“Number of medical students pursuing surgery specialty drops by half”

That was the headline in a September 10 Becker’s ACS Review article. The first sentence of the piece was more specific, “Only 4 percent of medical students surveyed in 2018 said their chosen medical specialty is general surgery, compared with 8 percent in 2016, according to Medscape's Medical Student Life & Education Report 2018.”

This caused some consternation among general surgeons on Twitter. I tweeted, “Interesting. Lifestyle is finally catching up to us. I think it will get worse.”

Papers about robotic surgery outcomes may be swayed by payments from the manufacturer

In 2015 alone, the top 20 surgeons receiving payments from Intuitive Surgical Inc., makers of the da Vinci robot, collected a median of almost $142,000. Of those surgeons, 12 have published 37 papers about the robot with 27 (73%) reaching strongly favorable conclusions about the robot’s effect on clinical outcomes, feasibility, or safety. Nine (24%) were equivocal, and one (2%) study was negative.

These results appeared in a paper published online in the American Journal of Surgery by investigators from the University of Michigan.

The 37 papers consisted of 36 observational studies and 1 randomized controlled trial. Robotic surgery patient outcomes were compared to patients operated on in the same institution or by the same surgeon in 11 papers, patients operated on in a different institution or by a different surgeon in 4 studies, to a database in 4, and to previously published papers in 2 instances. No controls or comparisons were used in 16 (43%) papers.

Intuitive Surgical sponsored six of the studies, all of which had positive outcomes.

According to the CMS Open Payments website, compensation received by the top 20 surgeons ranged from $106,176 to $325,164. Among the top 20 earners were 11 general surgeons, 4 colorectal surgeons, 3 thoracic surgeons, and 2 gynecologists.

Three of the 37 papers contained no conflict of interest disclosure statements.

Several limitations of the study were listed. Most journals favor publishing papers with positive results. It may be that surgeons not receiving any industry payments might have published similar numbers of positive studies. The accuracy of the Open Payments site has been questioned but it is the best resource we have currently.

The authors described their paper as a pilot study and called for more research on not only Intuitive’s effect on the medical literature but also the influence of industry in general.

The paper also illustrates the woeful state of research on robotic surgery—a device that has been used on patients for almost 20 years.

Is chronic pain after inguinal hernia repair a big problem?

Yesterday one of my twitter followers posted this:

He was referring to a paper in the British Journal of Surgery that said 15.2% of patients who had inguinal herniorrhaphies complained of severe chronic pain one year after the surgery. Open hernia repairs caused significantly more chronic pain than did endoscopic total extraperitoneal [TEP] repairs, but the reoperation rate was significantly higher for TEP procedures.

The study included almost 23,000 patients and was based on data from the Swedish Hernia Registry and a questionnaire sent to the patients one year after their initial hernia operation. Pain was rated on a scale of 1 to 7 and was considered chronic if it was present for more than 3 months and interfered with daily activities.

The recurrence rate for the 18,000 patients who had open anterior mesh repair was 3.4% compared to 23.3% for the 2688 who had TEP repairs.

The authors concluded that the trade-off for less pain was an increased recurrence rate. Only 232 [1.39%] of the 1666 patients with recurrent hernias had undergone repeat herniorrhaphy.

Some of the comments on Twitter were as follows:

When I was in private practice in the early 1980s, I invited all of my post-op hernia patients to return to my office for yearly follow-up at no charge.

One day, a nice elderly gentleman was sitting in the exam room when I walked in. After an exchange of pleasantries, I asked him how his hernia repair was doing. He said he had no problems and was quite happy.

I had him stand up and when he lifted his gown, I saw a softball-sized recurrent hernia. Ever since then, I have not trusted any studies in which follow-up was not done in person.

Based on my experience, the recurrence rate after groin hernia repairs could even be higher than the Swedish study reported.

The incidence of chronic pain after inguinal herniorrhaphy may depend on how surgeons follow their patients.

Residents, duty hours, and respect

The following is an email I received.

