My top 7 blog posts of 2016

I’ve written over 700 posts since I started blogging in July 2010. Here are my seven most viewed posts of 2016.

My perspective on the notorious “study” claiming medical errors are the third leading cause of death in the United States. Are there really 250,000 preventable deaths per year in US hospitals?

I followed up by commenting on the negative impact of naive reporting about that preventable death study in When bad research is not critically reported by journalists.

Radiologist Saurabh Jha and I discussed the risks of radiation and rationale for ordering a CT scan for the diagnosis of appendicitis in this post Irrational fear of CT scans in appendicitis.

Another post about appendicitis was my critique of a meta-analysis claiming that antibiotics were safe and efficacious for treating simple appendicitis. Needless to say, I disagreed. Antibiotics vs. surgery for appendicitis.

The issue of surgeon headgear doesn’t seem to go away. The traditional surgeon cap is being banned by some states and nursing organizations. This post, It's time to discuss surgeon headgear again, was popular. Bonus eighth post: The subject came up again when the Association of periOperative Registered Nurses and the American College of Surgeons had a dustup about it later in the year. OR head covering controversy: ACS versus AORN.

I reported on a controversial paper about the relationship between surgeons and anesthesiologists How frequently do surgeons and anesthesiologists lie to each other?

One of my favorite topics is the lack of consistency among the multitude of hospital rating systems. I gave some examples in this post Why hospital rankings are bogus.

Thanks for following my blog and reading my posts. Happy New Year.

Good patient safety news you didn’t hear about

In the last five years, there’s been a 21% reduction in hospital acquired conditions (HACs) says a report by the Agency for Healthcare Research and Quality. This means that patients suffered 3.1 million fewer HACs than if the HAC rate had stayed at the 2010 level.

Since 2011, the decrease in HACs has reduced healthcare costs by an estimated $28.2 billion and has saved almost 125,000 lives.

This graphic summarizes the AHRQ findings.

Central line-associated bloodstream infections have fallen by 91%, and postoperative venous thromboembolism by 76%. Here’s a chart that shows the percent decreases in HACs.

The report said the reasons for these improvements “are not fully understood,” but might be due to the following:

• Financial incentives created by the Centers for Medicare & Medicaid Services (CMS) and other payers’ payment policies,
• Public reporting of hospital-level results,
• Technical assistance offered to hospitals by the Quality Improvement Organization (QIO) program, and
• Technical assistance and catalytic efforts of the HHS PfP [[Pay for Performance] initiative led by CMS.

An thorough Google search found a few articles about this important and positive AHRQ report. Were they in the New York Times, Washington Post, Newsweek, US News, or The Daily Mail?

No. the news could only be found on HealthcareIT Analytics, Fierce Healthcare, the website of the Healthcare Association of New York State, Pharmacy Practice News, and HealthcareIT News where I obtained the multicolored graphic above.

Why do you suppose no major media outlet reported the story?

Good news doesn’t get clicks.

No improvement in complication rates after instituting an operating room checklist

A before and after study at the University of Vermont Medical Center found that a 24-item operating room checklist did not significantly reduce the incidence of any of nine postoperative adverse outcomes.

More than 12,000 cases were studied, and outcomes included mortality, death among surgical in patients with serious treatable complications, sepsis, respiratory failure, wound dehiscence, postoperative venous thromboembolic events (VTE), postoperative hemorrhage or hematoma, transfusion reaction, and retained foreign body (FB).

After the checklist was established, respiratory failure rates decreased significantly on the initial analysis, but the difference disappeared when the Bonferroni correction* was applied to the data set.

Why didn’t the checklist work? I have discussed this in previous blog posts here and here. As was true in previous papers of this nature, many of the complications studied—respiratory failure, wound dehiscence, transfusion reaction, postoperative hemorrhage or hematoma—could not have been prevented by a checklist.

Breaking residency placement fever

 By Francis Deng* and Skeptical Scalpel

A recent opinion piece entitled “Residency Placement Fever” in the journal Academic Medicine by Gruppuso and Adashi noted a recent intensification in the volume of residency applications submitted and interviews offered/attended per applicant.

