Over-thinking laparoscopic surgery training

Are we over-thinking the training of residents in minimally invasive surgery? Two recent papers in prominent surgical journals suggest to me the answer is “Yes.”

In the July 2012 issue of Surgery, a paper entitled “Cheating experience: Guiding novices to adopt the gaze strategies of experts expedites the learning of technical laparoscopic skills” investigated whether teaching novices to perform simulated tasks on a laparoscopic surgery training system by using the gaze strategies of experts would improve performance. The Methods section of the paper is well over 2 pages in length. The idea was to have some novices perform tasks by simply discovering how to do them by trial and error. A second cohort of novices was given a template reproducing the gaze-tracking used by expert laparoscopic surgeons.

Those using the gaze templates performed the tasks more quickly and with fewer errors. Here’s a section of text from the Results section. Note: punctuation as per the authors.

“Learning phase. Performance, completion time: Results revealed a significant main effect for block: F(9,225) = 13.97, P = < .01; but there was no significant main effect for group, F(1,25) = 0.89; P = .36; n_p² = .04; and no interaction effect, F(9,225) = 0.86; P = .57; n_p² = .03.”

I thought I knew something about statistics but I have no idea what the sentence [at least I think it’s a sentence] says. What I can see from the figures is that the difference in times for the tasks averaged less than 10 seconds per task and the number of errors was reduced in the gaze-trained group from 2 to 1.5 errors per task. Whether these differences are statistically significant is known only to the authors, but 10 seconds and a difference in errors of 0.5 don’t seem all that important to me.

The second paper, “Correlation of laparoscopic experience with differential functional brain activation” is from Archives of Surgery, July 2012. The link is provided so you can verify that I am not making this up. Investigators put novice and expert laparoscopists in a PET scanner and had them perform a laparoscopic simulated task [moving pegs from one place to another] while undergoing a total of 6 PET scans. The scans involved the injection of oxygen 15 labeled water. Since the full text is available on line, I invite you to view the photos of the set-up of the experiment and judge for yourself how comfortable the subjects must have been.

Rather than paraphrase the results of the study, I will quote the abstract directly.

“The novice group had a significantly (P = .001) higher activation (with deactivation in the expert group) in the left precentral gyrus and insula and the right precuneus and inferior occipital gyrus. The second analysis compared the 2 video scans and the rest scan. In contrast to the expert group, the novices had significantly (P = .001) higher activation in the right precuneus and cuneus but deactivation in the bilateral posterior cerebellum.”

It’s all very clear to me now.

Their Figure 2 shows that despite the differences noted in activation of brain areas, by the third peg transfer test, the novices equaled the scores of the experts on their first peg transfer. The novices also improved markedly compared to their first attempts.

The authors admit that one of the limitations of their study was that 4 of the 5 novices were women while all the experts were men, which may have confounded the results. [Note: the authors said this, not I.]

What does it all mean? They claim that understanding the neural pathways might help in developing better ways to train people. I think that remains to be seen.

In retrospect, I can’t imagine how I or anyone else ever learned to do laparoscopic surgery relying only on someone showing us how. I had no access to expert gaze-tracking templates or PET scans.

I guess a paper on the method “see one, do one, teach one” would not be accepted by a major journal these days.

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Why I wear a white coat

A recent article in a major newspaper asked why physicians still wear white coats. The theme echoed many recent stories of bacterial contamination of clothing and other inanimate objects. [For more on this subject, click on the "Infection" label on the right next to this post.] 

It also brought to mind a controversial rule instituted by the UK’s National Health Service in 2008 that all medical and nursing staff could not wear ties or white coats and had to have arms “bare below the elbow.”

Despite published papers reporting the existence of bacteria on white coats and ties, the UK policy was not based on any evidence linking coats, ties or long sleeves to transmission of infection to patients.

The subject has been debated for years. Yes, the white coat may be contaminated with bacteria. But whatever one wears may also be contaminated. What is the difference between wearing a white coat for few days and wearing a suit jacket or a pair of pants for a few days?

I wear a white coat for the following reasons:

• It has a lot of pockets
• It protects my clothes from blood, vomit, pus and poop.
• It is easy to clean.
• It is laundered by my hospital.

I change it at regular intervals, usually amounting to fewer than 5 days. I doubt very much that doctors who don’t wear white coats have their suits, sport coats or pants dry cleaned that frequently.

Taking advantage of the adverse publicity about ties, I have stopped wearing them because it’s more comfortable rather than for an unsupported notion of an infection risk for patients.

More importantly, I wash my hands or use a gel quite often.

Do you wear a white coat? Why or why not?

A version of this was posted on Sermo yesterday. A majority of those few who commented say they do still wear white coats.

“Damned if you do…”

Here’s a little story from the early days of my first job as a chairman of surgery.

Shortly after I assumed the role of surgical chairman in a community teaching hospital at the ripe old age of 40 and having absolutely no administrative experience, I visited a mentor of mine whom I had known since I was a medical student. He had been serving in a similar role at a larger hospital than mine, and I thought he might be able to share some wisdom about how to be a good chairman.

He was dispensing sound advice for most of the hour or so I spent with him. Then he said something that struck me: Sometimes the unexpected happens and there’s no simple solution. He told me that among the challenges he was facing were two lawsuits.

One was from the family of a patient who had died after a carotid endarterectomy that had been performed by a surgeon in his department. The plaintiffs were suing the hospital and my mentor, the surgical chairman, for allowing what they alleged was an incompetent surgeon to do complex vascular surgery.

