Monday, November 30, 2015

A curious trend in appendectomies by residents

Some experts are worried that laparoscopic cholecystectomy is so prevalent that future surgeons may have difficulty doing open cases. I was going to blog about the possibility that open appendectomy would become the next operation that next generation surgeon might have trouble with. But while looking at some data [link added 12/4/15] collected by the RRC for Surgery, I was struck by something else.

Since 1999, the total number of appendectomies (open and laparoscopic) performed by surgical residents who completed 5 years of training has risen by 65.1% compared to the total number of appendectomies done in the US, which has increased only 16.4%. Here are the numbers:

Except for the academic year ending in 2006, the average total appendectomy rate per resident has risen every year since 2000. The chart below displays that change and the changes in the numbers of open and laparoscopic appendectomies.

Click on chart to enlarge
The difference in the average combined number of appendectomies between the two academic years ending 2000 and 2014 is significant, p < 0.0001.

Friday, November 20, 2015

A medical riddle: Where do incident reports go?

Incident reports are frequently submitted by hospital personnel. Did you ever wonder what happens to them? I have.

Over the years, I estimate that I’ve heard of hundreds of such reports being filed, but rarely have I heard of a problem being solved or for that matter, any action being taken at all.

In fact, I don’t even know where they went or who dealt with them. When I was a department chairman, I sat on quality assurance and risk management committees. Yet we never discussed individual incident reports.

The original intent of incident reports was to identify patient harms and increase patient safety.

According to a 2009 post by patient safety expert Dr. Bob Wachter, hospital incident reports are a spinoff from the Aviation Safety Reporting System which had successfully used them for identifying potential safety issues such as near misses.

At Dr. Wachter's hospital, San Francisco General, about 20,000 incident reports were filed every year. That is about half of what the Aviation Safety Reporting System receives per year, and San Francisco General Is only one of about 6000 hospitals in the United States.

Dr. Wachter feels that analyzing incident reports is not worth it. He estimates that each incident report creates about 80 minutes of work times 20,000 reports, which equals about 26,600 hours of wasted time. He also estimated that about one fourth of US hospitals do nothing with incident reports. That saves time but renders the reports useless.

He says an even bigger problem is that incident reports in his hospital fail to capture most events that harm patients.

That has also been my experience. I think most incident reports were filed by people wanting to "cover their asses" and most of the reported incidents were minor. A reference in Wachter's article states that most incident reports are submitted by nurses with only about 2% by doctors.

Incident reports can backfire too. From a 2002 Medscape article: "In some states, under certain conditions, the incident report is considered confidential and cannot be used against the nurse practitioner in a lawsuit. However, if copies are made or the chart reflects that an incident report was completed, the incident report can then be subpoenaed by the patient and used against the defendants in court."

And from the Louisiana State University School of Law: "The nonjudgmental nature of an incident report is very important because in most cases the incident report will be discoverable in litigation. An accusatory remark in an incident report may gain unintended weight in a legal proceeding."

Since incident reports generate a massive amount of wasted time, fail to identify most events that harm patients, are frequently ignored, and can possibly have a negative effect on lawsuits, why are they still being filled out by the thousands?

Tuesday, November 17, 2015

Telephone and television evolution through my lifetime

6-5-4. That was my home telephone number when I was growing up in the early 1950s. You may wonder how that was possible. I'll explain.

We lived in a small town. Telephones looked like this.
In order to place a call, you picked up the handset from its cradle, and an operator said "Number please."

You said the number, and she (operators were always women) made the connection for you via a switchboard.
Some folks in my town were on "party lines," which were less expensive but involved more than one household on the same line. If you picked up the phone in a home with a party line and it was being used by someone in another house, you could hear their conversation. You would have to hang up and wait until they were through before making your call. For incoming calls, the ring sequence was different for each household.

Thursday, November 12, 2015

Is the surgeon still "captain of the ship"?

A Kentucky appeals court ruled that a surgeon was not responsible for a burn caused by an instrument that had been removed from an autoclave and placed on an anesthetized patient's abdomen.

According to an article in Outpatient Surgery, the surgeon was not in the room when the injury occurred and only discovered it when he was about to begin the procedure.

