tag:blogger.com,1999:blog-4968787219619380438.post2646215583502462993..comments2023-09-21T04:02:29.457-04:00Comments on Skeptical Scalpel: Deciding whether adverse events are preventable or notSkeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.comBlogger18125tag:blogger.com,1999:blog-4968787219619380438.post-62063897591186462016-06-01T08:00:44.709-04:002016-06-01T08:00:44.709-04:00Of course, the reviewers of the bile leak after la...Of course, the reviewers of the bile leak after laparoscopic cholecystectomy said it was a preventable complication. As noted in the comments above, most postop bile leaks are NOT preventable.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-18490693887080931552016-05-29T11:44:42.320-04:002016-05-29T11:44:42.320-04:00William, great points. We may have already lost th...William, great points. We may have already lost the battle though.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-8785250165633938372016-05-26T15:27:32.655-04:002016-05-26T15:27:32.655-04:00The Toyota story is illustrating a very important ...The Toyota story is illustrating a very important point.,<br />When big government or big business decides that a certain method should be universally applied, the rationale is that the use of this specific method will reduce errors which when multiplied by large numbers will result in a better product over all. However, when the method is in fact flawed,this results in<br />massive defects everywhere.<br /> Today we see the widespread acceptance of central planning<br />in medicine based on the notion that this will improve care for<br />the whole world.However, when the method turns out to be flawed ( eg: use of the 1-10 pain scale and a pain hotline ordained by the Joint Commission back in the 90's ) we see a massive problem created: the opioid epidemic. Will the insistence on all the "quality indicators" chosen by the central <br />medical authorities result in the realization in ten years that<br />the power thus used inflicted terrible damage in the heath of<br />Americans and the "health care system" itself. Unchecked bureaucratic power has the potential to do enormous damage.<br />The history of the Russian planned economy after the Revolution<br />which destroyed agriculture and resulted in widespread famine<br />demonstrates the risks in top down management by bureaucrats that made tragic errors in the name of progress. Are we witnessing the same phenomenon in medicine in the USA today?<br /><br /><br />William Reicherthttps://www.blogger.com/profile/10062067819184876941noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-44087720292514289512016-05-20T08:07:12.824-04:002016-05-20T08:07:12.824-04:00And many in medicine would like us to adopt "...And many in medicine would like us to adopt "Lean" methods because it has worked so well at Toyota which has recalled about 20 million vehicles in the last 10 years. I'm diving a car with airbags that can kill me and they can't be replaced until July because the parts are not available.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-40273285996244025432016-05-19T14:07:00.071-04:002016-05-19T14:07:00.071-04:00We live in a world where we cannot guarantee every...We live in a world where we cannot guarantee every car rolling off the assembly line will work flawlessly 100% of the time. This is something we created. How much more complex is the human body? There is so much we don't even know. To think we can prevent every complication or death is just narcissistic pride the likes of which would make Satan envious.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-83537750953739554822016-05-19T11:28:07.889-04:002016-05-19T11:28:07.889-04:00William, very well said. William, very well said. Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-16046347253926487492016-05-19T09:48:56.664-04:002016-05-19T09:48:56.664-04:00It is 100% preventable by not operating, of course...It is 100% preventable by not operating, of course. A few years ago, I was told I had gall stones, found during an echocardiogram.The tech said "while were here let's check".<br />I never had had symptoms. A surgeon met me in the hall and<br />asked when I wanted by gall bladder out. A GI guy said I better get it out in case I have an attack while camping out in Idaho. <br />Wary of duct leaks, which I have seen and can be very serious,<br />and to my mind not 100% preventable, I passed on the surgery.<br />That was 30 years ago. Still doing fine. Thank you.<br /> Obviously these leaks are not preventable. If they were, then<br />the word would get out that there was one method which prevents them. There is no such method. No one knows what causes these leaks. The supposition is that the surgeon did something wrong. That is not provable in court. We can say that the surgeon is responsible for the leak. In which case the surgeon<br />should increase his fees to pay for the costs incurred by the leak. This is what is known as malpractice insurance. This is a misnomer. It should be called adverse outcome insurance.<br />Getting the jury to call it preventable assists in larger payouts.<br />It is absurd for a committee to say an adverse outcome is preventable unless the committee can point to a method scientifically proven to prevent a certain adverse outcome.<br />This will be impossible in surgery due to the multiple actions the surgeon makes during operation.<br /><br />William Reicherthttps://www.blogger.com/profile/10062067819184876941noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-48237987529641738852016-05-18T07:32:12.783-04:002016-05-18T07:32:12.783-04:00Anon from 1:28 PM-you need to do what works best f...Anon from 1:28 PM-you need to do what works best for you. If blunt dissection is easier, I see no problem doing it that way.<br /><br />Anon from 10:46 PM-reports of complications and deaths are supposed to be adjusted for risks. However, many studies use administrative (billing) data not clinical data to report complications and death rates. Admin data are not as precise.<br /><br />It is well-known that some surgeons react to publicly published complication rates by cherry picking less sick patients. It may very well be that the best surgeons are the ones who take on the sickest patients. That's one of the fallacies of the so-called "Surgeon Scorecard" I have blogged about.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-4891866690149210692016-05-17T22:46:20.397-04:002016-05-17T22:46:20.397-04:00I have a question. How would any study handle adv...I have a question. How would any study handle adverse events and poor outcomes that come with higher risk patients? My mother was diabetic, prone to tia's, and had heart disease. She needed bypass surgery - I worked at a hospital [office staff] and our "best" heart surgeon refused to even consult - given her medical history. She had the surgery done at a different hospital - it was successful and she did well for 20 more years. But a realistic look at her possible outcomes was not the best. One doctor looked and decided his stats were more important [confirmed by a 2nd party], one doctor decided to operate.