For keen observers of the Match process, this trend is neither a secret nor a surprise. The Electronic Residency Application Service (ERAS) has seen an increase in applications filed per US medical school graduate from an average of 30.3 in 2005 to 45.7 in 2015.

Inflation of residency applications is getting out of control these days. Time for a limit in ERA$ pic.twitter.com/AsRn8c3fgd

— Francis Deng, MD (@francisdeng) October 31, 2016

Who really did the case?

According to the Residency Review Committee for Surgery, "A resident may be considered the surgeon only when he or she can document a significant role in the following aspects of management: determination or confirmation of the diagnosis, provision of preoperative care, selection, and accomplishment of the appropriate operative procedure, and direction of the postoperative care."

In nearly all instances, resident "determination or confirmation of the diagnosis, provision of preoperative care, selection of the operative procedure, and direction of the postoperative care" happen only in emergencies. For the majority of elective patients and same day operations, the residents do not play significant roles in most components of perioperative management.

What about "accomplishment of the appropriate operative procedure"? Are the residents really doing the cases they scrub on?

A recent paper from the University of Texas Medical Branch in Galveston, called "Who did the case? Perceptions on resident operative participation," looked at this question in a surprisingly candid way. The authors asked residents and faculty to independently assess what percentage of the operation the resident performed.

For the 87 cases for which responses from both resident and attending surgeon were available, agreement on percent of the case performed by resident (< 25%, 25 to 50%, 50 to 75%, > 75%) occurred in 61%, agreement of the role the resident played (first assistant, surgeon junior year, surgeon chief resident, teaching assistant) occurred 63% of the time, and agreement on both percent and role occurred only 47% of the time.

This reminds me of a story from when I was a resident. In the surgeons' locker room one day, someone asked a senior attending if the resident who scrubbed with him had done the case. The attending replied, "He thinks he did."

That's what the authors from Texas found too. In about two-thirds of the cases with disagreement about the percent of a case the residents did, the residents felt they performed larger portions of the case than did the faculty.

What constitutes "a significant role" is open to interpretation.

A resident once came to me and said, "I'm not really sure I should claim I was the surgeon for a case I scrubbed on today. Should I log myself as 'surgeon' anyway?"

I said, "If you have to ask, you probably shouldn't claim it."

Surgical residents are supposed to enter the cases they do in an online database, and the RRC uses these data in its accreditation process. The American Board of Surgery mandates that residents perform specific numbers of various types of cases in order to be eligible to take their boards.

A 2016 study in the Journal of Surgical Education surveyed 82 residents from various surgical specialties at UC Irvine and found only about half of the responding residents were told how to assess what their role was, and they were often delinquent [for more than one year at times] in logging their procedures leading to inaccuracies in the logs.

The authors concluded that the way cases were being logged raised "concerns about the use of the system for assessing surgical preparedness or crediting training programs."

The two papers cited above are small studies from single institutions, but in my opinion, probably reflect the reality in most residency training programs.

Submitted case log numbers may be misleading. This may be a previously unidentified factor in the crisis in confidence afflicting some graduating chief surgical residents.

Would competency-based training be better? The buzz about competency-based training has died down, and there are skeptics including the authors of this thoughtful editorial from the Journal of Graduate Medical Education.

Starting in the 2017-2018 academic year, the American Board of Surgery will require a minimum of 850 operative procedures for the five-year training period and 200 operations in the chief resident year—increases from 750 and 150, respectively.

Will competency-based training or increasing the number of operations required help?

Not if the residents aren't really doing the cases.

Lean methodology and patient safety

A recent story in U.S. News & World Report described how a Seattle hospital is taking a systems approach in improving healthcare quality and cutting costs. It said, "Virginia Mason Health System...has looked to adopt many of the much-admired and often-emulated business philosophies from Toyota."

The best-known of those philosophies is the so-called "lean methodology" which is based on eliminating waste and focusing on things that add value.

