Thursday, April 25, 2013

Attorneys and physicians share common goals?

Here is big news from the March 2013 issue of the American College of Surgeons Bulletin.
The headline reads, "Attorneys and physicians share common goals." 

The primary author is a medical liability plaintiff's lawyer from Washington, DC. 

The article states that surgeons and liability attorneys want similar things for patients. "Both surgeons and patient attorneys are committed to patient well-being and the relief of patient suffering." Really? So for liability attorneys, it's not about the money? I see; it's about "relief of patient suffering."

"Surgeons belong to an ancient and esteemed profession; every day, surgeons cure disease, relieve pain, and make lives better. Attorneys see themselves as members of another healing profession, helping to restore to broken lives some measure of independence and dignity." I did not know that attorneys were members of another healing profession. I've never heard it put that way before. I mistakenly assumed it might be about the money.

"When injured patients are treated fairly in the legal system, it helps restore their trust by facilitating communication between the clinician and the patient and providing clarity about a potential error and how it occurred." So the elaborate process that goes along with a medical liability lawsuit is all about communication and restoring trust? And I thought it was about the money.

"Liability cases and fair compensation are means of honoring patients. Because they draw attention to patient suffering and physician error, they help ensure that the opportunity to prevent harm to another patient will not be lost or wasted." It's good to know that plaintiff's attorneys are in business for the purpose of honoring patients. Silly, cynical me. I thought it was about the money.

"In the U.S., the 'deny and defend' response from physicians is quite common. This reaction may be due in part to the perverse and dangerous incentives that characterize the American medical system. For instance, the fee-for-service model provides a disincentive for less-qualified surgeons to refer patients to trained specialists." According to Mr. Malone, doctors' denying and defending lawsuits is the real problem. And that's because of the fee-for-service payment system? Sorry, I don't follow that line of reasoning.

"One legal reform could go a long way toward fixing this problem. If surgeons were employees of their hospitals and not independent contractors, the employer would have both the muscle and the financial motivation to better supervise individual practitioners." Mr. Malone may have a point here, but I wonder if he would opt for a system that made all lawyers employees and not independent contractors? Since we are both members of healing professions, I think it would be fair if everyone was salaried.

Regarding the use of guidelines as a malpractice defense which some have labeled a "safe harbor," he says, "However, the safe harbor concept becomes unacceptable if it allows guidelines to be used as a 'get out of jail free' card. Guidelines must be useful in exonerating and implicating clinician wrongdoing." What he seems to be saying is that it's OK to use a guideline to prove a clinician did wrong, but following guidelines shouldn't be a fail-safe defense strategy.

Maybe someone can explain to me why the American College of Surgeons would print an article such as this in its house journal.

Monday, April 22, 2013

Do BSN nurses provide better care?

A paper entitled "An increase in the number of nurses with baccalaureate degrees is linked to lower rates of postsurgery mortality" appeared in Health Affairs in March and  generated quite a lot of buzz on the Internet.

Its major finding was that hospitals in Pennsylvania that had 10% more nurses with BSN degrees were found to have 2.12 fewer deaths per 1000 postop patients than those that did not. The authors extrapolated this, saying that if all the hospitals they surveyed had the same percentage of BSN nurses as the best performers, 500 deaths may have been avoided.

The reduction in mortality rates was not significantly affected by staffing levels, skill mix or years of experience as a nurse.

The mechanism for the decrease in death rates was not explained but assumed to be better rates of "rescue" after the development of complications which also was significantly associated with the presence of more BSN nurses and not staffing levels, skill mix or years of experience as a nurse.

The abstract concludes, "The findings provide support for efforts to increase the production and employment of baccalaureate nurses."

The math in the paper is confusing. In 2006, 25,000 nurses responded and 1/3 (presumably about 8,333) of them were staff nurses in general hospitals. The information from those 8,333 nurses was the basis of the study. They go on to say that there were 134 hospitals with an average of 48 respondents. That computes to 6,432. That's a discrepancy of over 2000.

A cliché that is often used in comments about research papers is "the study raises more questions than it answers."

Here are a few. 

Could it be that the hospitals with improved mortality and rescue rates are simply better hospitals? And maybe BSN nurses are simply more likely to work at better hospitals. 

If 2/3 of the nurses who responded to the surveys are not working as staff nurses in general hospitals, just what are they doing? Going to committee meetings?

