Friday, January 31, 2014

Is advertising by doctors and hospitals worthwhile?



The decline of medicine as a profession began when it became legal for doctors and hospitals to advertise.

Apparently it all started when an Arizona lawyer sued for his first amendment right to advertise his services. In 1977, the US Supreme Court ruled that states could not prohibit advertising by lawyers.

This opened the floodgates for all professionals. Soon advertising by doctors and hospitals became common.

I don't know what it's like where you are, but I can't listen to the radio without being bombarded by doctors advertising their wares like car dealers and ads for bogus "university" hospitals.

Outrageous claims are made. The best, the most advanced, the newest, the latest, the most experienced, the most talented, and many, many more.

Just like car dealers, every hospital in my area is "#1" in something or other. Often more than one hospital is #1 in the same specialty.

Here's a sobering number. In the first half of 2011, hospitals in the US spent $717 million on advertising. This is despite the consensus that hospital advertising has not been shown to be effective at generating business. In fact, hospital CEOs admit that much of their advertising is aimed at stroking the egos of their doctors or boosting staff morale.

Regarding advertising by doctors, I don't know if that works either.

When I was in private practice in the late 1970s and early 1980s, advertising by physicians was mostly limited to the telephone book's Yellow Pages [younger readers may be excused for a minute to google the term].

Every patient who ever came to me via the Yellow Pages either didn't pay his bill, was non-compliant or both. Apparently, only a certain type of individual chooses his surgeon via the Yellow Pages.

I eventually stopped listing myself in the Yellow Pages.

In addition to wasting a lot of money, hospital and physician advertising is harmful because it creates unrealistic expectations among patients. A case in point is the ongoing debate about the supposed, but yet unproven benefits of robotic surgery. The ad below appeared in an airline in-flight magazine. Do you think it is effective? Do you believe it?


Although there is no proof that robotic surgery results in better outcomes than traditional laparoscopic techniques, hospitals have marketed robotic surgery by having potential customers play with the robot in such places as shopping malls and minor league baseball stadiums. [For a comprehensive look at robotic surgery advertising by hospitals, check out the Health News Review blog here and here.]

The public is flooded with advertisements promising miracles that often cannot be delivered. Disappointment surely follows

Is this the only reason for the medical profession's fall from grace? Of course not, but it certainly hasn't helped.

If advertising by hospitals and doctors disappeared tomorrow, we would all be better off.

Thursday, January 30, 2014

Is email like a malignant tumor?



A new paper says "metastasis of email at an academic medical center" may cost millions of dollars.

A pediatrician from the Penn State College of Medicine kept track of all of his emails for an academic year and found that 2035 mass distribution emails were received. They originated from the medical center in 1501, the department in 450, and the university in 84.

The emails were about information technology, academic and professional development, social events, and a combination of clinical care, research, or education.

Here's the fun part. Assuming it took 30 seconds to read each email and based on the average salary of a doctor at their institution, the cost comes to about $1641 per physician. Since there were 629 employed doctors, that's more than $1 million worth of time lost. If reading an email takes 90 seconds, multiply that by 3.

The paper points out that the barrage of emails is distracting, and important information may be overlooked. A new term "email fatigue" was coined.

They suggested several possible solutions to the problem, which probably wouldn't work and won't be tried anyway.

Like having a child, using email requires no license or training of any kind. Anyone with a computer or phone and an Internet connection can send an email.

Unfortunately, the ubiquitous practice of clueless people clicking "Reply All" when responding to every mass email, resulting in even more wasted time, was not addressed.

Sometimes I'm not sure they're really clueless. I think some people believe they are so important, so widely admired that they feel they must let everyone know that they will attend the next meeting of the task force to decide which brand of ketchup the cafeteria will carry.

Tuesday, January 28, 2014

Keep staying ahead of the news: Why you should follow Skeptical Scalpel



Last March, I blogged about some stories that national news organizations covered, but I had written about weeks or months before.

In the last few weeks, four more such episodes have occurred.

On December 10, 2013, a CBS article noted that patients who used proton pump inhibitors to control acid reflux were at risk for vitamin B12 deficiency. I wrote about the many side effects, including B12 deficiency, of these drugs back in June of 2012. Links are here: CBS/me

The New York Times ran a piece on December 12, 2013 asking if today's new surgeons were unprepared for practice. I have been writing about this for over three years. My most recent post about this topic was on April 18, 2013. Links are here: NY Times/me

On January 26, 2014, an op-ed piece in the New York Times by Nicholas Kristof discussed the ethical issues of doctors conducting body cavity searches at the request of police. My post on this same topic, which included all of the same cases, ran on Physician's Weekly on January 6 of this year. Links are here: NY Times/me

Also on 26th of January, the Washington Post published an article on high-ranking military officers who had significant behavior issues. I had written about three of these cases back in November of 2012. Links are here: WashingtonPost/me

Friday, January 24, 2014

New guidelines for health care personnel attire are short on evidence

The Society for Healthcare Epidemiology of America (SHEA) guidelines for healthcare workers attire have just been published.

