Appendicitis: Continuing debate about treatment

The other day on Twitter, Kenny Goldberg (@kghealth), a health reporter at KPBS News in San Diego, asked me, "Why all the stories on antibiotics vs. surgery for appendicitis? Are appendectomies inherently dangerous?" My answer was "Great question. The answer is a resounding 'No.' The complication rate is very low."

Yet the papers keep coming.

A new systematic review of all the randomized controlled studies on appendicitis found important shortcomings in all of them. Here are a few:

Bias in selecting patients was a problem in all six of the studies reviewed. Diagnostic criteria for inclusion in the studies were not standardized. Some of the studies enrolled patients with clinically diagnosed appendicitis only. Since some patients may not have had appendicitis, they would probably have improved regardless of how they were treated.

Patients were treated with a variety of antibiotics, Since most of the studies were done in Europe, open appendectomy was the more common surgical intervention. Laparoscopic appendectomy results in fewer complications and shorter lengths of stay than the traditional open procedure.

Follow-up in five of the six studies was one year with only one study following patients as long as a median of 17 months. Rates of recurrent appendicitis necessitating appendectomy ranged from 24% to 60% with an average of 35.4%. What will the recurrence rates be at 3 years? 5 years?

The authors concluded that although more evidence for treating appendicitis with antibiotics has emerged, the comparative effectiveness of that strategy is still unknown. They recommend that patients should be enrolled in clinical trials or registries to help answer this therapeutic question.

The second recent paper involves two issues I have commented about many times—research and medical reporting.

It's a study of 102 pediatric patients between the ages of 7 and 17 with uncomplicated appendicitis as judged by CT scan parameters. After informed consent was discussed, parents were permitted to choose the therapeutic arm, antibiotics or laparoscopic surgery.

Of the 629 patients who presented with acute appendicitis during the study period, only 102 (21%) met the study's inclusion criteria of whom 37 were selected for antibiotic therapy by their parents.

During the median follow-up period of 21 months, 9 (24.3%) patients initially treated with antibiotics had to undergo appendectomy.

I blogged about this study's preliminary results when they were published back in 2014. If you would like more details about its limitations, read that post.

The inadequacies of medical reporting on this paper were rather glaring. Under the headline "Not all kids with appendicitis need surgery. Antibiotics can work just fine," the Boston Globe's new website Stat News said the following:

“'Their parents began to question whether they needed surgery [for appendicitis],' said [lead author] Dr. Peter Minneci, a pediatric surgeon at Nationwide in Columbus, Ohio. Minneci decided to answer the question with a controlled study." Sorry folks, this wasn't a controlled study.

The New York Times reported: "The surgery group had more complications and two of those who chose antibiotics had to be readmitted to the hospital for appendectomies in the first 30 days." This is misleading because although 5 of 65 patients in the surgery group had postoperative complications compared to none of the 9 who eventually had appendectomies in the antibiotic group, the difference was not statistically significant (p = 1.0, Fisher's exact test).

But the most interesting thing about this paper was an entire page explaining why allowing parents to select the therapy was a better method than randomizing patients to one group or the other. It's very clever and must be read to be appreciated.

Here is an excerpt: "The patient choice design allows a therapy to be aligned with the preferences of the patient and his or her family, thereby minimizing the potential negative effects of preferences."

I don't know about you, but if I or anyone in my family had appendicitis, my preference would be for a laparoscopic appendectomy.

My top seven posts of 2015

I’ve been blogging since July of 2010. Here is a list of my most viewed posts of 2015. Thank you for reading and commenting.

“How much money do journal publishers make? A lot,” a look at the highly profitable world of journal publication, was number 1. Profit margins of the top for medical publishers range from 32% to nearly 42%. It’s a good business to be in.

Next was “A shallow water blackout is a silent killer.” What can happen if you hyperventilate before swimming underwater? You might die.

“How to pick the leading physicians of the world” was a humorous take on an “honor” bestowed upon me by a company that is a little careless about choosing its candidates.

In “Narcotics addicts can sue doctors and pharmacies for ‘enabling’ them,” we learned of a ruling by West Virginia’s highest court that spells trouble for both patients and physicians.

“Antibiotics for appendicitis? No thanks” was a critique of a Finnish randomized prospective trial of antibiotics vs. surgery in uncomplicated appendicitis. I had some serious concerns about the way the study was done and interpreted.

“Do surgeons still do postop care?” was a guest post by a medical hospitalist who felt that surgeons were no longer interested in taking care of their patients after operating. It drew a number of comments.

The seventh most-read post was “So you want to be a radiologist,” written by a radiologist who I asked to respond to an email I received from a pre-med student. It was a nice discussion of the pros and cons of the specialty.

Appendicitis and shared decision-making

Staying with the current theme of appendicitis on my blog, here is a summary of recent developments. A JAMA Surgery Viewpoint suggested that because of the findings of a Finnish randomized trial, surgeons now should give patients with appendicitis a choice between an appendectomy or treatment with antibiotics.

The paper acknowledged my criticisms of the Finnish study which found that simple appendicitis could be treated successfully with antibiotics in almost 75% of patients.

I respect the authors of the JAMA Surgery article and am happy they referenced the blog post noting my concerns about that Finnish trial: the trial compared antibiotics to open appendectomy—an operation with more complications than the more commonly performed laparoscopic appendectomy; the antibiotic used in the Finnish trial is not a first line choice in the United States; patients were followed for only one year.

The JAMA surgery paper answered three questions I posed in a previous post. One, the Viewpoint authors consider antibiotic therapy for appendicitis mainstream. Two, surgeons must assume that patients might opt for antibiotics despite at least a 25-30% chance of suffering a recurrence of appendicitis. Three, an informed consent discussion now should include a mention of antibiotics as an option.