I, a surgical resident, would like to ask for help navigating conversations about resident duty hours. You had a very strongly worded post on the subject. My intent is not to contradict your perspective, but perhaps get and give some insight on this question. First, I wish to show you the conversation with a surgeon "fossil" as I experience it:

Fossil: "In my day we worked __ many hours and operated all night and never slept or ate and were glad of it. It made me the surgeon I am today. You will never have this privilege."

Me: "Wow, I agree. You had it much harder." Meanwhile, I am thinking:

Is an autonomous robot better than a human surgeon?

That was the headline on the website BGR [“a leading online destination for news and commentary focused on the mobile and consumer electronics markets”].

Engineers working with the Smart Tissue Autonomous Robot (STAR) claim it can cut skin and tissue with more precision than a surgeon.

A paper they presented last month at the International Conference on Intelligent Robots and Systems featured a video supposedly proving the point.

STAR works “by visually tracking both its intended cutting path and its cutting tool and constantly adjusting its plan to accommodate movement.” The intended cutting path must be marked by a human beforehand. So, it is not really autonomous; rather it is semi-autonomous.

The video can be seen in its entirety here or you can watch two excerpts below. The first is the robot using cautery to make a straight 5 cm skin incision which is compared to an unidentified surgeon cutting a similar incision. Watch approximately 15 seconds of this clip.



As you can see, the surgeon strays from the intended path about halfway through the process. But note that the surgeon is not holding the cautery the way most surgeons would use it. The proper way to hold the instrument is as if it were a pencil. No human could possibly cut a straight line holding the instrument as far away from the tip as the video depicts.

A second video shows the STAR excising a geometrically shaped pretend tumor.

Note: Although the video is being shown at 4X speed, it is still painfully slow. It is not clear what would happen if the robot encountered a blood vessel that bled despite the use of cautery, which by the way is not the instrument of choice for excising many tumors.

What we have here is a nice example of a “straw man” which is comparing a new technique against a phony one to make the new one look better.

Another website, IEEE Spectrum, went with this headline:

The headline should have read:

[Type straw man or artificial intelligence in the search field to your right on my blog site for more posts about these two topics.]

Why public reporting of individual surgeon outcomes should not be done

Please take a look at my latest post on Physician's Weekly. It's called "Why public reporting of individual surgeon outcomes should not be done."

Click here for the link.

Some general surgery residency graduates may not be competent to operate

A new study says 84% of general surgery residents in their last six months of training were rated as competent to perform the five most common general surgery core procedures—appendectomy, cholecystectomy, ventral hernia repair, groin hernia repair, and partial colectomy. However the percentage of those judged competent varied from a high of 96% for appendectomy to a low of 71% for partial colectomy.

When analyzing the other 127 core operations of general surgery, the investigators found that 26% of residents in their last six months of training were felt to not be competent to perform at least some of those procedures.

The study was presented at the annual meeting of the American Surgical Association in April 2017 and reported in ACS Surgery News.

Data were compiled from ratings of 522 residents by 437 faculty yielding 8526 different observations.

For all of the procedures rated, maximum resident autonomy was observed for 33% of cases, and the more complex the case, the less ready the residents were to perform it on their own.

The lead author of the study, Dr. Brian George of the University of Michigan, was asked whether the duration of surgery training should be increased. He answered, “The 20,000 hours of surgical residency should be enough to train a general surgeon to competence—it's up to us to figure out how.”

More on artificial intelligence in medicine and surgery

Part 1

A survey published in the journal arXiv predicted with a 50% probability that high-level machine intelligence would equal human performance as a surgeon in approximately 35 years. See graph below. 

Click on the figure to enlarge it

We have already seen a machine beat the world’s best Go player. Although Go is a complicated game, it lends itself to mathematical analysis unlike what one might experience when doing a pancreatic resection.

A potential flaw in this study is that the surveyed individuals were all artificial intelligence researchers who predicted that machines would not be their equal for over 85 more years with the 75% likelihood of this occurring being over 200 years from now.

I suspect if surgeons were asked the same questions, we would say it would take over 85 years for machines to be able to operate as well as we can and 35 years until artificial intelligence researchers would be replaced by their creations.