An insufflator valve had been sterilized and was apparently still hot when an unknown hospital staff member put it down on the patient's exposed skin. [An insufflator is a machine that is used to pump CO2 through tubing into the abdomen for laparoscopic surgery.] When the doctor saw the mild second-degree burn, he asked what happened, but "but no one in the OR claimed any knowledge or responsibility."

The hospital had settled the suit on behalf of its staff, but the surgeon, who as a private practitioner had his own malpractice insurance, held out. The original lower court ruling dismissing the suit against him had been based on the plaintiff's lawyer's failure to prove that the surgeon was responsible for the actions of the hospital staff.

In December 2012, I wrote a post stating my opinion that activities such as counting the sponges during an operation were not the responsibility of the surgeon. Many who commented on the post were highly indignant that I could suggest such a thing.

I wrote another post last year on the subject in response to another surgeon's blog entitled "Everything's my fault: How a surgeon says I'm sorry." I felt that many things that happened to patients were beyond the control of the surgeon. Most of the comments agreed with me.

I keep hearing that medical care has become a team sport. If that's true, then the surgeon, like everyone else, is simply a member of the team. People on teams have different roles and must execute properly for the team to succeed.

One of the most interesting things about the case in question was that none of the OR team members had any idea how that hot insufflator valve found its way to the patient's abdomen.

One thing we know for sure, at least in Kentucky, is that a surgeon is not legally responsible for everything that happens to a patient in the operating room, particularly when he is not even present.

Is this decision the first nail in the coffin of the "captain of the ship" doctrine?

Tuesday, November 10, 2015

Should I go to med school?

A young man writes

I am thinking about pursuing medicine as a career. However, it is not something that I am entirely sure of because of the changing healthcare landscape.

Suppose I enter medical school at age 26. Four years later I have my MD. Five or six years later I will be done with a surgery residency and two years after that with my fellowship. I will 37-38 years of age with kids, a wife, and most likely a home. My kids will be around 9-11 years of age. In addition, I will be near $250K in debt from medical school because of interest accumulated throughout my residency and fellowship. This is of course not including retirement, car, house, investment, and kids’ college savings.

My friends tell me not to think about it, but if I don’t, I can end up in a position that I don’t want to be in. Even if I pay off my debt at age 50, I still have all those other things to address. And even if I do, when will I enjoy my money? What is perhaps most important though, is the time component. I am essentially giving up my entire life to a profession that will not allow me to transfer laterally to other professions if I choose to. I can be pursuing my other interests in the time that I would be becoming a surgeon such as business or engineering.

Lastly, I grew up in poverty and have no financial assets. It will take me years to accumulate wealth. And once I do (at around age 60), that wealth will be passed down to my children.

Did I miss something? What are your thoughts? 

While rereading and editing your email, I realized you did miss something. What's missing is enthusiasm for becoming a doctor. You listed several reasons not to go to med school, but nothing about why you want to do it. If you don’t truly love the idea, you will be very unhappy.

I think you need to reassess your future.

For those who want more information, I have written a couple of posts about questions related to this one [links here and here.] The comments on the more recent post are worth reading..

Monday, November 2, 2015

Hospitals Mess Up Medications in Surgery—a Lot

Yes, that was the inflammatory headline on Bloomberg Business News last week. It is great click-bait, but factually off base because the research it refers to was done at only one hospital.

Here's what the study found. During 277 operations with 3,671 medication administrations observed at the Massachusetts General Hospital, 193 (5.3%) involved a medication error or an adverse drug event. One or more errors or adverse drug events occurred in 124 (44.8%) of the procedures.

In all, 40 (20.7%) adverse drug events were not preventable—for instance, an allergic reaction to a drug that was not known about before. Of the remainder, “32 (20.9%) of the errors had little potential for harm, 51 (33.3%) led to an observed adverse drug event and an additional 70 (45.8%) had the potential [emphasis added] for patient harm."

Sounds bad, but the Bloomberg article goes on to say "While all the errors observed in the study had the potential to cause harm, only three were considered [potentially] life-threatening, and no patients died because of the mistakes. In some cases, the harm lay in a change in vital signs or an elevated risk of infection."