Wednesday, September 25, 2013

Can retired specialists be retrained to ease the shortage of family doctors? No

Last week there was some buzz on Twitter about a proposal from a retired plastic surgeon in San Diego who has developed a plan to retrain retired specialists as family practitioners. The idea is that this could alleviate the shortage of primary care physicians that exists now and is predicted to worsen as more people become insured.

The 15-module course created by some faculty at the University of California at San Diego involves 100 hours of online study with patient simulator testing on the campus for tuition of $7,500.

According to an article in U-T San Diego, at least one doctor, also a retired plastic surgeon, has completed the course and seven more have enrolled.

Is this a possible answer to the shortage of primary care physicians?

I think not.

Take the course—100 hours of online learning. Does that sound like enough to you? It takes three-years to complete a family medicine residency. Most plastic surgeons I know haven't touched a stethoscope since medical school, don't know the names of any drugs, and couldn't recognize a sick patient under any circumstances.

I rarely look at the comments for online articles, but I read a few family medicine physicians' comments on this. They were highly indignant at the mere mention of training anyone to do what they do for only 100 hours. I would have to agree.

As one commenter said, there must be quite a few lawyers in California salivating over this scheme. Maybe it was even cooked up by a committee of the plaintiffs' bar.

Another small flaw in this plan is just how many retired specialists would even want to do this?

With all due respect [this is what someone usually says to preface a disrespectful comment], I couldn't do it.

We all considered primary care when we were in medical school, but we did not do so for one reason or another. I'm glad some people did. Bless their hearts.

For me to become a family practitioner at this or any other stage of my life would be tantamount to going straight to hell without passing "Go" and without collecting $200.00.

The primary care shortage is going to have to be solved without me and, I suspect, most of my specialist colleagues.

Tuesday, September 24, 2013

Two new posts on "Ask Skeptical Scalpel."

There are two new posts on "Ask Skeptical Scalpel."

A pre-med student asks me some probing questions Link  


Is medical school worth it? Link

Monday, September 23, 2013

Medical errors and deaths: Is the problem getting worse?

Medical errors are a real problem. I won't deny that.

It was bad enough when the often-quoted Institute of Medicine figure that 98,000 deaths per year in the US are caused by medical errors was in vogue, but now a paper in the Journal of Patient Safety states that adverse medical events result in 210,000 to 440,000 deaths per year and 10 to 20 times those numbers of serious harms.

Since the paper disparages the medical profession, it has received a lot of media attention.

Most articles about it simply regurgitate the dismal estimates without any real attempt to dig into the paper's methods.

Let's take a closer look.

As is true of many papers, the abstract is a bit sketchy when describing how the paper arrived at its conclusion.

The full text of the paper reveals the author found four studies that looked at what are described as preventable adverse events in US hospitals within the last seven years. All four used the Global Trigger Tool which involves the screening of records for adverse events by nurses or pharmacists and a secondary review by physicians.

Based on opinions by "experts," the author made a key, but erroneous, assumption that all adverse events are preventable.

The basis of that assumption was apparently this statement in the methods section of a 2011 paper in Health Affairs about the Global Trigger Tool.

"Because of prior work with Trigger Tools and the belief that ultimately all adverse events may be preventable, we did not attempt to evaluate the preventability or ameliorability (whether harm could have been reduced if a different approach had been taken) of these adverse events."

The "belief that ultimately all adverse events may be preventable" is not supported by any facts, which are not necessary I suppose if one simply has a "belief."

Personally, I do not share the belief that all adverse events are preventable. Let me give you a few examples of why.

Aspiration of gastric contents is considered a preventable adverse event, yet I can see no way to prevent every single occurrence of aspiration. If you can, please share it with the rest of us.

Leukopenia [a dangerously low white blood cell count], which often leads to sepsis, and is a common side-effect of cancer chemotherapy could be prevented by never using chemotherapy, but is that a realistic solution?

Repeated studies of deep venous thrombosis have found that no measure, be it drug or mechanical device, is 100% effective in preventing DVTs.

Several papers addressing the use of the Surgical Care Improvement Project guidelines for prevention of surgical site infections after colon surgery have found that even when guideline adherence is nearly perfect, at least 8-10% of patients develop SSIs.

