Thursday, March 31, 2011

Too Many Diagnostic Tests? Says Who?

A recent Time magazine column attempted to analyze the reasons for the increased use of diagnostic imaging. The authors brought up many of the standard reasons including the need to practice defensive medicine, fallout from morbidity and mortality conferences, greed, etc. They say that doctors are no longer taught how to tell when patients need diagnostic tests and when they don’t. They make the following claim: “… the real value of so much testing has been widely questioned in scientific literature: imaging rates are going up, but doctors are not diagnosing (or necessarily misdiagnosing) more diseases.”

Respected medical blogger Kevin Pho (KevinMD) agreed with the Time article. Dr. Pho said that students are “…are spoiled by the easy access to the latest in imaging equipment and medical technology, and have become less dependent on physical exam skills previously relied upon in the past."

But as I have blogged previously, patients seem to want accurate diagnoses. Thus far, they are not moved by the theoretical increased risk of cancer secondary to radiation which may occur in the distant future. They want to know if they have appendicitis now and before they consent to surgery.

Contrary to what the Time magazine piece stated, there is some evidence that imaging does make the diagnosis of some diseases more accurate than history and physical examination.

In the April 2011 issue of the American Journal of Surgery, researchers from Howard University and the University of California, San Diego reported a 10-year review of negative appendectomy rates in the U.S. Using data from the National Inpatient Sample, they found that for nearly 500,000 appendectomies performed for presumed appendicitis from 1998 through 2007, the rate of removal of a normal appendix during surgery fell from 14.7% to 8.5%. This represents a 40% decline in the rate of negative appendectomy. The rate of perforated appendicitis also fell during that time period, indicating that the fall in negative appendectomy rates did not result in more occurrences of perforation.

Although the study was not designed to establish a link between the increased use of imaging studies and the falling rate of negative appendectomy, there are many papers supporting this conclusion such as one from Brigham and Women’s Hospital in Boston which showed a fall in the negative appendectomy rate from 23% to 1.7% over and 18-year period during which the rate of CT scan use went from 1% to 97.5%. Surgeons from Cornell reported similar results with the rate of CT scanning for appendicitis rising from 32% to 95% and the negative appendectomy rate falling from 16% to 7.65% from the late 1990s to the mid-part of the 21st century.

Having published a paper a few years ago which decried the use of CT scans in the diagnosis of appendicitis, I have completely reversed that opinion based on my personal series of over 125 appendectomies over the last two years with a negative appendectomy rate of just under 5%.

I never thought I would say this. The fact is CT scan is very accurate at diagnosing appendicitis. CT is better than I am and likely better than any human. It isn’t going to go away. It isn’t going to be replaced by ultrasound [not as readily available, not as accurate, not as easy to read] or MRI [not as readily available, not nearly as well-documented in the diagnosis of appendicitis, more expensive, not as easy to read]. So get over it.

Thursday, March 24, 2011

Chronic Widespread Pain. Is It an Epidemic?

The term Chronic Widespread Pain Syndrome (CWPS) is synonymous with fibromyalgia (FM). It is characterized by the finding of pain on palpation at 11 or more of 18 specific sites, although the diagnosis of FM apparently can be made with fewer sites involved.

A recent paper, “Road traffic accidents, but not other physically traumatic events, predict the onset of chronic widespread pain: results from the EpiFunD Study,” which was a survey of residents of three different areas in Northwest England, noted some remarkable findings. The publisher was kind enough to provide a full text copy of the paper. Some 17% of 6244 subjects had CWPS at baseline. They were excluded from further study. More than half of the remaining subjects were lost to follow-up. Even more remarkable is that over the four years of the research, 11.6% of the 2069 subjects who did respond to a repeat survey developed CWPS. The authors found that involvement in a traffic accident might lead to an increased incidence of CWPS.

The most remarkable finding was not addressed in the paper. If one does the math for a rate of developing CWPS of 11.6% over four years, one can see by the figure below that at about 22 years from now, half of the study population of 2069 subjects will have developed CWPS. The number of subjects appears on the y-axis and years is on the x-axis. The red arrow at 22 years points to the 1000 subject line.