The other lawsuit was by a surgeon in his department who had requested privileges to perform carotid surgery, which had been denied by my mentor on the grounds that in his opinion, the surgeon was not adequately trained in carotid surgery.

I never heard the outcome of either case, but it certainly seemed like a no-win situation.

Although that encounter occurred some 25 years ago, the problem persists today. For example, patient advocates are concerned that pain is not being adequately addressed. Yet there is an epidemic of abuse of narcotic prescription drugs that is sweeping all parts of the country.

We also are being criticized for runaway healthcare spending and being encouraged to reduce things like unnecessary testing, while a recent jury verdict for $6.4 million in Philadelphia went against two physicians for failing to order certain tests on a man who had a fatal heart attack 3 months after an emergency department visit for pneumonia.

Some say too many CT scans are being ordered for the work-up of appendicitis with worry that radiation will cause future increased cancer rates. However, in my experience, patients prefer accuracy in diagnosis over a theoretical increased risk of cancer 30 years from now.

Not long ago I was called by an emergency physician who said he had a 17-year-old boy with a textbook case of acute appendicitis. He felt a CT scan was unnecessary. I examined that patient and agreed. I explained to the boy’s mother that I was convinced he had appendicitis and needed surgery. She said, “What about a CT scan?” After a lengthy discussion, I convinced her that the CT scan was not needed. As I made the incision, I said to the OR team, “I sure hope this kid has appendicitis.”

I can think of many more such situations. How should we resolve them?

 

It seems to be the mantra for modern medicine. "Damned if you do and damned if you don't."

Things that puzzle me about surgical education

When I was a surgical residency program director, I often wondered what the establishment, you know those guys who ran surgical education, were thinking. Some may remember the rule that a resident had to see at least 50% of the patients he operated on in the clinic or the private surgeon’s office in order to claim credit for having done the case.

There was the emphasis that still exists today on making sure every resident did research. At last, some are questioning the value of this for the average clinical surgeon. Contrary to the prevailing wisdom, there is no evidence that a resident who is dragged kicking and screaming through a clinical research project or who spent a year in someone’s lab really learns anything about research or how to read and understand a research paper.

Then there is the obsession with a transplant rotation, recently noted in a published paper to be a waste of time in the opinion of surgical residency program directors.

The "Never Events" list should be reconsidered

You are probably familiar with the CMS “never events” initiative. CMS has decided it will not reimburse hospitals for treatment related to complications which it says should never occur. Here is the current list.

• Foreign object retained after surgery
• Air embolism
• Blood incompatibility
• Stage III and IV pressure ulcers
• Falls and trauma
• Manifestations of poor glycemic control
• Catheter-associated urinary tract infection
• Vascular catheter-associated infection
• Surgical site infection after coronary artery bypass graft, bariatric surgery for obesity and certain orthopedic procedures
• Deep vein thrombosis/pulmonary embolism after certain orthopedic procedures

According to American Medical News, two more complications have been proposed as additions. One is acquired conditions stemming from cardiac implantable electronic device surgeries and the other is iatrogenic pneumothorax associated with venous catheterization.

I have no problem with some of the items on the list. Foreign bodies like sponges or instruments should not be left in patients after surgery. Air embolism and blood incompatibility should be 100% preventable.

But I do not see how catheter-associated UTIs or vascular catheter associated infections can be completely prevented. Some sick patients with depressed immune systems are going to get infections.

I believe it is impossible to completely prevent wound infections in all clean cases. As has been shown in studies of SCIP compliance, some patients get wound infections after colon surgery despite the timely use of the right antibiotic.

DVT/PE cannot be prevented in every orthopedic procedure. I am unaware of any DVT study in which no patients in the experimental arm developed DVTs or PEs. Patients will develop DVT or PE even with the best evidence-based care.

With very few exceptions, every large published paper on central line insertions, even those using ultrasound guidance, reports some instances of post-procedure pneumothorax. There is no way it can be completely avoided. For example, this study of 937 ultrasound-guided central line insertions reported 2 (0.2%) post-procedure pneumothoraces. That’s a published study by radiologists. The real world incidence of pneumothorax is much higher, often quoted at 2-5%.

To me, these rulings are simply a way for CMS (and other payers who are sure to follow suit) to avoid paying. Where is the input from “organized medicine”? Was any evidence-based research looked at by those who decided all this?

Why are we standing around and allowing this to go unchallenged?

This post appeared on Sermo yesterday and most people who commented agreed with me.

Corporate speak taken to a higher level

I came across a wonderful example of corporate speak a couple of weeks ago and finally have the time to share it with you.

Having once worked in a large hospital which was thoroughly infused with all of the bad things about corporations including all of the jargon, I’ve always been a fan of the comic strip Dilbert. As evidenced by today’s (July 12) strip, the following is certainly Dilbert-worthy.

An article appeared in the Atlantic Wire about the continuing downfall of Research in Motion, the company that makes the once-vaunted BlackBerry. RIM badly misread the evolution of the smartphone and finds itself laying off 5000 employees and losing tons of money.

According to the story, the CEO of RIM had the following comment during a conference call about the companies plunging sales figures.

He said, "I am not satisfied with these results and continue to work aggressively with all areas of the organization and the Board to implement meaningful changes to address the challenges, including a thoughtful realignment of resources and honing focus within the Company on areas that have the greatest opportunities."

Fortunately, I do not own any RIM stock, but if I did I would not be reassured by a 48 word sentence that when read closely, says absolutely nothing.