Sometimes adverse events are due to patient-related factors. From an editorial in this month's JAMA Surgery commenting on a paper about SSIs:

"[W]e are left with the yet unanswered question about how to remediate the problem [SSI] beyond adherence to SCIP. Short of a large scale public health campaign to address smoking, obesity, and comorbid disease, the findings do not expose a practical way forward."

Pop quiz.

The Journal of Patient Safety paper estimating 210,000 to 440,000 deaths due to preventable adverse events was based on four papers with a total of how many deaths?

a. 38
b. 380
c. 3,800
d. 38,000
e. 380,000

If you said "c. 3,800," you would have only been wrong by a factor of 100. The correct answer is "a. 38."

Adverse events and deaths due to medical errors are serious issues that need to be addressed. But inflating the incidence of these problems does nothing but further erode the already shaky confidence of the public in the medical profession.

And creating the impression that such events are totally preventable leads to unrealistic expectations and unachievable goals.

Note: Upper range of supposed deaths from medical error corrected from 400,000 to 440,000 on 2/24/14.

Friday, September 20, 2013

A prank in the OR backfires

An anesthesiologist at a California hospital pasted stickers simulating a mustache and teardrops on the face of a hospital employee while she was having surgery on a finger.

According to the LA Times, the doctor said, "I thought she would think this is funny and she would appreciate it."

And if that wasn't bad enough, a "nursing attendant" took a photograph.

The patient, who said she had to quit her job because of the humiliation, is suing the hospital and the physician for this confidentiality breach.

The woman who took the photo said she deleted it after showing it to the patient and didn't post it anywhere. One version of the story is that she texted the photo to the plaintiff.

Others have testified that they saw the image on Facebook although the hospital said that there is no proof the photo was ever posted online. Multiple news outlets, including the LA Times, have published the photo which was obtained via court documents. 

One thing is certain. The photo is readily available now.
The plaintiff also claims that general anesthesia was unnecessary and only used so that the picture could be taken.

The anesthesiologist and some hospital employees were disciplined, but the hospital says the patient has fabricated and exaggerated some of her complaints.

At a deposition, a nurse manager at the hospital testified that in 2009, a sales representative took some pictures of a naked patient in the operating room. The hospital maintained that no such photos were ever taken. But then not only barred that sales rep from its OR, it also established a policy that no cell phones or cameras would be permitted in that area. This was an attempt to rectify a human error in judgment and common sense with a system correction. Obviously, it didn't work.

There are lots of issues to discuss.

It seems the OR is not a good place for a prank.

Bad ideas. One, pasting the stickers on the patient. Two, taking a photo (without consent). Three, texting it to the plaintiff. Four, posting it on Facebook (allegedly).

The Internet doesn't forget. Once something is posted it tends to stay there—somewhere—forever.

There is this thing called HIPAA, which contains many strict rules about patient privacy. People have been fired, fined, and even jailed for breaches of patient privacy.

Why didn't the hospital settle this case, which has gone viral? Do they really think they can win? Have they never heard of the "Streisand Effect"?

The hospital had a policy of no cell phones and no photos in the OR, but it was observed about as well as the 55 MPH speed limit. 

If there is nothing else to learn from this case, a hospital should not establish policies it cannot or will not enforce. Lawyers feast on that sort of thing.

Bottom line: The cell phone and its camera are not the culprits here. Smartphones don't take pictures of people; people take pictures of people.

Tuesday, September 17, 2013

Is this the most bizarre bad doctor of all?

There seems to be no shortage of bad doctor stories going around right now. Just when you thought you'd heard the worst, along comes another.

A "cosmetic surgeon" in California has lost his license to practice medicine and has been charged with involuntary manslaughter in the 2010 death of a 61-year-old woman during a 10-hour liposuction procedure being done in his office. She apparently died from an overdose of lidocaine, fentanyl and oxycodone.

Like some other cases involving doctors who lost their way, this physician trained at renowned institutions. In this case, the doctor was described as having done a residency at Columbia, a chief residency at Johns Hopkins and a fellowship at MD Anderson Cancer Center. 

