Folding a paper airplane. Amazing feat by the surgical robot?

A number of people have tweeted about a video that shows a surgeon using a Da Vinci robot to fold and throw a paper airplane.

Watch for yourself.

On Twitter, I commented facetiously that there is finally a use for the robot.

Then I watched it again and realized that the video is actually a good illustration of what I’ve been saying all along about what is wrong with robotic surgery.

Even with the apparent use of several edits, it takes the surgeon over two and a half minutes to fold the airplane, a task which might take about 30 seconds by a human hand. Also despite the edits, there are several shots of missteps and fumbling. Finally, the airplane does not fly. When thrown, it drops like a stone.

Rather than convincing me that the robot is great, it makes me even more skeptical about its utility.

Does size matter? Surgery residency program size & board passage rates

A study in the May 2012 issue of the journal Surgery found that the larger a residency program is, the more likely are its graduates to pass the written and oral board exams of the American Board of Surgery on their first attempt. Over the years 2006-2011, 85% of residents passed the written exam and 83% passed the oral exam on the first try.

The authors show linear regression lines with positive and statistically significant correlations between increasing size of a program and its residents’ first-time passage rates. They say, “This important finding may influence the application patterns and rank lists of medical students matching into general surgery residency programs.”

They mention only one limitation of the study, which is that they did not have first-hand knowledge of how the board passage data were produced. They apparently could think of no other potential confounding factors.

I can think of two right offhand.

One, it is well-known that larger programs, which are more apt to be based at medical schools, attract smarter applicants.

From a paper about factors predicting board passage on the first try:

Significant objective predictors of successful first-attempt completion of the examinations were Alpha Omega Alpha status [the Phi Beta Kappa of med schools], ranking within the top one third of one's medical student class, National Board of Medical Examiners/United States Medical Licensing Examination Step 1 (>200, top 50%) and Step 2 (>186.5, top 3 quartiles) scores, and American Board of Surgery In-Training Examination scores >50th percentile (postgraduate years 1 and 3) and >33rd percentile (postgraduate years 4 and 5).

These are all directly related to the degree of intelligence of the resident. First-time failure to pass the board exams are much more likely to occur with graduates of small programs on the basis of the above observation alone.

The second confounder has to do with statistics. In his book, “Thinking, Fast and Slow,” Daniel Kahneman points out in Chapter 10 “The Law of Small Numbers” that “extreme outcomes are more likely to be found in small rather than large samples.” He gives an example of a large urn filled with the same number of white and red marbles. If one draws 4 marbles at a time and repeats the drawing many times, one is far more likely to have extremes of distribution, such as all marbles being the same color, than is one who draws 7 marbles at a time.

Imagine that all residents are created equal [Well, try.] and drawing balls which are all red represents a resident failing to pass the board exam. This will happen approximately 4 times more often if one draws 4 balls instead of 7. As you increase program size to say, 10 residents per year, the disparity is even greater.

The size of the program is not the issue. Large programs and small programs have been put on probation or discontinued. It’s not about the teaching either. A recent survey revealed that residents in non-university programs felt they got better teaching than those in university programs. [See my blog about this here.]

I’ll tell you a secret. It’s about the individual resident. I’ve had residents who I am certain could have passed the boards if just given a textbook and access to patients and operations. I’ve had others who no amount of teaching, prodding or remediation could salvage.

Central Line Bloodstream Infections & Pay for Performance

The topic of central line bloodstream infection (CLBSI) is interesting to review because of its inclusion as one of the so-called “pay-for-performance” indicators and there is a large amount of research to look at. I want to focus on one aspect of the issue, which is the difference between information obtained from an administrative database and what is clinical valid.

Published ahead of print in the Journal of the American College of Surgeons is an article from the data mines of the Veterans Administration showing that some 63% of CLBSIs seen at VA hospitals over a 5 year period were actually coded incorrectly. They were falsely positive; the patients did not have CLBSIs.

You might wonder, “How can this be?”

Here’s how. When scrutinized carefully by clinician chart review, 27% had thrombophlebitis at a peripheral IV site, 7% had infected surgically placed arterial graft infections and 6% had cellulitis at an IV site that was not a central line. The rest of the false positives were as follows: chart coded as having a CLBSI when the work-up was actually negative for infection; the patient had no evidence of ever having had a central line; the patient had a CLBSI that was present on admission to the hospital and therefore not preventable during the admission being reviewed.

The problem is that the ICD-9 codes used during the study period (2003-2007) were not specific enough. New codes have been developed but are still not suitable as justification to withhold money from hospitals.

The paper also points out that the CDC has published three different sets of criteria for determining whether a central line is infected.

ICD-9 codes were created for billing purposes, not for studying clinical problems. They are also subject to coding errors as the paper clearly depicts. This is one of a number of papers that illustrate the problems associated with the use of administrative data in analyzing clinical problems.

I’m not necessarily against the pay-for-performance concept, but it must be based on accurate data.

What do you think about "pay-for-performance"?

This post appeared on Sermo yesterday and 84% of those physicians voting did not favor the use of pay for performance.