[Thanks to @EricTopol for tweeting a link to the arXiv paper.]

Part 2

Similar to the question “who is responsible if a driverless car causes an accident?” is “when artificial intelligence botches your medical diagnosis, who’s to blame?” An article on Quartz discussed the topic.

[Digression: The article matter-of-factly states “Medical error is currently the third leading cause of death in the US… ” This is untrue. See this post of mine and this one from the rapid response pages of the BMJ.]

If artificial intelligence was simply being used as a tool by human physician, the doctor would be on the hook. However indications are that artificial intelligence may be more accurate than humans in diagnosing diseases and soon may be able to function independently.

If a machine makes a diagnostic error, are the designers of the software responsible? Is it the company that made the device? What about the entity owns the system? No one knows.

The Quartz piece did not address this. Who is responsible if a nonhuman surgeon makes a mistake during an operation?

I’m sorry I won’t be around 35 years to hear how this is settled.

Radiologists have an identity crisis

Here's a question that has been debated for several years: Should radiologists talk to patients about their imaging results? Citing several issues, I came down solidly on the "No" side in a 2014 blog post which you can read here.

Two major radiology organizations have committees looking into the concept, and a New York Times article said, "they hope to make their case [for it] by demonstrating how some radiologists have successfully managed to communicate with patients and by letting radiologists know this is something patients want."

However, a recent paper presented at the annual meeting of the American College of Radiology raised a new issue.

Apparently patients need more basic information before talking to radiologists—namely what exactly is a radiologist and what does a radiologist do?

A group from the University of Virginia surveyed patients waiting to have radiologic studies performed and came up with some remarkable results. Of 477 patients surveyed, only 175 (36.7%) knew that a radiologist is a doctor, and 248 (52%) knew that radiologists interpret images.

Based on those findings, the investigators developed an educational program of PowerPoint slides which was shown to a new series of 333 patients in the waiting room. When surveyed after viewing it, 156 patients (47.7%) said they were aware that a radiologist is a doctor, and 206 (62.2%) knew that radiologists interpret images.

Both responses were significantly better after the educational presentation, but still, less than 50% of patients identified radiologists as doctors. Maybe the problem was the PowerPoint. Maybe radiologists need to wear scrubs or drape stethoscopes around their necks.

This is only a small study from one institution. Nevertheless before taking the big step of talking with patients, it suggests radiologists need to do a better job of explaining who they are and what they do.

We surgeons think we have an image problem when people say to us, "Oh, are you just a general surgeon?" They don’t know what we do, but at least they know we are physicians.

Finally, evidence clarifies the surgical caps controversy

A study of clean surgical cases found no significant difference in wound infection rates for 13 months before and 13 months after the use of bouffant surgical caps became mandatory. Infection rates for the 7513 patients operated on when surgeons were allowed to wear traditional skullcaps, was 0.77%, and for the 8446 patients who had surgery after the bouffant cap mandate, the infection rate was 0.84%. Subgroup analyses of only patients having spine or cranial operations showed similar insignificant differences in wound infection rates.

The study, from a group in Buffalo, New York, was published online in the journal Neurosurgery.

At the 2017 Americas Hernia Society meeting, Dr. Michael Rosen, director of the Cleveland Clinic Comprehensive Hernia Center, presented the results of a survey of 86 surgeon members of the society's quality collaborative.

Ventral hernia repairs were done in 6210 patients with a 4.1% incidence of wound infection. Risk factors for surgical site infection were obesity, hypertension, width of hernia, operation duration greater than two hours, and female sex. The type of cap worn was not associated with the occurrence of a wound infection or any other surgical site complication such as seroma, wound dehiscence, or enterocutaneous fistula.

Of the 79% of surgeons who responded, 48% said they wore disposable skullcaps, 9% wore cloth skullcaps, 29% wore bouffant caps with ears exposed, and 16% wore bouffant caps covering their ears.

[I know that adds up to 102%, but that's what the General Surgery News article about the paper said.]