<br />The pressure to keep M & M stats positive has to impact both physicians and hospitals. Seems like there is no good way to differentiate statistically between a patient with a greater expectation of good outcome over a patient with a greater expectation of poor outcome.<br /><br />Wordy and verbose, but I hope you understood my question.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-25141451064098704882016-05-17T13:28:27.642-04:002016-05-17T13:28:27.642-04:00SS, when using only cautery on difficult gallbladd...SS, when using only cautery on difficult gallbladders, I guess I found myself getting out of the proper plane of dissection more often.<br /> I guess that is what makes surgery so hard to study: the surgeon is an important (and unwieldy) variable.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-34679973778496690872016-05-17T09:23:34.619-04:002016-05-17T09:23:34.619-04:00Artiger, of course you are correct.Artiger, of course you are correct.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-47780393738566538772016-05-17T09:20:22.533-04:002016-05-17T09:20:22.533-04:00Anon, I agree with you that some by a leaks are pr...Anon, I agree with you that some by a leaks are preventable and some, such as the one you mentioned from a duct of Luschka, are not. <br /><br />That's why I chose that example.<br /><br />It's an interesting theory you have that perhaps blunt dissection is less likely to cause such a leak. It would be difficult to study because duct of Luschka leaks are so uncommon.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-79116818105544417642016-05-17T09:07:38.528-04:002016-05-17T09:07:38.528-04:00Scalpel, I'm going to guess that the reviewers...Scalpel, I'm going to guess that the reviewers called it preventable, no matter what the cause of the leak actually was. artigerhttps://www.blogger.com/profile/13361655152970244221noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-42351620191976066402016-05-16T20:43:18.607-04:002016-05-16T20:43:18.607-04:00As a general surgeon with 12 years of experience: ...As a general surgeon with 12 years of experience: I have never had a cystic duct leak or a major bile duct injury in my practice. I have had some duct-of-Luschka leaks, however; roughly the 1/200 rate quoted in the literature. In recent years, my bile leak rate is down. I think it is because of my increased use of blunt dissection to free the gallbladder from the liver bed, and decreased use of cautery (especially when I can't visualize a nice areolar plane.) Sometimes I essentially peel the gallbladder off of the liver. Staying out of the liver (and also staying out of the gallbladder), is a big deal in my opinion. I think it reduces the rate of bile leaks and of major bleeds from the liver bed.<br /> Regarding the cystic duct: I was trained to place two clips on it, while a resident. Since residency, if there was room on the cystic duct, I might even place 4 clips (I figured that nobody ever died of stainless steel or titanium poisoning.)<br /> However, SS, your point is very well taken, that bile leak may well be a non-preventable complication. Anybody who says otherwise, has only operated on cadavers or dolls.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-18466695810117042872016-05-16T20:18:13.645-04:002016-05-16T20:18:13.645-04:00I am simply pointing out that deciding if an error...I am simply pointing out that deciding if an error was preventable is not so easy and can be subject to bias.<br /><br />It's MDs who are writing these papers with wild estimates of the number of preventable deaths. Is it a conspiracy of us against ourselves?<br /><br />Artiger, you have saved me the trouble of explaining why the summary I cited is a good example of a case that can't be decided by a brief summary. Of course the complication could be preventable or not depending on what caused the leak.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-21495492481716058122016-05-16T18:12:15.555-04:002016-05-16T18:12:15.555-04:00Regarding the bile leak example, based on the info...Regarding the bile leak example, based on the information given, it could go either way. It depends on if the leak was a draining duct of Luschka, clips falling off the cystic duct stump, or the common bile/hepatic duct being cut. The first is likely something that would not have been visible during surgery, and usually is not avoidable. The second could go either way. The third is an error in a lot of cases, although we don't know if the patient had severe acute cholecystitis, which would make the situation more troublesome. <br /><br />Since the example only mentioned a four day hospitalization for observation only (i.e., no interventions or re-operation), I'd have to conclude that it was a leak that stopped, although that's a big assumption. That's not an error. It's impossible to know without looking at the whole record, which is the point Scalpel was making above. artigerhttps://www.blogger.com/profile/13361655152970244221noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-14903835841625966412016-05-16T16:39:17.648-04:002016-05-16T16:39:17.648-04:00Your question is very much rhetorical, but I think...Your question is very much rhetorical, but I think that, underlying all this, there's the fact that payers are more interested in driving a hard bargain than in science or even in basic fairness.<br /><br />If you complain that complications that happened under your watch weren't reimbursed, much of the lay public will tend to see you as money grubbing at best and criminally incompetent at worst--even if the complication wasn't entirely unavoidable in the first place.<br /><br />Even if your complaint is entirely justified, it will tend to corroborate the kind of sensational headline you mentioned in your previous post, giving Joe Public a warm fuzzy feeling of superiority over those pompous ass docs.<br /><br />In summary, there's a lot of interest--billions of dollars' worth of interest--in putting physicians on the defensive. Maybe this is biasing some conclusions out there.<br />Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-61478230388495446032016-05-16T16:33:41.117-04:002016-05-16T16:33:41.117-04:00I know way too many patients who have been the obj...I know way too many patients who have been the objects of medical mistakes and the like. Doctors have a way way different definition. When we see ego going into making a diagnosis and the resulting errors, doctors don't see it but we sure do. <br />Anonymousnoreply@blogger.com