The authors mentioned some of the limitations of the study in their discussion. The fact that fewer than 50% of those entered into the study were available at its conclusion and the self-reporting of pain and history of trauma were acknowledged as weaknesses.

According to the study's lead author, Dr. Gareth T Jones, whether the subjects with CWPS were being treated with pain medication or being followed by a physician could not be determined. In an email Dr. Jones said, "Individuals with chronic widespread pain are characterized as being high health service users, with multiple tests/investigations, and, yes, medication use (and complementary medicine use) is common."

He agreed that the baseline prevalence of 17% was high but pointed out, "Population studies have fairly consistently shown a prevalence [of chronic pain] of around 12-13%."

Also, there is the matter of potential secondary gain if a traffic accident victim is found to have CWPS. Dr. Jones stated: "Clearly, for people who are reporting a claim then there may be greater financial benefit if that pain is (a) more persistent; and (b) more severe and/or disabling. Of course, that's not to say that the pain isn't genuine. it may be that a long legal process will focus the mind on one's problems, and that this focused attention may genuinely contribute to the exacerbation of symptoms."

When asked about what seems to be a projected epidemic of CWPS in Northwest England Dr. Jones had these comments: "It's not quite as simple as that, but yes I agree, the numbers stack up fairly quickly. People move in and out of different pain states from no pain to regional pain, to widespread pain, to chronic widespread pain and also back in the other direction. Studies have shown, however, that it is rare for someone with chronic widespread pain to no pain at all in a subsequent survey."

What will become of these subjects over the years remains to be seen. Perhaps future studies will help clarify the issues raised.

Tuesday, March 22, 2011

Swimming in Chlorinated Water Causes Bladder Cancer (Not)

Here is a great example of what can happen when a press release is published as news.

Referring to a recent paper, several outlets came out with headlines such as “Swimming too often in chlorinated water 'could increase risk of developing bladder cancer', claim scientists” and “Swimming too often in chlorinated water 'ups bladder cancer risk.'” The paper, entitled “Socioeconomic status and exposure to disinfection by-products in drinking water in Spain,” is available in full text on line.

The researchers looked at data from a study of people in various regions of Spain. The 1271 subjects in the study had served as controls in a different study that was done 10 years ago. They concluded that those in higher socioeconomic groups drank less tap water but took longer showers and used swimming pools more often. It seems that by-products of chlorination, trihalomethanes (THM), have been linked to an increased incidence of bladder cancer. And THM can be absorbed through the skin, making a link of bladder cancer with swimming plausible.

Here is the catch and it can only be discovered by reading the full text of the paper. Participation in swimming was characterized as follows:

“swimming pool attendance, [was recorded] as a dichotomous variable: attending a swimming pool once or more than once per year contrasted with never (or less than once per year)”

In other words, a subject was asked whether he swam in a pool during a year. If he said “Yes,” he was listed as a swimmer, whether he swam once a year or once a day.

You need not be a scientist or a statistician to see the fallacy of this purported association of swimming and bladder cancer.

By the way, as far as I can tell, none of the 1271 subjects actually developed bladder cancer. The research wasn’t designed to look at that. It was taking a post hoc look at water usage by a group of people who were the subjects of a different research hypothesis.

Also, an author of the paper conceded in the press release that the risk of contracting bladder cancer from swimming was “small.”

Bottom line. Swimmers, please relax and ignore this overblown drivel.

And if you are worried about getting bladder cancer from drinking chlorinated water, here are two interesting points. One, a study from the New England Journal of Medicine a few years ago reported that drinking a lot of fluid decreases the risk of bladder cancer. Two, the incidence of bladder cancer has been remarkably stable over the last 30 years.

Friday, March 18, 2011

General Surgery, Acute Care Surgery and the Surgical Hospitalist

As medicine adapts to the 21st century, new specialties arise. General surgery is seeing two new fields emerge. One is “Acute Care Surgery,” which encompasses three facets of general surgery—emergency surgery, critical care and trauma care. The other is the concept of a surgical hospitalist. That is, a surgeon works only in a hospital and has no office or private practice. The idea is similar to the medical hospitalist movement, which has existed for several years now.