The report mentioned a series of postoperative infections caused by a mycobacterium at an Israeli hospital in 2004. At the time, a newspaper account of the 15 breast plastic surgery patients said an investigation found the source was a surgeon whose hair and eyebrows were colonized from his home Jacuzzi.

In 2016, the surgeon published a paper about the incident. The organism had never been identified before and was christened M. jacuzzii. Several patients suffered persistent infections and required removal of implants. In the paper, the surgeon revealed he wore a standard paper cap [presumably a skullcap] and the organism was also found on his facial skin.

While some might suggest this paper justifies the use of bouffant caps, the surgeon could still have contaminated the operative field with organisms from his facial skin or eyebrows. Other than with a space helmet, complete coverage of the eyebrows and facial skin is impossible.

The paper from Buffalo had some limitations. It was from a single hospital and was not a randomized trial. However, it was sufficiently powered to detect a difference in infection rates.

The hernia study was not as scientifically rigorous as the Buffalo study, but enough procedures were analyzed to detect a difference in infection rates had one been present.

In the GSN story, the Association of periOperative Registered Nurses (AORN) response to the American College of Surgeons statement supporting the use of skullcaps was quoted. “Wearing a particular head covering based on its symbolism is not evidence-based [nor is the AORN's bouffant cap rule] and should not be a basis for a nationwide practice recommendation.”

Now that we have evidence that skullcaps are not linked to increased infection rates, will the AORN at last get over its obsession with bouffant caps?

My previous posts on this topic can be found here and here.

Bizarre medical stories ripped from the virtual pages of the Internet

A 30-year-old California woman died after a naturopath gave her an intravenous infusion of turmeric—yes, turmeric, a spice used in curry, supposedly has anti-inflammatory properties when taken by mouth.

An naturopath who only uses turmeric orally was quoted in a San Diego ABC news report, "There are some doctors who use turmeric extract in IV form to try and heighten the physiological effects, so the anti-inflammatory effects of the turmeric. It hasn’t been well studied. It’s more theoretical, so it’s more investigational.” Unlike most naturopathic treatments, IV turmeric hasn't been well studied.

According to NBC San Diego, the medical examiner said she died of a heart attack and ruled the death an accident. In fact, the story was headlined "Tumeric Solution Through IV To Blame, in Part, For Women's Death: ME." In part?

The naturopath has yet to be named in any news story. How is this not manslaughter or criminal negligence? If an MD had given say, oregano intravenously, would it still have been an accident? Would the doctor's name still be unknown? I think it would be on Yahoo's front page.

Can a cop’s baton accidentally slip into a man’s anus?

I doubt it.

A French police officer has been charged with rape after a black man who was being arrested suffered severe anal injuries.

After witnessing an officer slap someone, the 22-year-old had allegedly approached a group of policemen. The victim claims he was handcuffed, called names, and beaten. He says his pants were lowered and he felt pain in his buttocks.

At the police station another officer noted that he was covered with blood. He was taken to a hospital and diagnosed with the anal trauma which required “major surgery” including a colostomy. The family was told incontinence may result.

Doctors said the injury had been caused by a police baton which had been forced into his anus.

The Washington Post quoted the findings of a police investigation: “The violent sodomy was accidental and occurred when the officer’s expandable baton happened to slip into the victim’s anus.”

According to another story, “a French police union spokesman said there was no evidence so far that ‘the truncheon was actually introduced’ into the victim's rectum. And if that actually happened, it was likely done ‘accidentally.’”

A third story said, “a lawyer for the officer charged with rape said ‘the blow had been carried out in a totally involuntary manner, without his being aware of any injury.’” The word “his” must be referring to the officer because I have no doubt the victim was quite aware.

Based on my 40+ years of experience as a surgeon, I can assure you the police version of the incident is highly implausible. A patient who does not wish to undergo a rectal examination by a physician with a gloved and lubricated index finger can easily prevent it from occurring by voluntarily contracting his anal sphincter and gluteus muscles.

