 and dropping, which is the opposite of what usually occurs; with elevations of ICP, the blood pressure goes up.

The surgeon ordered a unit of blood to be transfused and two more to be typed and cross-matched. Patients don’t bleed out from cerebral aneurysms. They die from brain damage due to the fact that blood fills the closed space of the skull which compresses the brain tissue. They rarely if ever need a transfusion.

The surgeon introduced himself to the patient who expressed concern that he was about to die. Not only was the patient perfectly lucid (an impossibility with an ICP of 40), but there was no sign of the ICP monitor.

After gowning and gloving, the surgeon walked over to a small machine and ran a blood sugar on himself by pressing a button WITH HIS STERILELY GLOVED HAND. It's not clear what would have happened to the patient in the OR if the surgeon's blood sugar had prevented him from starting the case. He did not don a new glove.

During the surgery, which was clipping of a cerebral arterio-venous malformation, the blood pressure falls to alarming low levels, presumably due to bleeding. However, the fake surgical field showed only some dribbling blood. This was about the only realistic part of the entire scene.

There were some tense moments and some sardonic wisecracks but the heroic surgeon managed to get a clip on the vessel just in time. The blood pressure shot up immediately.

All of this happened within the first three minutes of the show. See for yourself here.

As far as I can tell, there was no informed consent discussion and even worse, there was NO “TIME OUT.”

It turns out that the surgeon has 12-hour blackouts or something every night starting at 8:25 which can only be controlled by a powerful new sedative that a colleague gives him. People in administration know about this but still the guy is allowed to operate. There is no mention of who covers for him if a patient has a complication while the doctor is "out."

Here’s what the San Francisco Chronicle had to say: “NBC has had some problems launching new comedies, but at last it has a show guaranteed to have you falling on the floor in hysterics. Unfortunately, ‘Do No Harm’ purports to be a dramatic series.”

And that review doesn’t even mention all of the medical faux pas.

Here are my thoughts from two years ago about Grey’s Anatomy.

Note: This post was updated on February 1, 2013.

Tuesday, January 29, 2013

Patient Safety Summit Breaks New Ground

The first annual Patient Safety Science and Technology Summit (PSSTS) was held in Dana Point, California on January 13 and 14, 2013. The two days were filled with presentations and panel discussions on several areas of patient safety.

Unlike many such conferences, this one expected a commitment from its more than 300 attendees to actually do something about increasing patient safety when they returned to their respective institutions.

The keynote address was given by former president Bill Clinton, who challenged those in attendance to follow through on their promises to actively promote patient safety in their institutions and achieve the summit’s goal of no preventable patient deaths by the year 2020.

Noted patient safety experts from around the world covered topics ranging from medical and nursing leadership to specific safety issues such as neonatal monitoring, medication errors, failure to rescue and inappropriate use of blood transfusions.

Family members of patients who died after medical errors presented their moving stories on video and in person.

The event was sponsored by the Masimo Foundation, the philanthropic arm of the Masimo Corporation, makers of medical monitoring equipment. Masimo’s CEO, Joe Kiani, teamed with patient safety guru, Dr. Peter Pronovost of Johns Hopkins to assemble the distinguished faculty.

A significant problem that the PSSTS identified is that most medical devices cannot communicate with each other because of interface issues. Nine major medical device manufacturers have pledged correct this and work on other areas of patient safety improvement in the future. In addition to Masimo, they include Dräger, GE Healthcare, Cerner, Zoll, Smiths Medical, Cercacor, SonoSite Fujifilm and Surgicount Medical.

I spent a few minutes with Mr. Kiani, who said, “Masimo will keep track of progress and expect follow-up results to be submitted.” This will apply to both corporate and individual attendee pledges.

Videos of all of the sessions including speakers, panels and Mr. Clinton’s address can be viewed here.

In the coming days I will discuss in detail some of the major areas covered by the summit.

Disclosure: I attended the meeting thanks to a grant from Masimo who had no input into anything written here.

Monday, January 28, 2013

Choices: University residency with extra years of research or not?

In a new post on "Ask Skeptical Scalpel," a student is conflicted about choosing a university general surgery program with two years of research or not. Click here to see what I think.

Friday, January 25, 2013

Choosing antibiotics for appendectomy and cholecystectomy: Are "big guns" needed?

An emergency medicine physician asked me to comment on the use of antibiotics in patients having surgery for acute appendicitis and acute cholecystitis. He said in hospitals where he has worked in three different areas—New York, Miami and San Francisco—surgeons are using Imipenem for cholecystitis and Zoysn for appendicitis.

He wondered why those drugs were chosen and offered a few theories. They are as follows:

1) Surgeons are trying to avoid resistant bugs, so they’re using bigger guns
2) There is more pressure to reduce post-op complication numbers, so they’re using bigger guns
3) It’s easier to give one antibiotic to cover multiple bacterial types, instead of, say, cipro/flagyl or cefoxitin/flagyl
4) Patients do better with these big gun antibiotics
5) Residents are being taught incorrectly, and are just developing bad habits

Yes, it is mandated that everyone needs a dose of prophylactic antibiotics within an hour of surgery for appendicitis and cholecystitis. Of course, there are nuances.
Appendicitis is a disease involving an inflamed, eventually infected appendix so the use of antibiotics is possibly therapeutic and not simply prophylactic.
For acute cholecystitis, a similar argument can be made. The problem here is that it is often difficult to tell acute cholecystitis (with possibly infected bile) from biliary colic (pain caused by a gallstone impacted in the neck of the GB) without infection. Sometimes the GB ultrasound says acute cholecystitis, the surgeon says acute cholecystitis and the path report says chronic cholecystitis. There are many other permutations of those three observations. (e.g., US-biliary colic, surgeon-biliary colic, path-acute cholecystitis, etc.)
Note: I do not routinely culture peritoneal fluid in appendicitis or bile in cholecystitis because by the time the culture report comes back, most patients have been home for two or three days. There is evidence to support not culturing either fluid.
Honestly, I’m not so sure that people with early acute appendicitis really need antibiotics. Unless the appendix is perforated, I use only one preop dose. There are also similar differences in the imaging reports, surgeon description and path reports for this disease too.