The changes in surgery are in response to a number of forces. General surgeons are becoming increasingly more focused, especially in areas such as advanced laparoscopic surgery, bariatric (obesity) surgery, endovascular surgery and breast surgery. With these areas of concentration comes decreasing interest in taking emergency call, which interferes with elective cases and office practice. In addition, a concentration on something like breast surgery leads to diminished experience and skills in treating gunshot wound and bowel obstructions.

Acute Care Surgery arose in response to the need for emergency call coverage as well as the desire of trauma surgeons to increase their operative case load as trauma care itself becomes less involved with operative procedures. In many trauma centers, the percentage of blunt trauma cases is well over 90% and a large majority of these patients are treated without surgery. Many academic medical centers have established acute care surgery services which are staffed mostly by trauma/critical care surgeons.

A surgical hospitalist usually does acute care surgery but does not see outpatients unless they have emergencies. I have been working as a surgical hospitalist for the past two years. I am on duty for two five-day weekends per month. During that time I cover for the general surgeons in the area, make rounds on their inpatients, handle phone calls from their private practice patients, see consults from the emergency department and inpatient medical services and perform any emergency procedures that are needed. At the end of my tour of duty, I sign out my patients to one of the general surgeons. The positive features of my job are as follows: there is no office practice or overhead; it’s a salaried position; I have 20 days/month off; when I am not on duty, I am completely without responsibilities. The downsides include loss of continuity, having to pick up many patients often with complex problems all at once and occasionally having to leave a very sick patient for someone else to take care of. I am the sole surgical hospitalist at my institution, but there can also be groups which can cover inpatients and emergencies.

The surgical hospitalist model is a far cry from anything I would have dreamed of when I started in surgery years ago. But it is the wave of the future. Other specialties such as orthopedic surgery are getting on the bandwagon. The field will see much growth in the next few years as graduating residents, who are used to shift work, will see a surgical hospitalist career as a logical extension of their experience as residents.

Tuesday, March 15, 2011

Rite of Passage for Some Medical Students: “Scramble Day” Explained

UPDATED on 2/25/13: As of the 2012 match, "Scramble" no longer occurs. The NRMP instituted a much more orderly process, which I'm told worked well.

Ironically, this year the "Ides of March" marks the annual rite of passage for fourth year medical students known as “Scramble Day.” Graduating student participate in a matching program that links them to residency training positions. Throughout the fall and winter, students take electives and go on as many as 20 interview trips seeking coveted residency positions. They then submit a list to the National Residency Matching Program [NRMP] ranking the programs they want. Likewise the programs rank the students. A computer crunches the two lists and the next several years of a graduating med student’s life are revealed.

Unfortunately, some students, usually one or more from every US medical school and hundreds of students from international schools, do not “match” and today is the day they find out. Starting at noon today, they “scramble” to find residency training positions with programs that have unfilled slots.

The process is painful for both the students and the residency program directors. Unmatched students, whose predicament is usually the result of ranking programs “out of their league,” having some blemish on their record or simply being from non-US schools, have to quickly get over their embarrassment and disappointment and face the reality of scrambling to find a job for the coming academic year. Program directors [PDs] have unfilled positions either because their specialties are not in favor with graduates, their programs have problems or there are too many positions to fill.

General surgery has a unique issue in that so called “categorical” or full five-year positions are in high demand, but there are far more“ preliminary” [one-year] slots available than there are takers. These one-year positions are meant for those entering subspecialties like orthopedics or ENT. Due to the needs of the programs to staff their hospitals, there are some 400-500 preliminary slots in excess of the number of one-year positions actually needed by the subspecialties.

At noon today, phones will be ringing off the hook and fax machines will be overheating as the scramble gets underway. Residency program directors will have to decide which applicants to take based on brief telephone interviews, and the students face the same under-informed decision process. For US students, associate deans often act as agents trying to explain why their anxious student didn’t match. International students are on their own.

Many interesting deceptions take place. The records of some students, who didn’t match because they are crazy, lazy, just not too smart or all of the above, are buffed up by their deans. International students always claim to be at the top of their classes, and the information is impossible to check. Students who had their hearts set on orthopedics and didn’t match have to now say they wanted to be general surgeons all along.