A nurse who commented on a recent post of mine about a national organization setting up a "Transition to Practice" fellowship for graduating surgical trainees who lack confidence in their skills said,

I could say the same about nursing school. Why are there suddenly nurse residencies and nurse fellowships? Because there is too little clinical time while in school. My nursing school has a name that you would recognize. Our med-surg clinical days were one half-day per week spent at the hospital, about 26 in total over 2 semesters. Peds and maternity, about 5 half-days each. I was lucky because I was on a general medicine unit and got to see a variety of patients. We all complained that our clinical time was inadequate. The preceptorship in the last semester consists of working eight shifts one-to-one with a staff RN. No wonder, then, that hospitals are not confident in the capability of new nurses to practice safely and effectively.

Why is it that over 100 hospitals have established "nursing residency" programs? Click here to see a list of them published by the University of Pennsylvania. 

Here are quotes from two hospital websites about their nursing residency programs.

The Nurse Residency Program at Mayo Clinic in Arizona is a full-time registered nurse position with a one-year orientation program that assists you in transitioning from a new graduate to a fully competent, professional nurse at Mayo Clinic.

Children’s National Medical Center’s Pediatric Nurse Residency program provides the novice nurse with the knowledge base and skill set needed to transition to competence in clinical nursing practice.

What they are saying is that at least some graduating nurses are not competent. This meshes well with recent findings that graduating surgical residents are not ready to practice independently.

Why can't we teach nurses how to nurse in school and docs how to doctor during residency?.

Thursday, April 18, 2013

What? American College of Surgeons establishes "Transition to Practice" fellowships

The finding that more than 25% of general surgery residents are not confident that they can practice independently after finishing their residency training has prompted the American College of Surgeons (ACS) to create "Transition to Practice" fellowships.A pilot program at five medical schools and one rural community teaching hospital will place newly graduated residents with community hospital surgeons who will serve as mentors.

The program was introduced in an article in the February 2013 issue of the ACS Bulletin. It says, "current fifth-year residents often lack confidence in their capabilities and may be ill-prepared to enter practice due to a lack of general surgery mentorship and limited exposure to open surgical procedures."

The article goes on to say that the deterioration in training is due to "a number of factors, including reduced work hours, fewer hands-on experiences, and reduced volume of cases, especially emergency cases. Of particular concern is the lack of continuity of care and supervision."

But one of the members of the committee that planned the program said, "The transition from being a chief resident on June 30 to a surgeon in independent practice on July 1 is a daunting step. They haven’t done an operation without an attending across the table."

So which is it—not enough supervision or too much?

It seems to me the ACS feels that general surgery residency training is inadequate.

This confirms what I have said in previous blogs. Last July, I suggested that open surgery fellowships might be necessary to train residents who lacked sufficient exposure to open cases during their residencies. In January of 2012, I pointed out that residents who have never operated alone (the situation in most training programs—confirmed by the ACS) are analogous to pilots who have never soloed before. Would you want to fly with such a pilot? Back in November of 2011, I reviewed the paper that reported the lack of confidence expressed by 27% of residents who were surveyed. I have heard that in a paper about to appear in a major surgery journal, that number is approaching 40%.

If we can't produce confident graduates, why not simply change the way we train them instead of adding another year to the already long process (4 years of college, 4 years of med school, 5 years of surgery residency)?

I have discussed several areas of the curriculum that could be reduced or eliminated, such as insisting that all residents do research whether they want to or not, the heavy emphasis on basic science and the needless transplant rotation.

With a little thought, I am sure more changes could be made so that graduating residents will not feel the need to "transition to practice."

What do you think about "Transition to Practice" fellowships?

This post originally ran on General Surgery News in early March.

Tuesday, April 16, 2013

"Hospitals stumble in preventing harmful 'never events'"

A recent story in the AMA's American Medical News ( was headlined "Hospitals stumble in preventing 'never events.'" It reported that the Minnesota Department of Health said, "the number of patient disabilities attributed to the mistakes rose from 84 to 89, while related patient deaths jumped from five in 2011 to 14 in 2012."

Here’s a chart from that Minnesota DOH report. Deaths are in red and disabilities (harms) are in blue.
What do you think? Have the hospitals really stumbled?

Let’s take a closer look.

The report consists of all of the patient harms and deaths voluntarily reported to the state by hospitals for the years in question.

It is well-known that voluntary reporting captures less than 10% of all adverse patient events.