His training was in obstetrics and gynecology, and he was not certified by a legitimate American medical board. He called himself a cosmetic surgeon but apparently had no formal training in cosmetic or plastic surgery.

Here is a list of some of the other major issues with this doctor.
In addition to the manslaughter charge, he was charged with elder abuse of a 77-year-old woman who also had complications during liposuction.

He charged patients exorbitant fees for procedures, allegedly as high as $650,000, but routinely in the range of $50,000 to $100,000.

He once anesthetized a patient for surgery, and while she was sedated, had her sign for more surgery at an increased fee.

He offered discounts to patients if they would enroll in a Harvard University study, which was later proven to be fictitious by Charles Feldman, a persistent investigative reporter for a Los Angeles radio station.

He is currently in jail, having been tried and convicted of attempted grand theft for trying to sell $20,000 worth of medical equipment he did not own.

The California Medical Board was warned about him by other surgeons two years before the death of the liposuction patient.

He has been living illegally in the United States since his visa expired in 2006. Apparently the California Medical Board and most other boards do not check on things like visa status when doctors apply for or renew licenses.

After the death of his patient and the restriction of his license to non-invasive procedures, he started advertising his services using only his first name so that Internet searches would not reveal his licensing problems or stories about the patient who died.

At some point near the time of the liposuction patient's death, the doctor was rushed to a hospital from his office having called an ambulance when complications arose while attempting to perform a hernia repair on himself. The homicide detective who investigated the case said, "That caused me to question whether [the doctor] was in complete control of his faculties."

It is ironic that he even botched the surgery he tried to do on himself. He should never have believed his own advertising, nor should anyone else have.

Once again, this doctor could have been stopped before that liposuction patient died, but the medical board did not act.

It is sad for the patients and the families he harmed. 

PS: His Healthgrades score today is 4.4 stars.

Monday, September 16, 2013

Three more papers document the decline of resident education

A study of traditional every fourth night call compared to staggered shifts of every fifth night call or "night float" appeared in JAMA Internal Medicine.

Although interns working on the "night float" and every fifth night shifts got significantly more sleep than the control group of interns working longer shifts every fourth night, "both the every fifth night and night float  models increased hand-offs, decreased availability for teaching conferences, and reduced intern presence during daytime work hours. Residents and nurses in both experimental models perceived reduced quality of care, so much so with night float that it was terminated early."

A JAMA Surgery paper surveyed 213 surgical interns from 11 university hospitals in July of 2011 and May of 2012. This was the first academic year that the new 16-hour limit was in force.

Although 82% of the interns reported a neutral or good quality of life, more than a quarter of them had symptoms of emotional exhaustion and depersonalization and 32% said their work-life balance was poor. Two-thirds said they thought about their satisfaction with being a surgeon daily or weekly and 14% said they considered dropping out of surgery training at least weekly.

Over half of the residents said that the work hours changes had decreased their time spent in the operating room, and at the end of their intern year, 44% said they did not believe that the work hours limits led to reduced fatigue.

So in both medicine and surgery, the 16-hour work restriction has resulted in unintended consequences.

As if that is not bad enough, check out this blockbuster. The title of a paper in Annals of Surgery this month is "General Surgery Residency Inadequately Prepares Trainees for Fellowship: Results of a North American Survey of Program Directors."

General surgery subspecialty fellowship directors were surveyed and 91 (63%) responded.

From the abstract: "21% [of fellowship program directors] felt that new fellows arrived unprepared for the operating room, 38% demonstrated lack of patient ownership, 30% could not independently perform a laparoscopic cholecystectomy, and 66% were deemed unable to operate for 30 unsupervised minutes of a major procedure. With regard to laparoscopic skills, 30% could not atraumatically manipulate tissue, 26% could not recognize anatomical planes, and 56% could not suture. Furthermore, 28% of fellows were not familiar with therapeutic options and 24% were unable to recognize early signs of complications." [Emphasis added]
Note that the residents in the Annals paper had not yet been subjected to the 16-hour work limits as that rule was not in effect when they were first-year trainees.

The good news is that by the end of their fellowship training, 82% could perform advanced cases independently. There was no word on the fate of the 18% who could not perform advanced cases independently.

Now that's reassuring, isn't it?