Science Daily led with the headline "New Infection Control Recommendations Could Make White Coats Obsolete," which is rather misleading since the guidelines say no such thing.

I won't reproduce the entire 15-page document here since the full text is available online. But here are some highlights along with my comments.

The guidelines say that facilities may consider adopting a "bare below the elbows" (short sleeves, no watch, no jewelry, no ties) policy. They concede that the incremental infection prevention impact of a BBE approach to inpatient care is unknown but it is probably not harmful. I recently wrote about some comments from a microbiologist in the UK on the possible disadvantages of the BBE mandate already ongoing there.

Despite the Science Daily headline, the guidelines actually say that white coats are acceptable as long as they are removed before contact with patients and are laundered regularly. What constitutes "regularly"? The guideline says In our opinion, white coats worn during patient care should be laundered no less frequently than once a week and when visibly soiled. They discuss the debate about whether patients prefer to see doctors in white coats. I blogged about this a while ago too.

They stayed on the fence about whether clothing worn in the hospital should be laundered professionally or at home and surprisingly, did not recommend prohibiting the wearing of neckties.

The Science Daily story contained some interesting quotes from one of the authors of the guidelines.

"White coats, neckties, and wrist watches can become contaminated and may potentially serve as vehicles to carry germs from one patient to another," said Dr. Mark Rupp, who added, "However, it is unknown whether white coats and neck ties play any real role in transmission of infection," I wonder if he reads my blog?

Dr. Rupp did speculate that sometime in the future if studies show that white coats are harmful, they might disappear to be replaced by scrub suits. That is interesting because the wearing of scrub suits as also been criticized by many.

It's hard to disagree with two of the recommendations:

Appropriately designed studies should be funded and performed to better define the relationship between HCP attire and HAIs [hospital acquired infections].

Until such studies are reported, priority should be placed on evidence-based measures to prevent HAIs (eg, hand hygiene, appropriate device insertion and care, isolation of patients with communicable diseases, environmental disinfection).


But until those studies are done, the guidelines may produce more controversy than compliance.



If I could ask the well-meaning folks at SHEA one question, it would be, "Why issue guidelines if you have no evidence to base them on?"

Wednesday, January 22, 2014

Preoperative fasting and evidence-based medicine


The other day Mike Blackburn, a South African anesthesiologist I follow on Twitter, posted this: "Colleague just fb’d about a surgeon who said, 'I know we should wait 6 h but she ate at 12 and looks like a fast digester.'"

This was followed by a tweet from someone who calls him- or herself @LessIsMoreMed who said, "funnier still is the lack of evidence re: pre-op fasting" and included links to two references on the subject.

This reminded me of an incident that occurred about three years ago. I was working as a surgical hospitalist and had admitted a patient with acute cholecystitis in the middle of the night. I put her on the add-on OR schedule for that day.

By and by the patient was called for and when I got to the operating room holding area, the anesthesiologist met me with a frown on his face and told me the case would have to be postponed for a minimum of 6 hours.

I asked why. He told me that when he interviewed the patient, he noticed that the patient had a piece of hard candy in her mouth. He informed me that, in terms of gastric secretion, the act of sucking on a piece of hard candy was equivalent to having a eaten a full meal of solid food.

Friday, January 17, 2014

Non-English-speaking patients. Lost in translation?



What is one of the rules that medical people comply with the least?

My vote goes to "translation." The rule is that you must use a qualified medical interpreter for any interview or discussion with a patient who does not understand English.

How is lack of understanding defined? It is usually fairly obvious. If you aren't sure whether the patient gets it, he probably doesn't.

Why can't family members act as translators?

There is no guarantee that they will understand what is said or transmit it accurately to the patient.

What are the options?

You can summon a translator from the list of hospital personnel who have volunteered to translate. This works if the language in question is Spanish or maybe French. It's not often useful for Bengali or for most of the 13 or so national languages spoken in Mali.

The Joint Commission says if hospital employees are used, they must be qualified as translators and suggests ways that they can become qualified such as language proficiency testing, training in the practice of interpreting, interpreting experience in a health care setting and knowledge of medical terminology.

One website I found while researching this subject claims that the Joint Commission says all on-site interpreters must undergo an FBI background check. I could not verify this with the JC because its standards are only available if you pay. [Digression: If this is true, it is very interesting since doctors and nurses do not have to undergo FBI background checks.]

Many hospitals do not have formal training for interpreters nor are interpreters always available around the clock.

Sometimes hospital administrators take things too literally. In one hospital I know of, a fully bilingual surgeon was told he could not obtain an operative consent in Spanish (his native language) because he had not been trained as an interpreter.

There also are times when the hospital employee is not up to the task either because of education or attitude.