I would imagine a healthy 22-year-old man would react in exactly the same way if a policeman’s baton “happened to slip” with the end anywhere near his anus.

The incident has sparked many protests in France and has been widely reported by news media. Of the several accounts I have read, not one has asked a surgeon to comment on the nature or possible cause of the injuries.

Bottom line: A police baton slipping into a man’s anus is about as likely as a man accidentally falling on a woman and penetrating her.

From International Business Times

Thanks to @Tosk59 for the tip on the International Business Times story.

The occasional surgeon

On the Forbes website, Dr. Robert Pearl writes

"When I was selected to become CEO of The Permanente Medical Group, the Permanente half of Kaiser Permanente, the time required for my responsibilities forced me to give up doing surgery on a regular basis. But every year since then, during the week between Christmas and New Year’s Day, I have returned to the operating room. The timing works, as the leadership demands become minimal and it’s unlikely I’ll suddenly be needed to fly to another part of the country. It’s a magical time for me, contrasting dramatically with my world as CEO. For several hours each day, my focus is not on millions of Kaiser Permanente members—or, for that matter, on all the complexities of healthcare policy, politics and strategy—but, rather, on a single patient at a time."

Dr. Pearl is a Yale medical school graduate who trained at Stanford and has been board-certified in plastic surgery since 1979. The American Board of Plastic Surgery did not start requiring maintenance of certification every 10 years until 1995.

We do not know what specific surgical procedures he does during his magical time. Is he removing moles, performing reconstructive surgery, or doing facelifts and nose jobs? Do his patients know that he only operates a few days per year? What happens if a wound complication requiring revision surgery arises? Who follows up his patients?

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.

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. 

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.

How frequently do surgeons and anesthesiologists lie to each other?

More often than you might think.

Results of a survey published in the journal Patient Safety in Surgery found that 27% of anesthesiologists and 7% of surgeons admitted that they “misreported” information to each other at least once a month in the perioperative setting.

Surveys were mailed to 2260 anesthesiologists and surgeons. The response rate was only 11%, which the authors ascribed to the sensitive nature of the questions asked.

The demographics of the respondents in each group were similar regarding age, sex, years of practice, hospital type, and self-described involvement with religion.

The most commonly misreported events by anesthesiologists were actions that affected vital signs, and the misrepresentation of vital signs and amounts of fluid administered. Surgeons most commonly admitted to incorrectly estimating the expected length of a case and misstating the nature of intraoperative adverse events, degree of surgical risk, and how urgent a case was.

Operative risk and surgeon decision-making

Should it surprise you that surgeons might have differences of opinion about whether or not a patient should have an operation?

It doesn't surprise me, but apparently a lot of people were taken aback by an Annals of Surgery paper published online last week stating just that.

The authors gave 767 surgeons four brief complex clinical scenarios and asked whether they would operate on each patient. The vignettes were purposely designed to not have "correct" answers.

In response to the question would you recommend an operation, the surgeons could choose one of the following responses: very likely, unlikely, neutral, likely, or very likely.

If you were in the emergency department with mesenteric ischemia, would you want a surgeon who responded "neutral"?

Why the authors selected five possible choices is puzzling. In real life when you are faced with a difficult decision in the middle of the night, you don't have five options. You have only two—operation or no operation.

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.

OR delays: Who's responsible and what can be done?

Every two or three years, someone, usually a hospital administrator, decides that delays in operating room turnover time need to be looked into. A committee of 20 or 30 stakeholders (love that term) is appointed and assigns someone the job of measuring the time between cases and identifying reasons for delays. In years when turnover time is not being studied, first case starting delays are on the agenda.

In my nearly 24 years as a surgical department chair, one or the other of these issues was investigated at least 10 times. We were never able to conclusively determine the exact causes of delays or solutions to the problem, and we returned to business as usual.

An article in Anesthesiology News about a paper that looked at causes of operating room delays in over 15,500 cases at a single hospital got my attention.

The number one reason for delays was that the nurses did not have the operating room ready for the patient. Nursing also was responsible for the third most common cause "preop prep (IVs, meds, etc.)."