Attempts to incorporate lean into healthcare have met with varying degrees of success. I blogged about this six years ago and pointed out that a literature review done back then found "significant gaps in the [lean and six sigma] health care quality improvement literature and very weak evidence that [lean and six sigma] improve health care quality."

Randomized prospective trials of lean in medicine are lacking. A recent paper from the Journal of the American College of Radiology found only seven studies on the use of lean in radiology and they showed "high rates of systematic bias and imprecision." The authors concluded there was "a pressing need to conduct high quality studies in order to realize the true potential of these quality improvement methodologies [lean and six sigma] in healthcare and radiology."

In addition to the debatable evidence that lean actually works and the cost and time to develop and implement lean measures, the use of Toyota as a model for quality is also highly questionable.

In 2010, Toyota had recalled more than 9 million vehicles for various defects. Nothing has improved. So far this year Toyota has recalled over 11,654,000 vehicles. The problems included exploding airbags, brake failure, fuel tank defects, and minivan doors opening while cars were in motion.

Having adopted lean methodology in 2002, Virginia Mason is not really a new story. How is it doing?

About as well as Toyota.

In May of this year, the Joint Commission paid a surprise visit to Virginia Mason Medical Center and found 29 instances where the hospital was out of compliance with standards. The Seattle Times wrote that among the problems were not having an adequate infection prevention and control plan, failure to store medication safely, and failure to provide a "care, treatment, services and an environment that pose[d] no risk of an immediate threat to health or safety."

On September 17, Virginia Mason regained full Joint Commission accreditation status, and 6 weeks later the hospital announced that it received an "A" grade for patient safety from the Leapfrog Group.

A hospital that failed a Joint Commission site visit because of multiple safety issues gets an "A" for patient safety in the same year? I discussed problems with the Leapfrog patient safety rankings in a previous post.

And if lean works so well in healthcare, can anyone tell me how does a hospital that has been practicing lean methodology for 14 years achieve 29 Joint Commission citations?

Why is medical school tuition so high?

A couple of weeks ago, BoingBoing posted a picture of a tuition and fee schedule for San Diego State University in 1959. Tuition was free for California residents but they still had to pay $33 for materials and services and $8 for student activities. Nonresident tuition for a full-time student was an additional $127.50. These charges were apparently all per semester.

Using this handy inflation calculator, the total per semester cost for a California resident of $41 equates to $340.16 in 2016 dollars, an inflation rate of 729.6%. Free tuition ended in 1970. Current tuition and fees at San Diego State for the year are now $7084 or $3542 per semester—compared to $340.16 that’s a 941% increase.

Just for fun I decided to run the numbers for my medical school tuition. In 1967, my first year, the total tuition for the year was $1200 or $8674.06 in 2016 dollars. The current tuition for the private medical school I attended is $52,000, a 499% increase.

Do postoperative adhesions cause abdominal pain?

A reader asks whether I think adhesions cause postoperative abdominal pain and if so, how should they be treated?

I have always been skeptical (no surprise) about blaming adhesions for pain.

If adhesions cause abdominal or pelvic pain, what is the mechanism? We know that the intestine can be handled, cut, and cauterized without causing pain. What about tugging or pulling on the bowel? Would that cause pain? I doubt it. How much tugging or pulling can take place within the confines of the peritoneal cavity anyway? A literature search did not turn up any studies on  the mechanism of adhesions causing pain.

UpToDate, the online medical textbook, has a section on this topic. It doesn't address how adhesions cause pain but does discuss the evidence that reoperating on patients with adhesions is not worthwhile.

A medical oncologist weighs in on the treatment of appendicitis

It was an interesting fortnight for the debate about the treatment of appendicitis.

On November 1, David Agus, a medical oncologist and Director of the University Of Southern California's Center for Applied Molecular Medicine, had some thoughts about how appendicitis should be treated. He cited the Finnish randomized trial of antibiotics vs. surgery and said a 70% cure rate was good enough.