I disagree with the Viewpoint authors’ assertion that antibiotics are as safe and effective as surgery for treating appendicitis. Based on one flawed study, antibiotic therapy cannot yet compare to the many years of excellent results of laparoscopic appendectomy.

Here are some other problems.

On the shoulders of giants

The following was sent to me by a professor who sits on the admissions committee of a medical school in the United States. Here’s what he asks prospective students during interviews.

Sir Isaac Newton said, “If I have seen further, it is by standing on the shoulders of giants.”

If you want to become an astronaut, I’ll bet you know who Neil Armstrong is. If you want to become a rock-star, you likely know who the Beatles were or who the Rolling Stones are. If you want to become President of the United States, you know who Barack Obama is. But you want to become a doctor, right? That’s why you’re here.

So, who are those giants of medicine? What famous scientists or doctors who have advanced the science of medicine can you name?

The following would not be acceptable:

Mehmet Oz, MD
Sanjay Gupta, MD (Medical reporter)
Phillip McGraw (“Dr. Phil”)

Here are some names that would count: Drs. Watson, Crick, and Franklin

You wouldn't believe the answers I get. For example:

My blog cited in JAMA Surgery paper: Progress for bloggers

About a year and a half ago, I blogged that a medical student on Twitter used a blog post of mine as evidence. In January, the Canadian Journal of Anesthesia published an article I wrote under my pseudonym called “Why I blog and tweet.”

Last month, medical blogging took another step toward legitimacy. A JAMA Surgery Viewpoint formally cited my post critiquing the Finnish randomized trial of antibiotics versus surgery for the treatment of acute appendicitis.

Here is the first page with the portion of the piece discussing what I had written in the blog post.

Click on figure to enlarge.

Here is how citation appears in the JAMA Surgery article.

If you haven't read my entire post about the randomized trial, click here.

Last year I said this: “Journals may have to adapt and become more like blogs. In the future, medical information may be disseminated by blogs and comments rather than journal articles and letters to the editor.”

We have already seen prominent publications such as the New England Journal of Medicine starting online forums and the BMJ hosting blogs (at least 36 so far) and rapid responses to published papers.

The sea change in the way medical research is disseminated may be happening sooner than I thought.

A curious trend in appendectomies by residents

Some experts are worried that laparoscopic cholecystectomy is so prevalent that future surgeons may have difficulty doing open cases. I was going to blog about the possibility that open appendectomy would become the next operation that next generation surgeon might have trouble with. But while looking at some data [link added 12/4/15] collected by the RRC for Surgery, I was struck by something else.

Since 1999, the total number of appendectomies (open and laparoscopic) performed by surgical residents who completed 5 years of training has risen by 65.1% compared to the total number of appendectomies done in the US, which has increased only 16.4%. Here are the numbers:

Except for the academic year ending in 2006, the average total appendectomy rate per resident has risen every year since 2000. The chart below displays that change and the changes in the numbers of open and laparoscopic appendectomies.

Click on chart to enlarge

The difference in the average combined number of appendectomies between the two academic years ending 2000 and 2014 is significant, p < 0.0001.

A medical riddle: Where do incident reports go?

Incident reports are frequently submitted by hospital personnel. Did you ever wonder what happens to them? I have.

Over the years, I estimate that I’ve heard of hundreds of such reports being filed, but rarely have I heard of a problem being solved or for that matter, any action being taken at all.

In fact, I don’t even know where they went or who dealt with them. When I was a department chairman, I sat on quality assurance and risk management committees. Yet we never discussed individual incident reports.

The original intent of incident reports was to identify patient harms and increase patient safety.

According to a 2009 post by patient safety expert Dr. Bob Wachter, hospital incident reports are a spinoff from the Aviation Safety Reporting System which had successfully used them for identifying potential safety issues such as near misses.

At Dr. Wachter's hospital, San Francisco General, about 20,000 incident reports were filed every year. That is about half of what the Aviation Safety Reporting System receives per year, and San Francisco General Is only one of about 6000 hospitals in the United States.

Dr. Wachter feels that analyzing incident reports is not worth it. He estimates that each incident report creates about 80 minutes of work times 20,000 reports, which equals about 26,600 hours of wasted time. He also estimated that about one fourth of US hospitals do nothing with incident reports. That saves time but renders the reports useless.

He says an even bigger problem is that incident reports in his hospital fail to capture most events that harm patients.

That has also been my experience. I think most incident reports were filed by people wanting to "cover their asses" and most of the reported incidents were minor. A reference in Wachter's article states that most incident reports are submitted by nurses with only about 2% by doctors.

Incident reports can backfire too. From a 2002 Medscape article: "In some states, under certain conditions, the incident report is considered confidential and cannot be used against the nurse practitioner in a lawsuit. However, if copies are made or the chart reflects that an incident report was completed, the incident report can then be subpoenaed by the patient and used against the defendants in court."

And from the Louisiana State University School of Law: "The nonjudgmental nature of an incident report is very important because in most cases the incident report will be discoverable in litigation. An accusatory remark in an incident report may gain unintended weight in a legal proceeding."

Since incident reports generate a massive amount of wasted time, fail to identify most events that harm patients, are frequently ignored, and can possibly have a negative effect on lawsuits, why are they still being filled out by the thousands?

Telephone and television evolution through my lifetime

6-5-4. That was my home telephone number when I was growing up in the early 1950s. You may wonder how that was possible. I'll explain.

We lived in a small town. Telephones looked like this.

In order to place a call, you picked up the handset from its cradle, and an operator said "Number please."

You said the number, and she (operators were always women) made the connection for you via a switchboard.

Some folks in my town were on "party lines," which were less expensive but involved more than one household on the same line. If you picked up the phone in a home with a party line and it was being used by someone in another house, you could hear their conversation. You would have to hang up and wait until they were through before making your call. For incoming calls, the ring sequence was different for each household.

Is the surgeon still "captain of the ship"?