A hospital can contract with a service to provide interpreters via telephone. The advantages are that the interpreters are qualified and speak many different languages, far more than you might find among hospital personnel.

Among the disadvantages is the awkward nature of these conversations. If you use only one handset, you have to keep passing the phone back and forth and you can't hear what the interpreter is saying.

A two-handset phone set-up is somewhat better, but you have to find it. It is always stored in a different place on each floor of the hospital.

Accessing the service can be time-consuming. You must make an 800 call, log in, wait for the interpreter to join and so on.

Either in person or by telephone, the conversation can be frustrating.

I have had occasion to say something to the interpreter that took 2 minutes only to have the interpreter talk to the patient for 10 seconds. Here's a video example.

But the real problem is lack of true physician-patient interaction. You are both talking to someone else. Telling a patient she has cancer or what the risks and benefits of a procedure are is often accompanied by stunned silence from the patient. You really can't tell how much has been understood.

Also worth noting is that whatever the language, most of the time we then have the patient sign a consent form that is written in English.

You may have figured this out by now—many hospitals don't do any of this very well.

What do you do with a patient who speaks a language that even the telephone interpreter service doesn't provide?

We simply do the best we can. I'm not sure that any interpreter, phone or in person, can really communicate with some of these patients. 

Now that I think of it, I'm not sure how many English-speaking patients understand us either.

Wednesday, January 15, 2014

Preventing infection: The "bare below the elbows" rule for doctors doesn't go far enough



Here's a post about a paper on the possible transmission of bacteria on doctors' clothing that drew over 1000 comments on reddit in 24 hours.

It linked to a blog by an infectious disease/hospital epidemiologist physician. He discussed a small study which showed that bacteria could be transmitted by neckties.

The study looked at four different combinations of dress—long sleeves with and without ties and short sleeves with and without ties worn by a single physician who rounded on five mannequins simulating patients.

From the Methods section of the paper. "Micrococcus luteus (ATCC) was suspended in sterile saline and adjusted turbidometrically to a concentration of ~1.5X10 8th colony-forming units (cfu)/mL .A Dacron swab was dipped into the bacterial suspension and was rubbed over the terminal 6 cm [about 2.4 inches] of the tie for those tests involving the tie and the corresponding location on the front of the shirt for tests involving no tie. The terminal circumferential 2 cm of the cuffed portion of long and short sleeve shirts were inoculated in a similar manner."

The study found that wearing an unsecured (I guess meaning no clasp) tie was significantly associated with elevated level of contamination of the mannequins. The degree of  mannequin contamination was not significantly different whether long or short sleeves were worn.

The blogger concluded that everyone should wear short sleeves and no ties.

But wait a second—6 cm of tie covered with bacteria? How many people are getting that much contamination on their ties? If you are, then you need to reassess your approach to not only infected patients, but maybe activities of daily living in general. 

Friday, January 10, 2014

Expanding surgical residency training programs—good idea?

One of my Physician's Weekly posts last month was on the subject of surgeons possibly losing proficiency for doing open cases because of the ever-increasing popularity of laparoscopic and other minimally invasive techniques resulting in declining numbers of open operations for residents during their training.

Although some suggested that knowing how to do open cases would be unnecessary in the future, to me that is wishful thinking.

Another commenter said, "We are seeing the result of this in one of our hospitals with a new surgeon. He frequently aborts cases when he cannot complete them laparoscopically because he does not know how to do the open procedure. Worse, instead of seeking the help of someone who does, he transfers the patient to a medical center."

A resident said, "Observing the big name academic center that I train at, it seems that the massive cadre of fellows has led to an extremely low and less interesting case load for the rest of the general surgery trainees. Overload of floor management onto the trainees seems to exacerbate the problem. Why not substitute some of the current residency training with more focused experience with mentors—maybe even community mentors outside of academic centers—who perform the cases they’re lacking?"

The presence of fellows is a huge problem that academic centers and both the Residency Review Committee and the American Board of Surgery have glossed over for years. Fellows are usually not present in large numbers at community hospital programs; therefore, the residents get to do more surgery. Last year, I wrote about the fact that community hospital residents are more satisfied and do more cases.

The suggestion about mentors from outside of academic centers seems logical. However, it assumes that there are large numbers of community hospital surgeons who are dying to have residents around. In my opinion, that simply is not so. This is also a concern regarding the new surgical residency programs that are being established. I think some of them have been the result of initiatives by hospital administrators (residency programs still bring in government cash) and not the surgeons themselves.

I find it hard to believe that a hospital that has previously not had a residency program and has private practice surgeons who do nothing but operate can turn itself into an setting where surgical education is important.

Who is going to let the residents operate? Who will give didactic lectures? Who will write the research papers that are required by the RRC to prove that the faculty engages in scholarly activity? And so on.

I don't think it will work very well. What's your opinion?