In a brief article on the Fortune magazine website, Agus wondered why appendectomy "continues to reign supreme." He said it was "because 24/7 we’re taught you have to take it out if there’s appendicitis” and that the healthcare community is "stubborn and pigheaded" [pigheaded means stubborn] and that we focus on treatment instead of prevention.

The moon and hospital admissions

A few days ago we had a full moon. A lengthy discussion about the effect of a full moon on hospital admissions took place on Twitter.

Many papers say admissions increase and odd things happen, and many others have found there is no relationship between the phases of the moon and anything that goes on in hospitals.

Someone sent me a link to a paper that a lot of devotees of astrology like to quote. It's called "The influence of the full moon on the number of admissions related to gastrointestinal bleeding," and it appeared in the International Journal of Nursing Practice in 2004.

A brief tale of an 18th century Irish surgeon's demise

On my recent trip, I had the pleasure of visiting the Royal College of Surgeons in Ireland in Dublin. Its 200-year-old main building is steeped in history. During the 1916 uprising that led to Ireland's independence, the rebels used it as a billet. Pockmarks from British bullets are still visible on its front columns.

Today the RCSI houses a medical school with a diverse international student body. Thanks to my gracious host, vascular surgeon Sean Tierney, I was able to tour the college's modern classrooms. I also saw a well-equipped simulation laboratory and took part in some virtual reality exercises.

In one of the many beautifully appointed rooms is a statue of William Dease, a noted surgeon who was one of the founders of the RCSI in 1784 and its fifth president. He was also a member of the Society of United Irishmen which started the Irish Rebellion of 1798.

Although the circumstances surrounding Dease's death are somewhat unsettled, the most popular version of the story is that in June 1798 he learned he was about to be arrested because of his association with the United Irishmen and committed suicide by slicing open his femoral artery.

In 1886 his grandson donated a statue of Dease to the college. Some years later the statue developed a crack in a most unusual location. The photograph below shows why.

Incidence of speech recognition errors in the emergency department

Speech recognition errors occurred in 71% of emergency department notes and 21.1% of notes with errors were judged as critical with potential implications for patient care says a recent study in the International Journal of Medical Informatics.

Investigators looked at a random sample of 100 dictated notes and found 128 errors or 1.3 errors per note.

More than half of the errors were ascribed to speaker mispronunciation. Although when I use speech recognition software, it sometimes does not accurately discern what I am clearly saying.

Other errors involved deleted and added words, nonsense, and homonyms.

An example of a nonsense error was "patient up been admitted for stable gait."

Some of the critical errors (with possible interpretations) were as follows:

About that $39.35 charge for holding a newborn baby

By now you've probably heard about the hospital that charged $39.35 for a woman who just had a cesarean section to hold her baby.

The baby's father posted a copy of the bill on Reddit, and it drew over 11,800 comments. The story was also widely circulated on Twitter.

At least one labor and delivery nurse on Reddit and a spokesperson for Utah Valley Hospital where the baby was born stated that the charge was not for holding the baby, but rather it was because an extra nurse had to be brought into the room to watch the baby while the first nurse took care of the mother.

I'm not buying it. The only way to justify charging for the presence of a second nurse would be if she had to be called in from home. If the nurse was already in the hospital which I'm sure she was, the five or so minutes that it would take for her to stand by while the mother holds the baby would surely not take her away from the routine duties of a labor and delivery nurse.

This is especially true for Utah Valley Hospital which delivers about 3600 babies per year. Only about 30% of them or about three per day are born by cesarean section.

And who says a second nurse is even required? Most cesarean sections are performed under epidural or spinal anesthesia. The mothers are awake and perfectly capable of holding a newborn child. An anesthesiologist or nurse anesthetist is always in the room and is primarily responsible for caring for the mother anyway.

Like most hospital charges, the $39.35 figure appears to be the product of some bean counter's imagination. Why $39.35? Why not $39.95 or $68.87?

