Tuesday, May 31, 2011

Infections at the VA. Good News and Bad News

An interesting juxtaposition of news releases turned up today in an email called the “Critical Care SmartBrief.” One story described a significant reduction in infections at a Texas VA hospital, which had instituted a policy of swabbing the nose of every admitted patient looking for MRSA. The hospital’s program was part of a larger study published in the New England Journal of Medicine.

The other article described a problem of poor hygiene in VA hospitals in five states which has necessitated warnings to 13,000 veterans. Among other issues, a dentist was found to have used unsterile equipment. He also did not change dirty gloves between patients. So far, 61 patients have tested positive for hepatitis and 8 for HIV.

These two anecdotes raise some important issues. Although some health care quality gurus would have you believe that all errors are due to system failures, I believe that most are caused by humans. How could a 21st century dentist, presumably a graduate of an accredited school, use unsterile equipment and dirty gloves? You could ask, was he operating in a vacuum and should other personnel have noticed his poor technique? Can the VA ever improve its image? Is it possible to eradicate all mistakes in a complex environment like a hospital?

In the words of the late Roseanne Rosannadanna, “It’s always something!”

Thursday, May 26, 2011

Report from Australia: What I did on my spring vacation

Two weeks in Australia were wonderful. It’s a lovely country with nice people. They really do say, “G’day, mate,” but they don’t drink Fosters. In fact, I only saw one bar that even sold Fosters. [Not that I went to many bars, of course.] We saw the sights of Sydney, Melbourne, Cairns, Great Barrier Reef, Blue Mountains, Great Ocean Road and many more.

Here are some of the oddities encountered.

On line access is somewhat slow and expensive but in at least one area of technology, Australia has progressed further than the U.S. Note this business on William Street in Sydney.
Out near the Blue Mountains is a store that is much more definitive than its U.S. counterpart.
At the Twelve Apostles, an awesome seaside vista,
is a fairly explicit sign warning tourist about the hazards inherent in climbing on sandstone cliffs.
 In addition to kangaroos, emus and other strange creatures, unusual insects apparently threaten the land as this sign clearly warns.
Not to be overlooked are literary efforts such as these titles seen in the window of a Sydney bookstore.
And here’s another nod to classical literature.
We went to an Australian Rules Football (“Footy”) game. It seemed like organized chaos. A better name might be “Australian No Rules Football.”
A fad which apparently started down under and is spreading worldwide is “planking,” which is the assuming of a prone position in a public, preferably unusual or hazardous place while someone takes a photo. This has already led to one death and some workplace issues as a prominent retailer dismissing several employees for planking on the job.

Finally, no story about Australia would be complete without mentioning Tim Tams
They are positively addicting rectangular chocolate biscuits. While they are good when eaten alone, one can enhance the experience by performing a “Tim Tam Slam.” This is accomplished by biting off either end of the treat and sucking coffee or milk through the biscuit itself. You must try it.

G’day, mates.

Monday, May 9, 2011

Vacation Time

I'm leaving for Australia today and will be gone for two weeks. Itinerary includes Sydney, Cairns-Great Barrier Reef, Melbourne, Great Ocean Drive and more.

Will resume blogging when I return. Meanwhile, check out some of my older posts. Thanks.

Friday, May 6, 2011

Strokes, Sex, Headlines, Reportage

Today’s hot medical press release is about a paper describing factors which may trigger the rupturing of a cerebral aneurysm.

The study was performed using a questionnaire and included 250 subjects who had experienced a stroke related to a cerebral aneurysm. According to the article, published ahead of print in the journal Stroke, there are eight factors which can trigger the rupturing of a cerebral aneurysm.

In decreasing order of importance they are coffee drinking, vigorous exercise, nose blowing, sexual intercourse, straining to defecate, cola drinking, being startled and being angry.

There was some good news. Alcohol consumption mostly lowered the risk of stroke. Masturbation and using marijuana had no effect.

The study had some limitations such as those whose strokes left them with serious disabilities or death were unable to complete the questionnaire.

I have two comments.

Why is it that sexual intercourse, only the fourth most important factor in causing aneurysm rupture, was featured in the headlines of all of the organizations that printed the story—BBC News, Huffington Post, MSNBC, Eurekalert, Reuters to name but a few?

What the paper did not address was whether the risks were cumulative. For example, what if you had sexual intercourse while angry? Or even worse, what if you drank some coffee, then went to the bathroom to defecate [a common occurrence], while sitting on the toilet blew your nose and then were startled? Perfect storm?

Monday, May 2, 2011

Coming Soon to a Neighborhood near You: A Shortage of General Surgeons

There is much hand-wringing about the shortage of primary care physicians. But primary care not the only specialty with deficits. In a few years, all surgical specialties will experience significant decreases in availability. Here is what will be happening with general surgery.

Demand-Side Facts:

The current population of the United States is about 311 million people. Estimates are that by 2020, it will rise to over 340 million.

As baby boomers age, the increase in the population of the elderly will result in more need for general surgeons.

There are already many rural areas that are underserved by general surgeons.

Supply-Side Facts:

The number of general surgeons needed to adequately serve the population is estimated to be at least 7 per 100,000 people.

Currently there are about 18,000 active general surgeons in the US or 5.8 per 100,000 people.

The ratio of general surgeons per 100,000 population has dropped by 26% in the last 25 years.

Medical schools are expanding class sizes and a few new schools are opening but it will take several years for the impact of these changes to be felt.

Residency programs produce about 1050 new general surgeons per year, a rate that has been level for almost 20 years.

The prospects for increasing the number of surgeons being trained are limited. A recent paper in the journal Academic Medicine showed that even if all of the current 246 general surgery training programs expanded as much as they possibly could, the best-case scenario would be an increase to about 1500 new surgeons per year. The cost of funding this increase is estimated at several billion dollars, which have not been allocated. Even if the expansion took place by 2015, it would take 5 years (the length of general surgery residency training) before the extra new surgeons would be available.

At least 30% to 50% of graduating general surgeons take fellowships and ultimately narrow the scope of their practices. These surgeons do not perform all of the procedures that the average general surgeon does.

Almost 50% of medical school graduates are women and up to 40% of surgical residents are women as well. Here is “the elephant in the room” that no one wants to talk about. Although some surveys suggest that women do as many cases as their male counterparts, a recent study presented at the American Surgical Association showed the facts. Information submitted by nearly 5000 general surgeons applying for recertification by the American Board of Surgery during the years 2007-2009 shows that male general surgeons perform an average of 500 cases per year compared to female general surgeons, who do 375 cases per year. And the case mix of women surgeons is skewed with “far more” breast procedures and fewer abdominal and GI cases being done compared to male surgeons.

Recent papers have noted the increasing problem of “burnout” among surgeons. One paper from 2009 reported that 40% of some 7900 respondents to a survey of members of the American College of Surgeons considered themselves “burned out” and 30% had symptoms of depression. This will lead to attrition and/or earlier retirement.

Bottom line. There is already a shortage of general surgeons. The population of the US is growing and the supply of general surgeons is not. It will take money and time to rectify the problem. No one is doing anything about this.