A “rule” without foundation

The practice of medicine often involves “rules” that are not based on fact or evidence. Many of them are justified in a manner similar to that which we use with our children—“because.” The rationale for some rules is “that’s the way we’ve always done it.”

How about a rule prohibiting the clipping of hair in the operating room? My hospital has decided that if hair is to be clipped, it must be done before the patient arrives in the OR. One reason for this is said to be prevention of infection by loose hair.

Wait a second. It is generally agreed that the fewest wound infections result when patients are not shaved or clipped at all. If that is so (and the evidence is convincing), then why would hair cause a problem if loose? I am not aware of any data that supports the claim that clipping hair in the OR causes wound infections.

After asking about the source for this rule, I find it originates in standards promulgated by the Association of periOperative Registered Nurses (AORN). On page 367, the AORN 2011 Perioperative Standards and Recommended Practices states “Hair removal should be performed the day of the surgery, in a location outside the operating or procedure room.” The justification is said to be “Clipping the hair outside of the operating room minimizes the dispersal of loose hair and the potential for contamination of the surgical field and surgical wound.” No reference is cited.

Other sources such as the Association of Surgical Technologists’ Standards (I.3.B.) say the “shave prep should be performed in the preoperative holding area where the privacy of the patient can be maintained.” I don’t know about your OR holding area, but every holding area I’ve ever seen is far less private than the operating room itself.

The AST apparently hasn’t received the memo that “shave” is not the correct term and has not been for many years. So it’s not infection that’s the problem; it’s privacy?

In addition to not being evidence-based, the recommendation would be difficult to follow because clipping in an area outside of the OR itself will delay the case. If clipping is necessary for the purpose of applying tape after the operation, I prefer to do it myself because 1) I know it will be done without inflicting injury and 2) it will encompass only the area that I want clipped.

I performed a thorough literature search and found nothing to justify this rule regarding infection or privacy.

The problem with rules like these is that, as is the case with the 55 MPH speed limit, rules without reason are often not followed. This breeds mistrust of authority leading to failure to abide by reasonable rules too. General anarchy follows and civilization as we know it will be destroyed.

Do you know of any other "made up" rules like this?

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Pregnancy among women surgical residents

A paper reporting the results of a survey of women surgeons on the topic of pregnancy appears in Archives of Surgery online ahead of print.

Responses were received from 1937 female surgeons, which was 49.6% of those who were sent surveys. Not surprisingly, the findings were that women surgeons feel stigmatized about pregnancy during surgical residency training.

Things are improving, but slowly. The percentage of women reporting that pregnancy during training is stigmatized fell from 76% for women who graduated more than 30 years ago, all the way down to 67% for women who graduated less than 10 years ago. The difference was statistically significant [p = 0.001] but hardly significant in the real world. At this rate, pregnancy among female surgical residents should be no longer stigmatized by about the year 2127.

According to Table 3 of the paper, the cumulative rate of pregnancy of female surgery residents who graduated fewer than 30 years ago is 32.2%. To put it another way, 1/3 of all female surgery residents became pregnant at least once during their five years of training.

The most interesting finding was that even women faculty and women residents were perceived as having a negative influence on women surgeons contemplating childbearing and this negativity has not abated over the years. Meanwhile, the percentage of both residents who are women and those who become pregnant is increasing.

Male residents can get sick or be injured and miss time. Should there be any reason to deal with pregnancy differently?

What do you think about this?

This blog appeared on Sermo [registration free for physicians] yesterday and 38% of the 26 doctors who voted felt that female surgical residents should feel stigmatized about pregnancy.

An error occurred. Suspend all surgery in the US?

Here is an extreme “system error” type of response to an event which seems to have been a human error.

According to CBS News: “Mowing at all national parks has been suspended indefinitely because of safety concerns after a maintenance worker cutting grass along the Blue Ridge Parkway in North Carolina fell to his death.”

The unfortunate victim was killed when the mower he was riding on fell down a 140 foot embankment. The report says, “He was trimming a 12- to 15-feet-wide area between a wooden guardrail and a cliff when he lost control of the zero-turn riding lawnmower and went over the edge.”

The National Park Service investigation of the accident is already complete but the findings will not be released for months. It is not clear why it will take so long. [That’s a subject for another post.]

If you have been following my blog, you know that I have consistently questioned the tendency of organizations, including hospitals, to blame adverse events that seem to have been human errors on “system errors.” Once a problem is deemed a system error, policy changes must be made. New protocols are written. It gives the appearance that the organization is “doing something” about the perceived system error. In my experience, most of the time the changes are soon forgotten and everyone moves on.

Pending the results of the investigation, I could possibly understand suspending the use of all riding mowers of the type used by the victim or suspending the mowing of grass along the edges of cliffs, but to suspend all mowing of grass at all 397 national parks seems a bit excessive.

I had tweeted a brief mention of the CBS News story and one of my followers, @dockj, responded, “What if we stopped all surgery for the entire country every time there was an error?”

What a great question. I tweeted back that I wished I had thought of that. I hope the patient safety gurus don’t hear about this or it might be the next step.

Meanwhile, watch out for snakes in the tall grass when you visit a national park.

More of my blogs about system error here, here, here, and here.