Friday, August 17, 2018

Patient worries after accessing his chest x-ray report online

I received an email a few days ago. It has been edited for length and clarity.

I would like some advice please. I am a 46-year-old male with an off and on cough for 4-5 months. I have never smoked. After my primary care physician examined me, he ordered a chest x ray. A few days later I got a call from the doctor who said my x ray was normal. I was happy to hear that, but I am enrolled with My Chart which allows you to review your results online. Well, I read it and to me it doesn't sound what you would call totally normal, but I have no medical training so I could be wrong. I copied and pasted the report from the radiologist below. What concerns me is the "elevation" he refers to and using the word "fairly" clear lungs. Should I ask for another test or see another doctor for an opinion? If I was your family member would you suggest looking into this more?

CLINICAL INFORMATION: Cough

FINDINGS: The frontal view demonstrates fairly clear lungs with slightly increased elevation of the left hemidiaphragm compared with the prior study. This may be at least partially caused by air in the adjacent bowel. No pleural effusion or pneumothorax is noted. The cardiomediastinal silhouette is unremarkable. The lateral view demonstrates fairly stable appearance of the lung bases compared with the previous study.

Monday, August 6, 2018

More proof medical error is not the third leading cause of death

Over the last 20 years, estimates of the number of deaths caused by medical error have risen from 44,000-98,000 in 1999 [1] all the way up to 440,000 [2] and 251,000 [3]. Despite my efforts [4, 5] and those of others [6, 7] to debunk these guesses, they continue to permeate the lay press. If you Google “third leading cause of death,” you will find countless headlines naming medical error.

The papers claiming medical errors cause so many deaths assume that all complications result from errors and all complications are preventable. They extrapolate their final numbers from small studies not designed to or capable of estimating deaths due to medical error nationwide.

The most recent figures available from the National Hospital Discharge Survey [8] state that the number of hospital deaths dropped from 776,000 in the year 2000 to 715,000 in 2010. It is simply not plausible that 251,000 (35%) or 440,000 (61%) inpatient deaths are due to medical error.

A recent study [9] from Norway found that of 1000 consecutive in-hospital deaths reviewed, only 42 (4.2%) were judged to be probably (greater than a 50% chance) to definitely avoidable.

Friday, July 13, 2018

Everything you ever wanted to know about operating room head coverings

In case you might want to challenge your hospital’s policy on the subject, I have gathered all of the recent research I could find on surgical head wear.

In response to a 2013 question from a reader, I blogged about the complete lack of evidence that OR staff hair caused wound infections or any other problem. After a similar question from another reader three years later, I pointed out nothing had changed.

Finally a 2017 paper in the journal Neurosurgery appeared online comparing the incidence of wound infections in clean cases for the 13 months before and the 13 months after the institution of a ban on the wearing of the traditional surgeons’ ca`p. Over 15,000 patients were included in the study which found no statistically significant difference in the rate of wound infections.

Monday, July 9, 2018

Are neckties dangerous to your health?

Wearing a necktie significantly decreases cerebral blood flow says a new study in the journal Neuroradiology. This finding caused a minor flurry of activity on Twitter, and as usual, the press sensationalized and misinterpreted the study’s results.

Here’s a headline from the Deccan Chronicle: “Wearing ties hamper [sic] productivity in office; here’s why.” The sub- heading is “Study suggests men who wear T-shirts in the office may produce better work.” T-shirts were not mentioned in the paper. The name of the journal that published it was incorrect in the article too.

Forbes didn’t do much better. It’s lede is “Neckties are stupid. Could they also make you stupid?” The paper said nothing of the kind.

Friday, June 29, 2018

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.

Tuesday, June 26, 2018

We need less research

“We need less research, better research, and research done for the right reasons. Abandoning using the number of publications as a measure of ability would be a start.” Although I have expressed similar sentiments in blog posts [here and here], I didn’t say it. It was written by Douglas Altman, a well-known statistician and researcher who died in June.

Altman made that statement in a 1994 BMJ article entitled “The scandal of poor medical research.” Here we are, 24 years later, and nothing has changed. In fact, thanks to the rise of predatory journals, things are much worse.

Altman lamented research containing flaws such as “the use of inappropriate designs, unrepresentative samples, small samples, incorrect methods of analysis, and faulty interpretation” and felt many poor studies were the result of pressure on researchers to publish.

Monday, June 18, 2018

Some data is better than no data at all

Do you believe that?

I heard it frequently when the infamous Propublica Surgeon Scorecard first appeared three years ago. Back then I blogged about it saying “To me, bad data is worse than no data at all.”

A recent study in BJU International confirmed my thoughts about this type of publicly posted data and identified a previously unreported issue. The paper attempted to determine whether the public was able to accurately interpret statistics used in the Surgeon Scorecard. It turns out they were not very good at it.

Investigators from the Department of Urology at the University of Minnesota surveyed 343 people who attended the Minnesota State Fair in 2016. Those who took the survey had a median age of 48, were 60% female, 80% white, and 60% college educated. Their median annual income was $26,550 with an interquartile range of $22,882-$32,587.