Monday, September 24, 2012

The effect of the robot on surgical education

Having taken an extended break from writing about the problems associated with robotic surgery, I think it’s time to explore an area not previously discussed.

What is the effect of the robot on surgical resident education?

The robot at the OR table (babe not included).
Let’s review a few points about robot-assisted surgery. The surgeon actually doing the case is not scrubbed. He sits at a console away from the patient and manipulates the instruments. Another doctor has to scrub and insert the instruments through small incisions and “dock” (connect the instruments) to the part of the robot that is next to the patient. 

The assistant at the patient’s side views the operation on a video screen. Sources tell me that residents get to do a lot of docking, observing, inserting and removing instruments and closing incisions but not much time, if any, at the console doing the operation.

There is a dual console capability but many hospitals do not invest in it because of the added cost of the fully equipped second console.
Two consoles. Resident (left) shown participating in the operation.

So how are the residents going to learn to perform surgery? There is already evidence that they lack confidence in their ability to operate independently. See my earlier blog on this subject.

The majority of graduating chief residents in surgery take at least one year of fellowship training. One can only hope that they train in a hospital that has at least one dual-console robot or they may end up practicing on you and me.

Friday, September 21, 2012

Cranberry juice may help lower BP but…

All you need to do is drink two 8 ounce glasses of cranberry juice per day for 8 weeks and your blood pressure will be statistically significantly lower. So states a randomized, blinded placebo-controlled trial presented at this year’s American Heart Association's High Blood Pressure Research.

According to the MedPage Today report, mean diastolic blood pressure fell by a whopping 3 mm Hg from baseline at the end of the study period. The difference was significant at the level of p = 0.049. Subjects given placebo showed no change in their average BP.

Unfortunately, as appealing as this may sound, it’s another situation where statistical significance and clinical significance part ways. I have blogged about this before.

What are the problems with cranberry juice study?

The subjects were people of normal body mass index (average BMI, 28) who did not have hypertension.

The mean fall in diastolic blood pressure was from 72 mm Hg to 69 mm Hg, both of which are in the normal range. A 3 mm Hg difference in diastolic blood pressure, even if it had occurred in a patient with hypertension, is not a clinically important difference.

Systolic BP also fell by 3 mm Hg but the difference was not statistically significant, p = 0.12. A quote from the article states, “The trend didn't meet traditional criteria for statistical significance, but the 89% odds of a systolic blood pressure reduction with the cranberry juice was still pretty good, [a study author] suggested.” Sorry, not only is that baloney, a 3 mm Hg difference in systolic BP is also not clinically important.

A study from the Mayo Clinic found that when blood pressure is measured every 10 minutes throughout the day in healthy adults, both systolic and diastolic BPs varied as much as 8 to 10 mm Hg whether the subject was active or not. This indicates that a 3 mm Hg difference is very likely to have occurred by chance.

Finally, the study was funded by Ocean Spray Cranberries and one of its employees was a co-author.

You can drink cranberry juice if you like its taste, but don't throw away the BP pills.

Thursday, September 20, 2012

Anguish. Choosing a medical specialty is difficult, Part II

The following was recently posted by an anonymous woman as a comment on a blog post I wrote about the difficulty one has in choosing a medical specialty. I was so taken with it that I wanted to give it more exposure. [Note: The comment contained a few typos which I have corrected. Otherwise it is unchanged.] My response has been amplified slightly.

Since you are so senior to me, let me ask you for your thoughts. I got into medical school, studied, worked hard, got into residency and learnt, spent hours and hours in hospital, loved critical care and got into fellowship. Along the way met a guy (both were residents at that time), fell in love and we both dreamt and read and learnt and discussed cases. He decided on cardiology and I decided on critical care. Both got into fellowships ....worked hard, spent long hours into fellowship...we were committed. We ARE committed but divided.... We had kids and now every day I feel divided. I have a feeling that all "old timers " like you who worked for longer hours and did frequent night calls, had " spouse" who take care of your kids and you did not have to worry as much. Times were different. Times were not so dangerous and kids’ safety outside of the house was not so concerning.