A Kentucky appeals court ruled that a surgeon was not responsible for a burn caused by an instrument that had been removed from an autoclave and placed on an anesthetized patient's abdomen.

According to an article in Outpatient Surgery, the surgeon was not in the room when the injury occurred and only discovered it when he was about to begin the procedure.

An insufflator valve had been sterilized and was apparently still hot when an unknown hospital staff member put it down on the patient's exposed skin. [An insufflator is a machine that is used to pump CO2 through tubing into the abdomen for laparoscopic surgery.] When the doctor saw the mild second-degree burn, he asked what happened, but "but no one in the OR claimed any knowledge or responsibility."

The hospital had settled the suit on behalf of its staff, but the surgeon, who as a private practitioner had his own malpractice insurance, held out. The original lower court ruling dismissing the suit against him had been based on the plaintiff's lawyer's failure to prove that the surgeon was responsible for the actions of the hospital staff.

In December 2012, I wrote a post stating my opinion that activities such as counting the sponges during an operation were not the responsibility of the surgeon. Many who commented on the post were highly indignant that I could suggest such a thing.

I wrote another post last year on the subject in response to another surgeon's blog entitled "Everything's my fault: How a surgeon says I'm sorry." I felt that many things that happened to patients were beyond the control of the surgeon. Most of the comments agreed with me.

I keep hearing that medical care has become a team sport. If that's true, then the surgeon, like everyone else, is simply a member of the team. People on teams have different roles and must execute properly for the team to succeed.

One of the most interesting things about the case in question was that none of the OR team members had any idea how that hot insufflator valve found its way to the patient's abdomen.

One thing we know for sure, at least in Kentucky, is that a surgeon is not legally responsible for everything that happens to a patient in the operating room, particularly when he is not even present.

Is this decision the first nail in the coffin of the "captain of the ship" doctrine?

Should I go to med school?

A young man writes

I am thinking about pursuing medicine as a career. However, it is not something that I am entirely sure of because of the changing healthcare landscape.

Suppose I enter medical school at age 26. Four years later I have my MD. Five or six years later I will be done with a surgery residency and two years after that with my fellowship. I will 37-38 years of age with kids, a wife, and most likely a home. My kids will be around 9-11 years of age. In addition, I will be near $250K in debt from medical school because of interest accumulated throughout my residency and fellowship. This is of course not including retirement, car, house, investment, and kids’ college savings.

My friends tell me not to think about it, but if I don’t, I can end up in a position that I don’t want to be in. Even if I pay off my debt at age 50, I still have all those other things to address. And even if I do, when will I enjoy my money? What is perhaps most important though, is the time component. I am essentially giving up my entire life to a profession that will not allow me to transfer laterally to other professions if I choose to. I can be pursuing my other interests in the time that I would be becoming a surgeon such as business or engineering.

Lastly, I grew up in poverty and have no financial assets. It will take me years to accumulate wealth. And once I do (at around age 60), that wealth will be passed down to my children.

Did I miss something? What are your thoughts? 

While rereading and editing your email, I realized you did miss something. What's missing is enthusiasm for becoming a doctor. You listed several reasons not to go to med school, but nothing about why you want to do it. If you don’t truly love the idea, you will be very unhappy.

I think you need to reassess your future.

For those who want more information, I have written a couple of posts about questions related to this one [links here and here.] The comments on the more recent post are worth reading..

Hospitals Mess Up Medications in Surgery—a Lot

Yes, that was the inflammatory headline on Bloomberg Business News last week. It is great click-bait, but factually off base because the research it refers to was done at only one hospital.

Here's what the study found. During 277 operations with 3,671 medication administrations observed at the Massachusetts General Hospital, 193 (5.3%) involved a medication error or an adverse drug event. One or more errors or adverse drug events occurred in 124 (44.8%) of the procedures.

In all, 40 (20.7%) adverse drug events were not preventable—for instance, an allergic reaction to a drug that was not known about before. Of the remainder, “32 (20.9%) of the errors had little potential for harm, 51 (33.3%) led to an observed adverse drug event and an additional 70 (45.8%) had the potential [emphasis added] for patient harm."

Sounds bad, but the Bloomberg article goes on to say "While all the errors observed in the study had the potential to cause harm, only three were considered [potentially] life-threatening, and no patients died because of the mistakes. In some cases, the harm lay in a change in vital signs or an elevated risk of infection."

Surgical training is different in Japan

Quite different than what we are used to in the United States as a paper published online in the American Journal of Surgery explains.

In the US, all residency programs are vetted by the Accreditation Council for Graduate Medical Education (ACGME). Japan has no central accrediting organization. Each hospital establishes its own training program without any national standardization.

Medical school graduates in Japan take a national practitioner examination and then complete a two-year rotating internship. Specialization in general surgery residency takes three more years after which the residents may obtain board certification.

The authors surveyed 76 teaching hospitals in Hokkaido, a prefecture in the north of Japan, and 49 (64.5%) responded.

Program directors were in place in 81% of the residency programs. Of that number, 79.3% devoted less than 5 hours per week to education [compared to an ACGME mandate that 30% of a program director’s time must be devoted to education], and 72.4% had dialogues with residents only when necessary.

Of those responding to the question, 31/36 (86%) "had teaching activities outside of clinical settings," but no program had protected time dedicated to teaching.

Fewer than half of the programs had skills or simulation laboratories, with 12.5% having formal simulation training as part of their educational agenda.

Only 55.6% of the programs evaluated the competency of their trainees in knowledge, skills, or scholarly activities.

Not surprisingly, only 8.6% of program directors were satisfied with the way their programs functioned.

To become board-certified in Japan, residency graduates must take a written exam for which the pass rate is 82.1% and an oral examination which has a pass rate of 100%. The pass rate for the oral exam has been an issue. A medical specialty board was established in 2014 and is preparing to oversee the quality of resident education and certification.