Want proof?

Minnesota has about 150 hospitals. Here are some numbers for the last reporting year (10/11-10/12).

Number of wrong patients operated on? None
Number of intra-operative/postoperative deaths? None
Number of misuse or malfunction of devices? None
Number of contaminated drugs, devices or biologics? None
Death or disability due to medication error? 2 (both disability)

Do you believe those numbers? I don’t.

And of course, the good news, if it’s true, was not mentioned in the article

The number of pressure ulcers declined by 8%. This is the first decline of this magnitude in the nine years of reporting. This year’s total of 130 is down from an all-time high of 141 last year. If you’re a skeptic, you might just question that figure as it means that the incidence of pressure ulcers averages less than 1 per hospital per year.

Retained foreign objects declined by 16 percent, the first drop in this category in five years.

Medication errors dropped by 75% from the previous year and were at the lowest level in all nine years of reporting.

Now here's the real problem with the report and the story.

Here are charts of the deaths and harms without the annoying 3-D bars, but with trend lines clearly showing that if anything, the trend is that both harms and deaths are decreasing, albeit not significantly. They certainly aren’t getting worse.
As I have written many times, a bit of knowledge about statistics can be quite useful if you are doing research or reporting on it.

So yes, "hospitals stumble" but maybe not in preventing "never events." The stumble is in the reporting of "never events" by hospitals. I think stumbled there too.

Monday, April 15, 2013

Two new posts are out today

I posted two new entries today.

On Physician's Weekly, I comment about a new study from the British Journal of Surgery on trans-gastric (NOTES) appendectomy. The authors say the results are "promising." I don't think so. Here's a link:
On General Surgery News, a reader asks "Are program directors the reason that surgical residency training is a mess?" I explain here:

Wednesday, April 10, 2013

C. diff dangerous in ESRD but so is inaccurate reporting

Here are the first three paragraphs of a story from the medical news site, MedPage Today.

"ORLANDO – Patients on kidney dialysis who are infected with Clostridium difficile appeared to have a greater risk of infection relapse and also appeared to have a higher all-cause mortality that patients who do not have kidney disease, researchers said here.

"Mortality related to C. difficile infection was 3.8% among the 104 patients with end-stage renal disease (ESRD) and 1.46% among 300 controls without ESRD, said Massini Merzkani, MD, resident in internal medicine at the Albert Einstein School of Medicine's Jacobi Medical Center in Bronx, N.Y. (No data as to significance were presented.)

"In his poster presentation at the National Kidney Foundation 2013 Spring Clinical Meetings, Merzkani told MedPage Today that the relapse rate in severe C. difficile infection was 34.7% in the controls and 45.2% in the patients with ESRD. (No data as to significance were presented.)"

Does it make you nervous that "No data as to significance were presented"?

It should.

The authors didn't analyze the data for statistical significance. Would there be any way to do it yourself?

Yes, if you knew which statistical test to use.

Should a science reporter know something about statistics?

Yes, and the story was reviewed by an emeritus professor of medicine at an Ivy League medical school who should have known too.

In addition, there is a rather interesting math error. The mortality rate of 1.46% for the 300 controls doesn't compute. [300 x 0.0146 = 4.38] Unless 4.38 people died, the figure must be wrong.

Since both the mortality and relapse rates are categorical (yes or no) variables, the correct statistical test to use is Fisher's exact test.

The p value for mortality is 0.21 and for relapse is 0.061. Neither difference is statistically significant which means that based on this study, one cannot say that "C. diff is dangerous in ESRD."

You might point out that a p of 0.061 is pretty close to the magical value of 0.05. That is true, but there is another major flaw in the study. The article says the ESRD patients "were compared with patients without chronic kidney disease who were admitted with C. difficile infection during the same time period. The researchers calculated that randomly selecting 300 of the 2,400 control patients would produce a valid comparison of outcomes."

Despite that "calculation," the comparison is invalid. One cannot simply compare ESRD patients to random patients. They would at least need to be matched for age, sex, co-morbidities other than ESRD and perhaps other variables to eliminate confounding.

It is possible that ESRD patients will have worse outcomes if they contract C. diff colitis. But this study doesn't prove that, and the story is misleading.

It's 2013. I agree with The Guardian's Observer column which says that Nate Silver's accurate predictions highlight "the importance of statistical literacy in our data-heavy age."