In my situation, my spouse and I are both physicians in fields that require us to spend lots and lots of hours in hospital. If I were to find a traditional practice and work every 3rd night, who will raise my kids? Who will teach them right from wrong? Everything is on rise–drug abuse, physical abuse, drop-out rates. I WANT to raise my kids and be there to guide them. So yes I want a practice where call frequency is lesser, where I can spend evening with my kids (not because I want to have fun but I want to be there).

We do not think about all this when we get into medical school and I did not think about this when I married my husband and we did not think about this when we chose our subspecialities. Perhaps that was a mistake.

It was easier for us. There were far fewer women in medical school. My class of 180 had only 20 women in it. Our chances of marrying another doctor were much lower, especially since same sex marriage was not in vogue back then. I was fortunate to have married a woman who is both a nurse and a saint. She took 13 years off from work to raise the children.

Have you thought about joining a group and working part-time, maybe with shorter hours and fewer nights on call?

I was touched by your palpable internal turmoil. My heart goes out to you. I hope you can find the balance you seek. Your last paragraph sums it up. Everyone in medical school should read it.

Tuesday, September 18, 2012

A HIPAA and ethical conundrum

Do you know anything about HIPAA?

Here’s a scenario for you.

Patient A comes in from the parking lot of a doctor’s office and said to the nurse, “I just saw a patient leave here and when she was backing out of her space, she hit another car. Then she just drove away.” Patient A was able to accurately describe the perpetrator and said she would sign a statement saying she witnessed the incident.

The nurse finds out that the car that was struck belonged to Patient B. Patient B then asks the nurse to tell him who was driving the car that struck his.

The nurse, knowing exactly who the hit-and-run driver was, said, “I can’t tell you that. It would be a HIPAA violation.”

Patient A and Patient B appeal to the doctor. What would you tell the doctor to do?

Monday, September 17, 2012

Signs that the apocalypse is near. Part 2

I reviewed a few signs of the impending apocalypse in a previous blog. It looks like it will take many blogs to cover all the signs that keep appearing. Here we go.

Tech company Citrix released the results of a national survey which showed that 51% of Americans think that the weather can affect cloud computing.

A Swissair flight from Zurich to Beijing had to turn back when two passengers began to fight over a reclining seat. The men fought in the aisle, rolled around and cursed at each other. Why can’t we all just get along?

If you’re a man, it’s OK to walk around naked in San Francisco. However, what you cannot do is wear a ring (ahem) … down there, but only if someone complains about it. I haven’t been to San Francisco in quite a while and the photo (SFW) accompanying the article does not make me miss being there at all.

The Chief Diversity Officer at the State Department has issued an advisory which says that the use of phrases like “hold down the fort," “going Dutch” and “rule of thumb” are racially or culturally insensitive and should not be used.

In cooperation with the Discovery Channel, Harvard University, which made my first list because of its cheating scandal, is presenting a “media training boot camp for doctors.” The advertisement says, “This amazing 3-day event is only $1997 to attend.” I’ll pass.

A cheating scandal has rocked the world of competitive Scrabble. A contestant was caught with extra blank tiles. I’m not sure how he planned to use them since the game has only two and it would have been pretty obvious is he played a third one. I suppose the next thing will be doping in chess.

Professional image consultants charge $300 per hour to coach young women on what to wear and how to speak during college sorority rush week. The business is called “Rushbiddies.” The ABC news story has a happy ending as the woman featured in the story was accepted into Alpha Phi, which was her first choice.

A 2011 test of US eighth and twelfth graders reveals that only about 27% had proficient writing skills even if they had access to spell check. The problem is those who didn’t do well had poor organizational and grammar skills. According to the story, “In 2007, 33 percent of eighth grade students scored at the proficient level, which represents solid writing skills, as did 24 percent at grade 12.” The most recent test was done on computers while the 2007 students used things called pencils and paper.

A dance school in British Columbia is offering pole dancing classes to grade school children. If that's not bad enough, note that parents have enrolled children at $70 for an hour session. “The kids just love it,” said [the] president of the Canadian Pole Fitness Association, which is said to be holding championships in what it association president says is becoming a “sport.”