Lead author Dr. Yo Kurashima, Director of Surgical Education Research at Hokkaido University Graduate School of Medicine, answered a few questions via email. He said some of the hospitals limit resident work hours and allow residents to go home after call. However, "most do not define work hour limitations, so residents usually work from early in the morning to midnight every day."

No universal surgical residency curriculum exists in Japan, but a national surgical society recently listed criteria that must be achieved prior to board certification.

Dr. Kurashima did some training in Canada where he became familiar with North American residency methods.

For his next project, he said, "We are just starting a national survey which will investigate resident satisfaction regarding their residency.”

I suspect the residents might raise some concerns. I wonder if they will have time to respond.

Misconceptions about oxygen by alternative medicine practitioners

An article called “Simple ‘4-7-8′ breathing trick can induce sleep in 60 seconds” claims that this trick can get you to go to sleep within 60 seconds. All you have to do is the following:

♦ Exhale completely through your mouth, making a whoosh sound.
♦ Close your mouth and inhale quietly through your nose to a mental count of four.
♦ Hold your breath for a count of seven.
♦ Exhale completely through your mouth, making a whoosh sound to a count of eight.
♦ This is one breath. Now inhale again and repeat the cycle three more times for a total of four breaths

An integrative medicine expert, Dr. Andrew Weil, said it works because it allows the lungs to become fully charged with air, allowing more oxygen into the body, which promotes a state of calm.

“Promotes a state of calm” is nonsense. Let’s concentrate on the science. Does it allow more oxygen into the body? Ich don't think so.

The air we breathe contains about 21% oxygen. Nearly all oxygen in the blood is carried by hemoglobin. No matter how many deep breaths you take, you cannot get the oxygen saturation of hemoglobin (normally > 92%, closer to 98% in healthy people) above 100%. This is explained in more detail in a previous post of mine about why athletes don’t benefit from breathing pure oxygen after exertion.

This simple trick would be hard to remember but might work through the power of suggestion. It doesn’t cost anything, and unless you hyperventilate and pass out (but you'll be in bed anyway), it is harmless.

The next misconception about oxygen is neither inexpensive nor harmless.

Two naturopathic “doctors” have been accused of injecting a woman with oxygen or perhaps purified water that had been taken from an Octozone machine. The oxygen was supposed to destroy any pathogens in the woman’s blood. In the process of trying to kill the pathogens, the injection killed the patient who paid $500 for the treatment.

The naturopathic duo left town and were at large for several months before eventually being caught and charged with homicide.

An autopsy found her death was due to an air embolism.

According to a recent review of the subject, “Traditionally, it has been estimated that more than 5 mL/kg of air displaced into the intravenous space is required for significant injury (shock or cardiac arrest) to occur. However, complications have been reported with as little as 20 mL of air (the length of an unprimed IV infusion tubing) that was injected intravenously.”

Pure water should never be injected IV either because it causes blood cells to die from hemolysis.

How about we just take our oxygen the old-fashioned way—normal breaths and never intravenously?

Do doctors charge too much?

We all know that some doctors’ fees are excessive. I have blogged about this myself citing a neurosurgeon’s $117,000 charge for assisting on a case.

We also know that doctor bashing is a popular sport right now.

In an otherwise reasonable article about high-deductible health insurance on Vox.com, reporter Sarah Kliff’s second paragraph read as follows:

The bolded text was hyperlinked to a Washington Post piece about a study that showed wide variations in hospital charges for appendectomies in California. The study was not about physician fees. No matter how difficult the case was, no surgeon would ever have been paid $186,955 for performing an appendectomy.

Yesterday, I twice asked Ms. Kliff to please correct this grossly misleading paragraph. She acknowledged my request that evening, but as of 9 AM today, nothing had been changed.

Even if Ms. Kliff had correctly identified the hospitals as the culprits, using appendectomy as an example of why patients should shop for the lowest prices was a poor choice.

Nearly every patient with appendicitis does not know he has it until he has gone to an emergency room, seen an ED physician, and had some tests. I doubt most people in this situation would A) ask how much it’s going to cost to have an appendectomy and B) decide to go to another hospital for care. The fact is, hospitals are so secretive about their charges that a patient would be unable to comparison shop especially if the emergency department visit occurred outside of normal working hours.

Even trying to find out the charges for elective surgery remains difficult in 2015.

Physicians—particularly surgeons—have taken a lot of heat recently. We don’t need articles like this to inflame patients (and journalists) even more than they already are.

ADDENDUM 9:45 AM 10/15/15

The article was just changed. The bolded mistaken passage was corrected, but the next sentence (underlined in red) remains the same. Still blaming those "really expensive doctors."

Code Black Part II: "It gets worse"

Last week, I reviewed the premier of the new medical television series "Code Black" and pointed out several flawed or impossible scenarios. I didn't think I'd watch another episode.

But I was alerted to a rather shocking error on last week's installment. I had to see it for myself.

On this typically chaotic day in the emergency department, a young woman was brought in after a car crash which occurred while she was in her way to the ED because of abdominal pain. A CT scan of her abdomen and pelvis was negative, but her serum lactate level was elevated. They then decided to examine her abdomen and noted tenderness. A bedside ultrasound done in the ED revealed a left ovarian torsion (twisting of the blood supply to the ovary which if not rapidly corrected, could cause irreversible damage). The patient had already had her right ovary removed. Further heightening the drama was that her husband died of lymphoma but had banked his sperm, and the patient wanted to have his baby.

She needed immediate surgery, but all of the hospital's operating rooms were busy. As the window of opportunity to correct the problem was closing, an operating room opened up. But alas, there was not a single gynecologist or surgeon available to do the case. According to the back story about Dr. Neil Hudson, he's a fully trained surgeon who decided to work in emergency medicine. One of the new ED residents begged Dr. Hudson to do the case, and he resisted for a while until it was almost too late.

Live tweeting from #ACSCC15

As many of you know, I have not been a fan of live tweeting conferences. I blogged about the issue last year (here and here) and received a lot of feedback about the posts, most of it strongly opposing my views.

Vigorous live tweeting from the American College of Surgeons Clinical Congress (#ACSCC15) in Chicago is underway. Here are a couple of examples of tweets from that meeting. Twitter handles are blocked to protect the innocent (or guilty).

First, the good. Here is a nice montage showing what surgical program directors are looking for in residency applicants.

The photos are in focus and well-positioned. Anyone not in the audience for the talk can get something useful from this tweet. My one complaint -- we do not know who the speaker is. That information may have been provided in an earlier tweet, but this retweet is the only one I saw.

OR tech: "How do I deal with an abusive surgeon?"

Have you ever come across problems with rage and temperament issues in the OR. I have been an operating room tech for many years and have been in a variety of surgical settings.

A certain surgeon brings in a lot of money to the hospital, but he is terrible. I have been called things no one has ever called me. He throws instruments on my table and mayo stand, screams, and implies that I and my colleagues have no idea what we are doing. I have reported him to my manager and the OR director, but nothing ever comes of it.

Other surgeons have witnessed his behavior and have said something, but nothing was ever done. I understand the OR is a beast of its own, but the culture has to change with these newer guys coming out of residency. The mindset of the surgeon being our 'customer,' which is being rolled out to us now, is not reason for us to put up with abuse. What have you encountered on a peer-to-peer level on how to handle such demeaning behavior? I trained and worked at a level 1 trauma center with emotions that constantly ran high, and still it was less stressful than this particular surgeon. Thank you for your advice. 

A recent paper in the American Journal of Surgery addressed this topic. The authors interviewed 19 OR personnel including nurses, medical students, surgical residents, anesthesiologists, and 2 scrub technicians. Dr. Amalia Cochran, the paper's lead author, told me the reason there weren't more scrub techs was that they were reluctant to participate.

“Code Black” should be pronounced dead

A new television series called “Code Black” debuted last night on CBS. The show’s name supposedly means the emergency department has too many patients and not enough staff. In my over 40 years in medicine, I’ve seen many busy, understaffed EDs but never heard anyone call it a "Code Black."

There is the usual array of standard medical characters—the inexperienced new residents on their first day at work, the savvy nurses, and the cocky, overconfident attendings. This one has a few twists. The world-weary head nurse is a Hispanic man, and the headstrong know-it-all attending is a woman, Dr. Leanne Rorish. She has early conflict with the handsome, more cautious Dr. Neal Hudson, but I see romance in the future should this show manage to stay on the air.

It takes 5 people to push an empty gurney at Angels Memorial

The show started off with a gunshot wound to the neck that the docs had to retrieve from a car which had been abandoned in the hospital parking lot. Although no one had been putting pressure on the damaged carotid artery for an undetermined period of time and blood was visibly spurting out of the wound, the patient pulled through the resuscitation thanks to Dr. Rorish who replaced all his blood with cold IV fluid. She spiced up the resuscitation by asking the new residents questions about what she was doing.

Another Caribbean med school graduate needs advice

I did not attend St. George's, Ross, or Saba. I chose my school because it has a premed program which leads to an MD program. My USMLE Scores on Step 1 and Step 2 CK are above 230.

I did not apply for the 2015 match because I did not have my step 2 CK results until November. It would have been too late. I could have rushed my step 2 but I wanted to get a good score and be a solid applicant. Also I would not have been able to complete my surgical electives in time to get letters of recommendation. At some point, I will be doing research at [a very well-known medical school]. I felt that for these reasons this would make me a better applicant the next year.

Since graduating I have been trying to find a medical related job (scribe) but have had no success. I have reached out to many institutions regarding research opportunities but have come up dry. I may be able to secure a volunteer research position by next month. Do you have any suggestions for me? I knew I would hate being out of the medical field for this long but this was my best bet. Does this gap hurt my chances?

I am concerned that despite your excellent USMLE scores, taking a year off from clinical medicine may cause your application to be rejected immediately. I do not know if a 9 week research elective, even at a premier med school, would be enough to offset your lack of clinical experience over the entire year. Acting as a scribe would not be considered clinical experience.

Another issue is what is the record of your school regarding matching graduates into surgical programs? Since you didn’t tell me your school’s name, I cannot give you any insight into that situation. Even if I did know the school’s name, it may not have published its match results.

To answer your specific questions:

How many gen surg programs should I apply to? I was thinking ~100. That seems reasonable. You should be able to gauge your chances better after you see if you receive any offers for interviews from the 100 programs.

During a gen surg interview, should I be open about my backup specialty? I would advise you to say that you would take a preliminary spot in general surgery if you didn’t match in a categorical position. Admitting that you would do internal medicine is often seen as a lack of commitment to surgery.

Most hospitals I am looking to apply are IMG friendly. Which means the surgery and medicine programs are both IMG friendly. Would it be a bad idea to apply to different specialties at the same hospital? I think it would be a bad idea. I suggest you wait and see if you get interviews from the general surgery programs. If you don’t, then there would be no problem applying to internal medicine at the same place. I doubt very much that the two services would talk about any specific applicants. Most surgery programs get hundreds of applications and those applicants who are not offered interviews are not remembered.

Some readers may have other opinions. I hope they will comment.

Gladwell says just about any college grad could become a cardiac surgeon

"I honestly think that…the overwhelming majority of college grads, given the opportunity, could be better-than-average cardiac surgeons," said pop author Malcolm Gladwell in a discussion with David Epstein. Gladwell qualified his astonishing statement by stipulating that it could only occur with 10,000 hours of deliberate, highly structured practice by very motivated people.

Epstein, author of "The Sports Gene," challenged Gladwell to produce some evidence to support his opinion regarding cardiac surgeons. Instead of evidence, Gladwell replied, "I have a very low opinion of the difficulty of cardiac surgery" and equated the complexity of cardiac surgery with that of driving a car.

If you don't believe me, watch a few minutes of this video, which I have cued to the start of his comments about cardiac surgery.

Both Gladwell and Epstein are somewhat off base. While there is no question that doing operations on the heart requires psychomotor skills, there is much more to it.

Like all procedural specialties, cardiac surgery involves deciding who would benefit from an operation, when should the operation be done, who would be better served without an operation, and what should be done if an unexpected finding or a complication occurs either during surgery or in the postoperative period.

Equating driving a car with performing cardiac surgery is absurd. Most of the time, driving does not require intense concentration. Nearly everyone has had the experience of driving a car on a highway for several miles and realizing that they have no recollection of the scenery or any other vehicles that may have passed going the other way.

Not so with cardiac surgeons, who do not have the luxury of "zoning out."

The "10,000 hours" rule has been challenged by many including David Epstein in his book. If you don't have time to read that book, here is a link to a blog called "The Science of Sport" by Ross Tucker, a PhD in exercise physiology. Do not be put off by the length of the piece, which is worth the few minutes spent reading it. He explains how the original research on the topic of 10,000 hours by psychologist Anders Ericsson was flawed.

And here's an article from Salon called " Ditch the 10,000 hour rule!" that says approaches to learning other than massed practice yield better results.

Finally if hard work and time expended is all it takes to be an expert, my tennis game should be a lot better than it is.

One true statement Gladwell made in the video was, "This is going to offend all medical doctors in the room." But he should have added that it would also offend anyone who is a rational thinker.

This post originally appeared on Physician's Weekly on 11/3/14. It has been revised and updated.

What comes after the Heimlich maneuver?

At the end of an otherwise informative article about the nuances of performing a Heimlich maneuver, New York Times science reporter Jane E. Brody recommends that if all else fails, a cricothyrotomy should be attempted.

She goes on to briefly explain how the procedure is done. In the right hands, a cricothyrotomy is safer and easier to perform than a formal tracheostomy. However, for a layperson who has never seen either procedure done, does not know the relevant anatomy, and has never put a knife to anyone's skin, it is highly unlikely to be successful.

Ms. Brody includes a link to website with some static drawings of the procedure. The site is called Aaron's Tracheostomy Page and it bills itself as "The Internet's leading tracheostomy resource since 1996."

Here's an excerpt from that description of the operation:

"3. Take the razor blade or knife and make a half-inch horizontal incision. The cut should be about half an inch deep. There should not be too much blood." Yes, there should not be too much blood, but sometimes there is.

Both the Times article and the reference repeat the medical urban legend that the barrel of a ballpoint pen can be used as a breathing tube.

A 2010 paper found that due to high resistance to airflow, most ballpoint pens are not adequate airways, and the two that were acceptable (the Baron retractable ballpoint and the BIC Soft Feel Jumbo) are unlikely to be on hand. An earlier paper also reported similar high airflow resistance with ballpoint pens.

A small study involving inexperienced junior doctors and medical students found that they were able to successfully perform cricothyrotomies in only 8 of 14 cadavers. Injuries to the thyroid and cricoid cartilages were common.

Remember these important points—cadavers don't need an airway in a hurry and they don't bleed.

Evidence of successful cricothyrotomy by bystanders is lacking. A 2010 review of American soldiers killed in Iraq between 2003 and 2006 noted that five of those who died appeared to have had attempts at cricothyrotomy, all of which failed.

I once was asked to see a patient whose "cricothyrotomy" done in an ED by an experienced emergency physician and a resident turned out to be a laryngotomy. The tube was inserted directly into the larynx.

To the uninitiated, surgery looks easy. Last year I blogged about Malcolm Gladwell's outrageous claim that just about any college graduate could become a cardiac surgeon.

I suppose one might say "What have you got to lose? The patient is dying. Try the cricothyrotomy." I can’t stop you. But be certain it is necessary, and realize your chances of success are extremely low.

If you’re considering it, at least look at some of the many instructional videos available online.

Warning: Graphic. There is some blood. Here’s one by an ED doc. In a non-hospital setting, you would not have all the help and equipment he had. Here’s another, this time by a surgeon—with lots of help and equipment. Both patients were relatively thin.

Now imagine doing it with a pocket knife and a ballpoint pen on an obese person. Still think it’s easy?

Is obesity a disease, a disability, both, or neither?

In 2013, the American Medical Association recognized obesity as a disease. Dr. Peter Ubel, writing in his blog on the Forbes website, thought this was a bad idea. He feared that calling obesity a disease will result in people having less motivation to lose weight and cited a study which found that people who were told that obesity is a disease tended to be less concerned about their weight and when offered a sandwich for a hypothetical lunch, chose less healthy food.

Although he gave good reasons why obesity should not be considered a disease, he favored retaining the disease label because it would help reduce the stigma attached to obesity and build public support for programs to conquer obesity. I am not sure about that.

Back in December, the BBC reported that the European Court of Justice heard the case of a 352 lb Danish childcare worker who was fired from his job because he couldn't bend down to tie children's shoelaces. He denied the allegation.

The European Court "ruled that if the obesity of the worker 'hinders the full and effective participation of that person in professional life on an equal basis with other workers,' then obesity can fall within the concept of 'disability.'" Danish courts need to hear the case and decide if the worker is truly disabled. The ruling affects all other countries in the European Union.

The Editorial Board of the Chicago Tribune commented on the issue in a piece entitled "the dangers of treating obesity as a disability." It mentioned a Texas case in which a court said a company that dismissed a 600 lb materials handler could not do so because they had not tried to "find ways to help him perform his duties."