Apparently Intermountain Healthcare (a system which includes Utah Valley Hospital) has some other interesting billing practices. This is what one Reddit commenter had to say:

Hey, I know this world: we had to pay $700 for our son to stay in my wife's room. Here, I'll explain: my wife was billed $700 per night after her c-section, and my son was also billed $700 per night for his room.

Here's the kicker: they shared the same room!! So, I thought it was a mistake, right? So I called the horrible people at Intermountain Healthcare to point out that they had billed two charges for the same room. They're [sic] response? "We bill each patient for the full room charge." Yep, they billed my wife $700 for her room, and my baby $700 for the same room. They also doubled the nurse charges (even though, again, my baby didn't have his own nurses.)

He refused to pay, and the bill was sent to a collection agency.

Congratulations on the birth of your son.

Vacation Notice

The majestic 700 ft. Cliffs of Moher, one of my favorite places in Ireland.

I will be in Ireland with possibly limited Internet access for the next 7 days.

Please browse my list of previous posts and read a few if you have time.

Any comments you submit may take a day or so to appear so please be patient.

Thank you for visiting my blog site and for reading my musings.

Social media solves a medical riddle

This foreign body was removed from a non-healing abdominal wall incision in an elderly lady with many comorbidities and previous operations. It was a rigid plastic tube which was 7 cm long and 2-3 mm in diameter. There were four transverse grooves at either end.

Physicians caring for her were unable to identify it. One of them emailed me the photos and asked for help. I didn't know what was, but I knew where to look for the answer.

I tried a Google image search, but the brownish discoloration of the object was interpreted as wood by the algorithm. None of the many images on Google resembled the foreign body.

Review: Online question bank for med students and residents

I just finished evaluating a study aid for National Board of Medical Examiners shelf examinations. It’s called ExamGuru, an online question resource for the major specialty rotations encountered by a third-year medical student.

The surgery shelf exam has a total of 395 questions. You can create your own multiple-choice tests of any length, timed or not, and you can focus on the subsections of surgery you want to emphasize.

What makes this set of examinations unique is that you not only get the answer, you also can see whether the question is easy or difficult and how you compare to your peers who have answered the question previously.

Questions that are too hard or too easy are revised or replaced.

How long is too long for robotic surgery?

A surgical chairman writes [some details were changed to obscure the surgeon’s identity]:

We currently have surgeons who are trying to establish themselves as experts in performing a certain robotic operation. As an open case, it rarely takes more than about 4-5 hours.

With the robot, it is generally taking around 6 hours as reported in the literature, and morbidity and mortality in expert hands appears to be pretty good.

What is happening in the real world is that surgeons are taking 12 or more hours to perform these operations robotically. I am aware of one death after a 14 hour procedure in another hospital. One case in my own institution took 16 hours, and luckily the patient did well. Of course this sort of data never gets reported publicly. 

A white coat is more than just a symbol

The raging controversy over whether doctors should wear white coats has been based on the theoretical problem of possibly infecting patients with organisms that can be cultured from white coats vs. the lack of an apparent benefit from wearing a white coat.

A 2012 paper by investigators from Northwestern University in the Journal of Experimental Social Psychology sheds some new light on the latter issue.

Rather than summarizing the study myself, I will quote the excellent New York Times article about the three experiments that were done [emphasis added by me]:

In the first experiment, 58 undergraduates were randomly assigned to wear a white lab coat or street clothes. Then they were given a test for selective attention based on their ability to notice incongruities, as when the word “red” appears in the color green. Those who wore the white lab coats made about half as many errors on incongruent trials as those who wore regular clothes.

Surgeons are burned out in, of all places, France

More than half of French gastrointestinal surgeons in training are burned out says a paper published ahead of print in the American Journal of Surgery.

Five hundred gastrointestinal surgery trainees were surveyed, and 65.6% responded. Of those responding, 52% had indications of burnout syndrome—emotional exhaustion, depersonalization of relationships, and lack of self-fulfillment at work—on the well-validated Maslach Burnout Inventory.

Other notable findings were 67% had insomnia, and 12% had thoughts of suicide.