It is the epitome of a “crapshoot” for both parties.

Thankfully for me, I am no longer a participant in this nightmare, but I empathize with both the PDs and the students. Good luck.

Sunday, March 13, 2011

Major Ethical Breach at Bronx Trauma Center

Not to diminish the magnitude of the tragic bus accident that occurred in New York yesterday, but as a surgeon, I am compelled to mention the almost astonishing ethical and privacy violation committed by an unnamed surgeon at a Bronx trauma center.

According to a New York Times article published on March 13, 2011, the following took place:

“The wife of a Jacobi Medical Center surgeon said her husband called her from work and described a passenger with a crushed skull and others with hand and arm amputations. She showed an iPhone photo, texted from Jacobi, of a hand and forearm, severed just below the elbow, lying on an operating table.”

I have many concerns here.

One, why would you call your wife to discuss a victim’s injuries?
Two, why would you text a photo of a severed extremity to you wife?
Three, did the victim sign consent for photographs and did he agree to let the surgeon disseminate information about his condition to the wife or the New York Times?
Four, why would the wife discuss this case with a New York Times reporter and show him the picture?

In the next few days, I expect that heads will roll on this, and rightfully so.

Friday, March 11, 2011

Basketball is an awful sport. Here’s why.

Basketball is difficult to watch. What makes it so for me is the way the games end. I can’t think of another sport in which breaking the rules can result in an advantage for the team which does so. Here is what I mean.

A typical scenario is that the Lakers are leading the Knicks by 9 points with two minutes to go. At this point, the strategy for the Knicks is to foul the worst free-throw shooter on the Lakers as soon as he touches the ball. The idea is that if he misses his shots, the Knicks will gain possession with a chance to narrow their deficit. This goes on and on until the game mercifully ends 20 or 30 minutes later.

The reason the end of the game takes so long is that the clock stops when the foul occurs and the free-throws are taken. And each team has about 10 time-outs which are called at every whistle. To me, there are basically two phases of a basketball game. Phase I consists of about 38 minutes of what passes for basketball today. That is, a lot of one-on-one offense and minimal-to-no defense. There is no such thing as “traveling’ or “palming the ball” any more. Phase II is the last two minutes which involves a lot more walking back and forth than a soldier on guard duty can imagine.

Try as I might to come up with something, I just don’t think there is any other sport that rewards rule-breaking. Baseball? No. Football? No [but certainly right up there with basketball as far as the duration of the last two minutes of a game is concerned]. Hockey? No, in fact a foul gets you a chance to play with fewer men. Soccer? No. Tennis? No. Golf? No. Swimming? No. NASCAR? No [not a sport].

Why don’t they just skip the basketball game altogether and have dunking contests instead? Then it could be more like gymnastics, figure skating or diving.

Slate Says Mauritius Is the Greatest Country on Earth. Huh?

Slate, the on-line magazine, posted an article on March 7, 2011 claiming that Mauritius is the “Greatest Country on Earth.” The article’s subtitle reads, “What the United States can learn from the tiny island nation of Mauritius.” According to the author of the piece, Joseph Stiglitz, Mauritius, an island nation of 1.3 million people, provides “free education through university for all of its citizens, transportation for school children, and free health care—including heart surgery—for all” despite the fact that it is not rich and has no budget problems. And 87% of its people own their own homes, a figure not nearly matched by the United States. Stiglitz thinks we should emulate Mauritius and provide similar amenities for our citizens. Over 1200 comments have been logged with a high percentage of them expressing skepticism.

I sent the link to the article to a friend who recently lived in Mauritius for six months. He had plenty to say. He asked to remain anonymous as he still does business there.

He started with this, “While I think Mauritius is a beautiful country and has some very nice people, the standard to which they have attained some of the ‘achievements’ is based on a pretty low bar, and I would question many of the author's statistics.”

On medical care he wrote, “while medical care may be freely available, our experience with the local medical community left me feeling that I would not want to have any medical procedures done there, unless the alternative was death.”

On transportation, we have, “Roads are a nightmare, with only one main road through the whole island, going from the airport in the south east to the nice beach area in the NW. It goes right through the main city of Port Louis, and is a continuous traffic jam from 7 AM to 9 PM.”

Home ownership, “The home ownership statistic intrigued me and I cannot figure how they arrived at it, unless they include the large number of squatters who live in houses made of corrugated tin with stolen billboards for roofs (my company lost a billboard in the middle of the night that way). For those that do own their own homes, most are small, made of cinderblock and only partially finished…” And this: “…the 87% stat has to be fiction. Interestingly, a large percentage of houses remain unfinished (usually unpainted on the outside or with only a framework for a second floor) because you don't have to pay property taxes until it is completed. So it never is.”

It’s not all negative, in fact he said: “Mauritius has accomplished a great deal since independence, and should be very proud of what they have done. I actually think Mauritius is a lovely country with great people in charge who, for a population of 1.3 million, have done a fabulous job of developing the local economy and raising the standard of living in what I hope will be a sustainable fashion. The education system is solid, which is critical for the future and has been a very wise investment. Their approach is very tied to the local culture, where people's goals, expectations and standards are not the same as the US. So projecting it as a solution for…the US and Europe is a bit of a stretch.”

Stiglitz said that he recently visited Mauritius. One wonders just what he saw or perhaps was shown. Maybe he wrote the article just to see what kind of reaction he could stir up. If that was the goal, it worked although one could argue that 1200 comments from a nation of 325 million people is not really a massive response. Read the article and see for yourself.

Monday, March 7, 2011

Air Fares, Price Fixing and Justice

On March 6, 2011 AP reported that 21 non-US airlines were fined some $1.7 billion for fixing passenger and cargo fees. Several executives have been charged with four having been sentenced to prison. The cases were brought by the US Department of Justice.

I have always wondered about this. Everyone knows that gas stations peg their prices to what nearby gas stations are charging. To me, that smacks of price fixing too. But how do airlines get away with their fare policies? Today [March 7, 2011 at 9:30 a.m. EST] I went to the Orbitz website to book a trip From LaGuardia, NY to Chicago. Here is what I found.

How can it be that multiple airlines have the exact same fares? And it is not just Orbitz. If you go to the carrier’s websites, the $176.00 fare appears on all of them.

What is interesting is that I have always been told that if a surgeon discusses his fee structure with another surgeon, we would both be guilty of anti-trust violations. But somehow, the airlines can all just happen to have the same fares for their routes and no one says anything.

I wish someone would explain this to me.

Friday, March 4, 2011

Difficult Choice for Men: ED or Parkinson’s Disease

Would you rather have (a) erectile dysfunction or (b) Parkinson’s disease?

Research published in the last few days has shown that the use of aspirin and other non-steroidal anti-inflammatory drugs (NSAIDS) can lead to a 22% higher incidence of erectile dysfunction (ED). Conversely, men who use the NSAID ibuprofen (Motrin, Advil) on a regular basis may lower their risk of developing Parkinson’s disease by 33%.

Let’s think it through. You don’t take NSAIDS so your risk of ED is lower. But your chances of getting Parkinson’s disease are higher and Parkinson’s can cause ED too. Wait, no, take the NSAIDS and lower your chances of getting Parkinson’s while increasing your risk of ED.

No sure what to do? Here’s some more useful information. While offering relief for arthritis and other painful conditions, regular NSAID use has also been associated with an increased chance of suffering a stroke or heart attack. Other risks associated with NSAID use include gastrointestinal bleeding and kidney failure. But the use of aspirin and other NSAIDS may actually decrease the risk of developing colon cancer.

OK, it’s all settled now.

Thursday, March 3, 2011

Nine Maryland Hospitals Report Higher-Than-Average Complication Rates

On March 2, 2011 the Consumers Union Safe Patient Project posted the following tweet:

If you click on the link, you will find that of the 46 hospitals in Maryland, 9 did indeed have worse complication rates than the others. Another 23 had better-than-average rates of complications. The rest were average with the exception of one which reported no data. The complication rates were based the predicted number of complications [derived from the average number of risk-adjusted complications per hospital in the state] vs. the actual number of complications at each hospital.

At first glance, this seems like a good idea, track the hospitals and post the information for all to see. But wait a second. Whenever you do something like this, there are going to be some hospitals with better, some with average and some with worse rates of complications. The only way this would not be true is if all 46 Maryland hospitals somehow were average, which is highly unlikely. And every hospital cannot be above average. There is only one group that I am aware of that contains nearly all above average people and that is medical students. [See my previous blog on that subject.]

Also, comparing them to the average rate of complications for the state could be misleading. For example, what if Maryland hospitals have a much higher average rate of complications than the average national hospital complication rate? Then the average rate, or even the better-than-average rate, for Maryland might still be an unacceptable rate of complications.

It’s good marketing fodder for the 23 hospitals with better-than-average complication rates. But it will send each of the 9 poor performers into a tizzy. There will be task forces, ad hoc committees, consultants and meetings, meetings, meetings.

Will it result in better patient care? I don’t know. What I do know is that next year there will be some hospitals with better-than-average, some with average and some with worse-than-average complication rates.

Wednesday, March 2, 2011

More from the Book of Existential Mathematics

Here is another question from the interesting fifth grade math book that I have highlighted in previous posts here and here.

In case you can’t read it, it says, “Number Sense: How do you know that 5 1/4 is less than 5 4/10?" This question has puzzled philosophers through the ages. I am not sure that a fifth grader can explain it, nor do I think he should have to.

Perhaps this concept can be extended to other areas. Here are some potential candidates:

1. Why does air exist?
2. Why is a monkey called a monkey?
3. Why are there nine innings in a baseball game?
4. Why is water made of hydrogen and oxygen?
5. Why are there 435 members in the House of Representatives?
6. Why are daffodils yellow?
7. How do you know that this isn’t all a dream?

Tuesday, March 1, 2011

America’s Top 50 Hospitals. Says Who?

If you are looking for a chuckle, read the recently published HealthGrades list of America’s top 50 hospitals. The Healthgrades people have come up with a formula that selected 50 hospitals based on the following two parameters: “To be recognized with this elite distinction, hospitals must have had risk-adjusted mortality and complication rates that were in the top 5% in the nation for the most consecutive years. On average, patients treated at America’s 50 Best Hospitals had a nearly 30% lower risk of death and 3% lower rate of complications.”

That’s nice but it leads to some curious anomalies. For example, there are no university teaching hospitals on the list. By university teaching hospital, I mean a university hospital that serves as the primary teaching hospital for a medical school. Teaching affiliates rarely have the resources and research backup that university hospitals have. There are a few university-affiliated teaching hospitals on the list such as Hackensack University Medical Center in New Jersey. [Note: for those of you outside the New York City metropolitan area, there is no Hackensack University.] But even if you want to count the university-affiliated hospitals, there are not even 10 on the list. Twelve of America’s top 50 hospitals are in Florida with an impressive six of those located near the apparent Mecca of modern medicine [if you believe HealthGrades], West Palm Beach.

Let’s say I live in New York City and get sick. No hospitals in the states of New York or Connecticut made the top 50 list. My choices for hospital care are either the aforementioned Hackensack University Medical Center or the Community Medical Center of Tom’s River, both in New Jersey. I have never set foot in either place. They might be great hospitals. But I think I’ll take my chances at Columbia Presbyterian, Cornell or NYU.

Do you live in St. Louis? Sorry, no top 50 hospitals there. But you can go to the only hospital in Missouri on the list, St. Luke’s Hospital in Chesterfield. Pennsylvania? Sorry, no top 50 hospitals in Pittsburgh or Philadelphia but there are four in the Allentown-Bethlehem-Scranton area. Boston? Too bad. No Massachusetts hospital is good enough to be included in the HealthGrades Top 50 list. I hope Mass General, Deaconess and the Brigham don’t have to shut down.

I could go on. But see for yourself.

I posted a similar blog on this topic in August of 2010. I think lists like this are misleading, if not actually harmful. I wish they would stop publish them. But I guess the unsuspecting public eats this stuff up. Oh, and it is certainly a boon for the public relations people at the 50 lucky hospitals on the list.