The Tribune article pointed out that one-third of Americans are obese with 15 million (7% of the population) classified as morbidly obese. The board felt that this was a potentially very costly expansion of the Americans with Disabilities Act, which they say was intended to help those who were disabled not by individual decisions, but rather were "victims of fate." It did not address the fact that many are disabled from smoking-related emphysema. Are they victims of fate or poor choices?

A recent editorial [full-text here] in the American Journal of Medicine took it up another notch. The author, Dr. Robert M. Doroghazi blamed obesity on eating more calories than one burns—a hypothesis held by many. Regarding the war on obesity, he said, "We will not make progress until we tell obese patients they eat too much, and it is their personal responsibility to eat less." Too harsh?

Disease, disability, both, or neither? What's your opinion?

In what specialties can a surgeon be autonomous?

I am a medical student who is trying to decide on a field. I am not chasing money but rather autonomy; thus I would prefer to work for myself rather than a hospital. So my question is, which fields of surgery are more amenable to private practice, and which fields tend to require the resources of a hospital or don't work as well without a hospital?

The way things are going; future use of the words “autonomous” and “physician” in the same sentence will be rare, if not unheard of.

Here are some figures from a July 2015 American Medical Association report.

• Younger physicians were more likely than older physicians to be employed. About 59% of physicians under the age of 40 were employed, versus 46.0% of physicians aged 40-54 and 33.3% of physicians 55 and above.
• Nearly one-third of physicians are in practices with more than 10 physicians, including 13.5 percent in practices with 50 or more physicians.
• Multi-specialty practice physicians were more likely than single-specialty practice physicians to report that their practices were hospital owned—44.6% compared to 23.0%.

Who knows what the percentage of employed physicians will be by 2020, but it surely will be higher.

I can think of only two surgical specialties that can be mostly independent of hospitals, otolaryngology and plastic surgery. I am not including ophthalmology because it isn’t really a classic surgical specialty.

The only way otolaryngologists and plastic surgeons can be autonomous is by concentrating solely on cosmetic surgery or working only in an ambulatory surgery center.

Otherwise, you would need a complete operating room—staffed by a nurse, an operating room technician and for some cases, an anesthesiologist—in your office.

Very few surgeons are able to limit their practices to cosmetic surgery directly out of residency or fellowship. Unless you join an established cosmetic surgeon in practice, which would of course limit your autonomy, you will need to be on call for trauma and be available for consults involving problems like pressure sores in hospitals to pay the bills.

My observation as a surgical chairman in community hospitals was that it takes years before the average plastic surgeon is able to develop a reputation and focus solely on cosmetic surgery.

You should also be aware that both of those specialties are highly competitive. In this year's match, only 1 of 299 ENT positions went unfilled, and 364 US seniors had ranked ENT as their preferred choice. For plastics, there are two ways to obtain a position. The NRMP handles an integrated match which filled 144 of 148 positions. There were 162 US seniors who listed Integrated plastics as their preferred choice. The other match is independent of the NRMP and takes residents who have done varying years of general surgery. For that 2015 match, which placed applicants in positions starting in July 2016, 85 applicants submitted rank lists, and 68 of 70 positions were filled. That left 17 candidates unmatched.

Additional reading: A post on KevinMD entitled “So doctor, who’s your boss?”

Variation is not causation

I made a rookie mistake in statistics of the “correlation is causation” genre by confusing variation for causation in the recent JAMA Surgery paper referred to in my last post. I contacted Dr. Timothy M. Pawlik, the lead author of the Johns Hopkins study, who said the following:

"The model is explaining and attributing variation in readmission and not attributing readmission itself to the different domains. The model suggested that only 2.8% of the variation in readmissions was attributable to surgeons. This is different than saying that only 2.8% were the 'fault' of surgeons. A more accurate interpretation would be that only 2.8% of the variation seen in readmissions was attributable to provider level factors. The majority of the variation in readmission was due to patient factors."

He added that some of the 82.8% variation in readmissions attributable (note: attributable doesn’t mean it’s the patient’s fault) to the patient could be modified by better medically managing patients' comorbidities or not operating on some of these patients.

That readmissions can be explained by a single domain or a single person is simplistic. Dr. Pawlik's clarification confirms my original concern that attributing differences in patient outcomes solely to differences in technical quality of surgeons is probably inaccurate, statistically speaking.

Variation is not causation but variation is still a call to action. Regardless of who is to blame for unfavorable outcomes, surgery is a team sport. The incision is just as important as the community care. In this regard, I am certain that ProPublica and I are on the same side. Let’s work together so that we see the whole story behind the numbers.

Are surgeons the cause of high postoperative readmission rates?

No, according to a recent paper published online in JAMA Surgery.

The authors concluded, "The majority of the variation in readmission was attributable to patient-related factors (82.8%) while surgical subspecialty accounted for 14.5% of the variability, and individual surgeon-level factors accounted for 2.8%."

The investigators looked at data for over 22,000 surgical patients treated at Johns Hopkins and found the overall rate of readmission within 30 days was 13.2%. After the exclusion of those who performed fewer than 21 operations per year, 56 surgeons made up the study cohort.

Multivariable analysis showed significant non-modifiable patient-related factors associated with readmission were African-American race/ethnicity, more comorbidities, occurrence of postoperative complications, and an extended length of stay.

Variation in readmission by subspecialty ranged from 2.1% after breast, melanoma, or endocrine surgery to 37% following cardiac surgery.

The authors pointed out that this study "echoes growing concerns regarding the use of readmission as a quality metric based on its current methods."

Let's compare it to the controversial ProPublica Surgeon Scorecard.

Both the Surgeon Scorecard and the JAMA Surgery paper used data from the years 2009 through 2013. The scorecard involved only eight high-volume low-risk in-patient procedures while the paper looked at in-patient surgery of all types.

From an article written by the authors of the Surgeon Scorecard: "If a patient was readmitted to any hospital (not just the hospital where the surgery was performed) within 30 days of a surgery for one of the conditions we identified, we counted the case as a complication for the surgeon who performed the initial procedure."

What we learned from the JAMA Surgery paper raises some questions about the the Surgeon Scorecard. On Twitter, I asked for comment from Marshall Allen, the lead author of a white paper [not peer-reviewed] describing the methodology of the Surgeon Scorecard.

Between attacks on my credibility because I choose to use a pseudonym, he said that they did not count most readmissions as complications. It is unclear from the article, the white paper, or its appendices exactly which complications were included. For clarification, we could ask the "surgeon experts" who advised ProPublica, but their names have not been disclosed. They are anonymous, just like me.

According to the white paper, surgeons were blamed for 64,367 (46%) of all complications incorporated into the Surgeon Scorecard. Table 3 of the white paper lists the 20 most frequent complications. The top three, comprising 26,795 complications, were postoperative infection, iatrogenic pulmonary embolism, and infection/inflammatory reaction due to internal joint prosthesis.

Other studies have shown that not all occurrences of those three complications are attributable to a surgeon's misdeed. Among the rest of the top 20 causes of readmission were postoperative pain, fever, and dysphagia (difficulty swallowing)—again possibly not the fault of a surgeon.

So the JAMA Surgery paper says surgeons are responsible for 2.8% of readmissions within 30 days, but ProPublica's self-published white paper says 46% of all readmissions are due to something a surgeon did or did not do.

Who to believe?

Note added at 7:27 a.m. on 9/2/15: See my next post for a clarification about causation and variation. 

The full text of the peer-reviewed JAMA Surgery paper is available here.

In 22% of kids with appendicitis, antibiotics do not prevent perforation

Those clambering aboard the "antibiotics for appendicitis" bandwagon should read this interesting paper about appendicitis in children.

A group of emergency physicians from Maimonides Medical Center in Brooklyn, New York found that "Increasing in-hospital time delay from ED presentation to OR appendectomy is associated with increased risk for developing appendicitis perforation in children who present with CT-documented uncomplicated appendicitis."

Children with simple appendicitis who were taken to the operating room longer than 9 hours from the time of ED presentation were much more likely to develop a perforation than those who had surgery in less than 9 hours.

During the four years of the study, 404 consecutive children ≤ 18 years of age had a CT scan diagnosis of acute appendicitis; 156 (38.6%) had evidence of perforation at the time of presentation and were not included in the final analysis.

A medical student in Cuba is looking for advice

Someone writes: I am trying to help a friend's brother who is not a US citizen and currently a medical student in Cuba, and I came across your very informative web site. The brother most likely is going to be able to come to the United States in the fall.

My friend is wondering if he should complete the last year of medical school there in Cuba or come here and continue on. It seems like there is no benefit from completing med school in Cuba, given the difficulty to be licensed in the U.S. And the difficulty in getting a residency position.

Does any of the course work from his studies in Cuba transfer over to U.S? Is it likely that he'd have to get a bachelor's degree here before ever going to a U.S. Med school? My friend says that he has an outstanding record in the Cuban medical school, speaks excellent English, does well on tests, etc. Any advice you could give?

As far as I know, no medical students from Cuba have transferred to a med school in the United States recently or possibly ever. Regarding your questions, I can only give you my best guesses.

I doubt very much that a course from the Cuban medical school would be accepted here in the US. US med schools that accept a few transfers from Caribbean schools like Ross or St. George's usually take those students at the beginning of the third year of medical school.

A few schools are doing combined BS/MD degrees in five or six years, but I don't know of a single US school that would take a student directly out of high school into a 4-year program.

Male docs are more often involved in medicolegal actions than female docs

"Male doctors are more likely to have experienced medico-legal actions compared to female doctors. This finding is robust internationally, across outcomes of varying severity, and over time," concluded a recent meta-analysis.

The study, published online in BMC Medicine, said men were 2.45 (95 % CI, 2.05–2.93) times more likely to have been the subject of legal proceedings.

Legal action was defined as disciplinary action by a medical regulatory body, malpractice experience, complaints received by a medical regulatory or healthcare complaints body, a criminal case, or when a paper on the topic did not specify one of the above.

Data from 32 published papers were pooled and analyzed. At first glance, the methods seem reasonable, and the conclusion may even be correct.

But to their credit, the authors mention that the paper has some limitations which, in my opinion, probably invalidate the results.

A “shallow water blackout” is a silent killer

In Jacksonville, Florida, a 50-year-old woman was found at the bottom of her backyard swimming pool. She was an experienced scuba diver who “often stayed at the bottom of the 9-foot deep end without oxygen to increase [her] lung capacity for future dives.”

Despite receiving CPR from her son, she could not be revived.

The Associated Press story about this tragic incident did not explain why a swimmer with her background drowned.

It appears to be a classic case of “shallow water blackout.” This phenomenon occurs when people hyperventilate before diving.

An increasing level of carbon dioxide (CO2) is what triggers the urge to breathe. Hyperventilating causes hypocapnia, a reduced amount of CO2 in the blood. If a swimmer uses up enough oxygen to pass out before the CO2 trigger point for breathing is reached, drowning will occur without notice. Victims are usually found at the bottom of the pool.

Here’s what it looks like in a diagram from Wikipedia:

A physician who lost her son to this little-known phenomenon started a website to heighten awareness of the problem. The site contains more information and stories about other drownings caused by shallow water blackouts.

Here is a video of a woman swimming laps of a pool underwater. Advance to the 0:50 point and watch what happens as she begins to slow down. [Addendum 8/13/15 12:50 pm: Warning. The video is graphic. It shows the unconscious swimmer being pulled from the water.]
 

A shallow water blackout may have been responsible for the death of Natalia Molchanova, the world’s foremost freediver, who went missing a few days ago.

Hyperventilating prior to diving is not recommended. Tell your friends.