On multivariate analysis, the significant factors associated with burnout syndrome included being confronted with aggression from patients, lack of gratitude from senior colleagues, trainees feeling they had too much responsibility, and not participating in extracurricular activities.

The prospects for switching to a different specialty

Could you comment on how an applicant switching into general surgery compares to one that applied directly from medical school would be viewed? I had a very difficult time choosing between specialties and have been regretting my decision not to apply into surgery. I am currently in a prelim year in medicine and am currently matched into radiology. I want to reenter the match process this year but am nervous to give up my guaranteed radiology position at a top program for an unknown where I can go unmatched or matched into an undesirable program. I graduated from a US med school. My USMLE Step 1 score was 235, Step 2 252, and I have published 2 articles in a surgical sub-specialty field.

You are what is known to the National Resident Matching Program (NRMP) as an "independent applicant" (graduate of a US med school going back into the match).

Go to the NRMP website, download the PDF "Main match results and data 2016" and look at Figure 6, you will find that 52.2% of independent applicants in general surgery failed to match compared to only 9.9% of US seniors.

 

This holds true for most specialties. Note that 43% of independent grads did not match in neurology.

Your USMLE scores are quite good, and the fact that you have published to articles will probably help a little. However, the reality is that you probably have about a 50-50 chance of matching in general surgery.

I wish I could explain why this is. All I know is it has been this way for years.

I can't tell you what to do. I suggest you give this some serious thought. It is probably not ethical for you to reenter the match and not tell your anesthesia program that you are doing so, but I suppose that is an option. If you don't match in general surgery, you would still have your anesthesia spot, but if you do match, you will leave your anesthesia program high and dry.

If you decide to apply to general surgery, you should go with mostly community hospital programs and send out lots of applications. By lots, I mean more than 50 or as many as you can afford.

You will be able to better assess your chances as you see how many interviews you are offered.

Good luck with your decision and please let me know how it turns out.

 

OR head covering controversy: ACS vs. AORN

In early August, the American College of Surgeons (ACS) issued a statement on operating room attire. Much to my surprise and delight, it said this about headgear:

The skullcap is symbolic of the surgical profession. The skullcap can be worn when close to the totality of hair is covered by it and only a limited amount of hair on the nape of the neck or a modest sideburn remains uncovered. Like OR scrubs, cloth skullcaps should be cleaned and changed daily. Paper skull caps should be disposed of daily and following every dirty or contaminated case.

The Association of periOperative Registered Nurses (AORN) responded with a statement of its own:

Several types of evidence exist that support recommendations that perioperative personnel cover their head and ears in the OR. This evidence includes the fact that human skin and hair is naturally colonized with many bacteria, and perioperative personnel shed microorganisms into the air around them. We know airborne bacteria in the OR can fall into the operative field, contribute to the overall air contamination of the OR, and place patients at risk of surgical site infections. Completely covering the hair can reduce the number of bacteria introduced into OR air by perioperative personnel.

Unfortunately, the "evidence" cited by the AORN is all circumstantial. Yes, human hair and skin may be colonized with bacteria. There is no proof whatsoever that a single surgical patient has ever been infected by a hair or skin droppings from OR personnel. If you want to extend this logic to its inevitable conclusion, the entire neck and face should be covered too. Eyebrows and eyelashes could be deadly. Maybe all OR personnel, including circulating nurses and anesthesia, should wear helmets like those used by astronauts or deep-sea divers.

Some say it is impossible to do a study about this, but one of my Twitter followers came up with a perfectly reasonable suggestion. Simply have several teams of operating room personnel, some of whom are wearing bouffant caps and some wearing skullcaps, stand over an OR table. Instead of a patient, culture media could be placed in strategic locations. The OR teams should move about in scripted ways for an hour or two. Let's see whether there's any difference in the amount of bacteria grown in the cultures.

Perhaps the AORN should get its own house in order first. Many of the OR nurses and techs that I have worked with over the years wear their supposedly fully covering headgear like this: