My response to a misguided opinion piece about surgery

"There is no place for the surgeon myth in modern medicine" says writer Alexis Sobel Fitts in Aeon Magazine.

Having a sister in medical school apparently qualifies Ms. Fitts to critique the specialty of surgery.

She starts with an old joke "An internist can figure out what’s wrong with you, but he can’t fix it. A surgeon has no idea what’s wrong with you, but he’s happy to fix it." If you read it carefully, you should note that it’s not that funny, and it’s wrong on both counts. No surgeon would ever fix something unless she knew why, and internists have these things called pills which can successfully treat a number of diseases.

She goes on, "After all, fixing problems is corporeal, often removed from the more intellectually nimble task of diagnosis." Apparently she is unaware that surgeons often make diagnoses—occasionally even correct ones, and I’ve written before about the misconception that doing an operation doesn’t require thinking [here and here].

"Surgeons are descended from the barber or the butcher," she says. That was hundreds of years ago. Nowadays, surgeons complete four years of medical school just like her sister and all the other doctors.

"Any missteps might incite devastating consequences, as the surgeon navigates around the vagus nerve, which dictates facial response…" I hope her sister didn’t give her that information. The vagus innervates many structures, but the face isn't one of them.

"Before anaesthesia and antibacterials, a patient undergoing surgery could be assured of two things: immense pain and the likelihood of infection and death." That’s actually three things. Of course without surgery, patients experienced immense pain, infections, and death anyway.

"Since the 1950s, laboratory science has increasingly been the origin of medical innovation. Which is why, over the past four decades, merely a 10th of the articles published in The New England Journal of Medicine have covered surgical innovation." Or maybe it's because The New England Journal is a medically, not surgically, oriented journal.

Here’s the winner. "Surgery’s place at the bottom of the medical hierarchy can be attributed to the crude cruelty of early surgical procedures." Other than Ms. Fitts, who has placed surgery at the bottom of the medical hierarchy? It’s certainly not US medical students who make the surgical specialties among the most competitive of all.

In the 2015 resident match, surgical specialties filled their first-year positions with 80% or more US medical school graduates. In fact, orthopedics matched with 94.3% US grads. Compare those numbers to internal medicine and family medicine, which filled their first-year positions with 49% and 44% US graduates, respectively.

Here's what Wikipedia has to say about its Aeon Magazine entry:

This article has multiple issues. Please help improve it or discuss these issues on the talk page.

The neutrality of this article is disputed.

This article contains content that is written like an advertisement.

This article contains weasel words: vague phrasing that often accompanies biased or unverifiable information.

That pretty much describes the Aeon essay about surgeons too.

Electronic medical records: Documentation of care and upcoding

Electronic medical records make documentation easier and that may be a problem.

There are many interesting unintended consequences of electronic medical records (EMRs). I was reminded of this by a recent blog I wrote about what interns really do when they are on call. According to a study from a VA hospital using trained time-motion observers, interns spend 40% of their time on a computer and only 12% of their time taking care of patients. This meshes well with other reports noting that doctors are staring at screens instead of talking to patients.

Here’s the problem. The system actually rewards extensive documentation which may result in less patient contact. The saying “If you didn’t document it, you didn’t do it” has morphed into “Document it, and you can use a higher billing code.”

Here are some CPT billing codes for hospital visits.

99221 Initial Hospital Care, Physician spends 30 minutes at the bedside

99222 Initial Hospital Care, Physician spends 50 minutes at the bedside

99223 Initial Hospital Care, Physician spends 70 minutes at the bedside

Sources tell me that they know of physicians who never bill for less than 99223 or 70 minutes for a history and physical (H&P) examination. In order to do this the doctor must document such things as having reviewed at least 10 different systems (e.g., respiratory, GI, musculoskeletal etc.). This is easy to document without having actually done it. The EMR may have popup windows with lists of systems and symptoms that can be checked off as reviewed.

This problem is more prevalent among the so-called “cognitive” specialties like internal medicine and primary care because for procedure-based specialties like surgery, the H&P is usually “bundled” (included) as part of the fee for the surgery.

Now that it is so easy to write a very detailed H&P, it must be tempting to bill every encounter at the maximum level. However, this may come back to bite those who try it. Medicare has been known to audit hospital charts and office records. They have profiles of what the distribution of the various levels of care should be.

Also, there are only so many hours in a day. Let’s say you are working a 12-hour shift and bill for eight 75 minute H&Ps and ten 25 minute subsequent visits. That’s 600 + 250 = 850 minutes or over 14 hours. If you are audited, you will have some explaining to do.

You may think that I am exaggerating but I am not the only one to raise this issue.

A recent long-read from the Center for Public Integrity confirms my thoughts. Here’s a quote from that piece, “And Medicare regulators worry that the coding levels may be accelerating in part because of increased use of electronic health records, which make it easy to create detailed patient files with just a few mouse clicks.”

The article points out that billing for higher codes has risen over the last several years and it’s costing the taxpayers over $6 billion. It warns that Medicare audits might be forthcoming, but some feel that audits might cost more to perform than the revenue they generate.

We will see.

Shortage of Primary Care Physicians Persists: Causes and Solutions

For at least the last 20 years, graduates of U.S. medical schools have resisted pleas from organized and disorganized medicine to become primary care physicians (PCPs). Since there is already a severe shortage of PCPs, pundits are wondering who is going to take care of the hordes of newly insured by 2014. Many have speculated about the possible reasons for this dilemma such as the relatively paltry earning potential of PCPs, the amount of debt incurred by graduates of medical schools, the perceived lack of prestige of a PCP career etc.

I have some theories of my own. One, primary care is boring. It has been estimated that 90% of patients appearing in PCP offices have no treatable illnesses. This leads to another issue which is that a physician assistant or nurse practitioner can treat most of these patients, often without input from a physician. PCPs function as triage officers. If an interesting case should somehow happen along, the PCP refers the patient to a specialist who deals with the problem. Since the advent of hospitalists (physicians who restrict their practices to hospitalized patients only), PCPs are never seen in hospitals which almost guarantees that they will not be involved with anything interesting.

What is the solution? Bear with me. I will make a point eventually. About 15 years ago, medical schools in the New York City area were scrambling to climb aboard the family practice bandwagon. (Grant money was available for schools to establish departments of family practice.) This was a real problem for the schools since there were about as many family practitioners in metropolitan New York as there were blacksmiths. One school managed to set up a family practice department with a chairman who practiced in a town about 50 miles north of the city. Students were offered tuition forgiveness for the fourth year of medical school if they promised to do a family practice residency after graduation. Of some 12 initial enrollees in the program, a grand total of one ended up in family practice, proving one couldn’t even bribe students to become PCPs. I recall asking a few students why they thought the program did not work. The answer was that the new rotation in family practice was too realistic. It was as boring as actually being a family practitioner.

The solution to recruiting more students into family practice is to replicate the situation that exists in specialties the medical students highly desire like emergency medicine, anesthesiology and dermatology [the most competitive residency training program in all of medicine (see page 11)]. Most schools offer very little or no exposure to these disciplines in their curricula. Medical schools should disband their family practice departments. Thus, a mystique would be created and the students would be seduced. I believe this would work. If needed, I am available to chair a task force or blue ribbon panel on this issue.