I doubt that patients with biliary colic benefit from antibiotics either. The problem is that one may not discover that acute cholecystitis is present until one is in the abdomen. The same issue occurs with appendicitis where an unsuspected perforation may be found at surgery.

At least for now, at least one pre-op dose of an appropriate antibiotic seems reasonable.
Where I practiced for the last few years, we did not use Imipenem for GBs and only occasionally is Zosyn used for appys. Most of us used Unasyn for both except in the penicillin-allergic patient. For that patient, we used Levaquin and Flagyl. The problem with the latter two drugs is that they each are supposed to be infused over an hour. This is not always possible because the surgery may be started within an hour in certain circumstances, such as when an operating room happens to be vacant and the patient is ready to go. It’s a rare event, but it does happen.
There is no evidence that patients with either disease, who usually present from home, have resistant bacteria, and postoperative complications, especially infections, are not common with either disease. There is no evidence that patients do better with “big gun” antibiotics. In fact, most of the evidence that prophylactic antibiotics are even needed in these two operations comes from the pre-laparoscopic era. Wound infections are extremely uncommon with laparoscopic appendectomies and cholecystectomies. This is probably due to the fact that the wounds are small and in most cases, the specimen is removed in a plastic bag so the infected organ does not touch the subcutaneous tissue.
If residents are being taught to use “big gun” antibiotics for these two diseases, I agree it’s incorrect. There is little hope of changing this.

It is similar to the unfounded practice of giving everyone who is NPO a proton pump inhibitor, which I wrote about here. There is no scientific rationale for it. Yet everyone does it, and no amount of discussion will convince people to stop.

[Note: A version of this post appeared on General Surgery News a few weeks ago. The version above is better because I thought about it more.]

Saturday, January 19, 2013

Fecal transplants

New on Surgery Watch.

CDC says fecal transplant donors needed urgently. 

To read the story, go to this link:

Wednesday, January 16, 2013

Is Maintenance of Physician Board Certification a Sham?

Over the last few years, medical specialty boards have begun to compel physicians to maintain board certification by a number of means. This is an extension of recertification requirements which have been in existence since the mid-1970s.

Here is what the American Board of Surgery (ABS) mandates for Maintenance of Certification (MOC) every three years except where noted:

1. You must have an unrestricted medical license, hospital privileges in surgery, and references from the chief of surgery and the chair of the credentials committee of your hospital. It’s hard to argue with the need to have a license and practice in a hospital. However, if a surgeon had real quality issues, shouldn’t they have come to light before the end of a three-year cycle of MOC?

2. You must document 90 hours of CME credit, 60 of which must include some sort of Q & A testing which must be passed with an average score of at least 75%. I have previously blogged about the inadequacy of most CME programs. Even CMEs that require testing are often laughably simple. The American Board of Internal Medicine offers (for a price) open-book and Internet-based courses. Regarding self-assessed CMEs, the ABS website states, “[t]here is no required minimum number of questions and repeated attempts are permitted.”

3. You must successfully complete a written recertification examination every 10 years. Surely that must be an effective measure? Maybe not. For the last five years, the pass rate for recertification in general surgery is 94% or greater. The American Board of Internal Medicine (ABIM) recert exams must be a little tougher or those who take it may not be as smart as surgeons. The pass rates for the ABIM recert exams have been 88% to 92% for the last four years with similar rates for all of the medical subspecialties.

4. You must participate in a national, regional or local outcomes registry or quality assessment program. Participation in a national outcomes registry sounds great, but none of the available registries have policing powers and many rely on individual surgeon input to track outcomes. As mentioned in the critique of the first requirement, quality issues are far more likely to be discovered at the local level than by a registry that collects data submitted by the surgeon herself.

As if all of the above issues are not enough, how about this for a hot potato from the ABS? “Periodic communication skills assessment based on patient feedback may also be required in the future.” I can’t wait to see how that information is going to be collected. By what criteria will communication skills be judged? And what will happen to someone deemed a poor communicator?

I suppose the boards are doing all of this to forestall government or other regulatory bodies stepping in. Meanwhile, let’s everyone play along.

None of the MOC requirements address another issue, which is fitness for practice. A December 10th article in the Washington Post on aging physicians notes that some hospitals are setting age limits at which doctors are required to have physical and mental evaluations in order to maintain staff privileges. That’s great but not for just the elderly; every doctor needs to have period fitness testing.

Right now, all you have to do to stay on the staff of most hospitals is have a colleague attest to the fact that you are in good health, hardly a rigorous standard.

I’ve known a few physicians well under the age of 65 who could have used a checkup from the neck up.

To answer my own question, maintenance of certification is a sham.