Institute of Medicine: Obesity is not caused by lack of willpower

In a 48-page report, the Institute of Medicine “refutes the idea that obesity is largely the result of a lack of willpower on the part of individuals.” [You know the IOM, the same folks who brought you the “98,000 people are killed each year by medical errors” report, the accuracy of which has been challenged.]

According to a spokesman for the IOM, “"When you see the increase in obesity you ask, what changed? And the answer is, the environment. The average person cannot maintain a healthy weight in this obesity-promoting environment."

The report goes on to say, “People cannot truly exercise ‘personal choice’ because their options are severely limited, and biased toward the unhealthy end of the continuum."

Quoting further from an article about this revelation from the IOM, “The panel recommended tax incentives for developers to build sidewalks and trails in new housing developments, zoning changes to require pedestrian access and policies to promote bicycle commuting.”

"We've taken fat and sugar, put it in everything everywhere, and made it socially acceptable to eat all the time. We're living in a food carnival, constantly bombarded by food cues, almost all of them unhealthy," said David Kessler, former head of the U.S. Food and Drug Administration. Maybe Kessler should have done something about this when he was in charge of the FDA.

Are they serious?

Things like this really aggravate me. [Lots of things aggravate me.]

Everyone who drinks alcohol doesn’t become an alcoholic. The IOM says it's not willpower. How is it then that some who are exposed to the same environmental factors and food cues as obese people manage to maintain a normal weight?

How much did the IOM’s 48-page report cost and who paid for it?

Do you think building sidewalks and promoting bicycle commuting will really decrease obesity?

What do you think of the IOM report?

A version of this post appeared on Sermo yesterday. Most of those who commented felt that the IOM was out of touch with reality or al least, mistaken.

Overused Words

While reading the iconic New York Times the other day, I happened to notice that the word “iconic” was used in a few different articles.

The world-wide resources of the Skeptical Scalpel Institute for Evidence-Based Outcomes and Advanced Research were mobilized. Fact checkers swarmed over the Times and discovered that in the last 30 days, the word iconic has appeared 87 times in the paper for an average of 2.9 times per day.

The range of occurrences was 0 (on July 20, July 30 and August 6) to 8 (on August 1, a truly iconic day). The mode, or most frequent number of occurrences per day, was 1, which happened on 10 separate days.

By comparison, the previously unchallenged overused word of the century “artisanal” has only appeared 52 times in the Times during the last 30 days or about 1.7 times per day.

Now I am a mere blogger and am admitted somewhat (artis)anal retentive, but it seems to me that iconic just may have achieved cliché status.

May I suggest that the Times consider removing Iconic from its style book? In my opinion, doing so would increase its iconicity and help to maintain the artisanality of its writers.

Reduced Rate of Infections in Colorectal Surgery: Real or Hawthorne Effect?

There was some buzz last week on medical news sites like MedPage Today, Fierce Healthcare and Science Codex, about a paper from Johns Hopkins describing how the institution reduced its surgical site infection (SSI) rate for colorectal surgery. A multidisciplinary project called the Comprehensive Unit-Based Safety Program (CUSP), involving 36 people including a “team coach” and a hospital executive, began when the SSI rate was 27.3%. After meetings and suggestions for change, they came up with six interventions that they felt would make a difference. They were

• Standardization of skin preparation with chlorhexidine
• Administration of preoperative chlorhexidine showers
• Selective elimination of mechanical bowel preparation
• Warming of patients in the preanesthesia area
• Adoption of enhanced sterile techniques for skin and fascial closure
• Addressing previously unrecognized lapses in antibiotic prophylaxis

In the year following the implementation of the changes, the SSI rate dropped to 18.2%.

Sounds great, doesn’t it? Let’s take a closer look at a few of the interventions.

The issue of chlorhexidine for skin preparation is not quite settled. One of this paper’s own references cites a study which says that povidone iodine use leads to significantly fewer SSIs than did chlorhexidine.

The bowel prep intervention is very confusing. To quote the paper, “In December 2011, the CUSP group reviewed the literature again and decided to change from no mechanical bowel preparation to mechanical bowel preparation with oral antibiotics beginning in February 2012.” This is interesting since the paper was submitted to the journal in January of 2012.

Regarding enhanced sterile techniques for skin and fascial closure (which means they changed gloves and some instruments after the intestinal anastomosis was completed), there is no evidence that doing so prevents wound infections. The only reference they provided was to a book of standards from the Association of periOperative Registered Nurses (AORN), a notoriously non-evidence-based document. [See my previous blog on rules without foundations.]

The lapses in antibiotic prophylaxis involved patients who were allergic to penicillin, a condition that affects only about 10% of the population. There were 602 patients in the study of whom about 60 would probably have been allergic to penicillin. That’s hardly enough to make a big difference in the infection rate.

These policy changes reduced the infection rate of colon surgery from 27.3% to 18.2%. A quick search reveals that in 2010, the colon surgery SSI rate for all hospitals in the state of New York was 5.3%. That’s all hospitals, not just university medical centers. The respected medical resource UpToDate also says the expected SSI rate for colon surgery is 5%.

Despite the well-known effectiveness of 36-person committees (and wouldn’t you have liked to have attended those meetings?), I think there is another explanation for these results. It’s called the Hawthorne effect, which is the name given to the fact that the behavior of experimental subjects changes if they know they are being watched. For example, if you tell the staff of an ICU that there will be changes to the hand washing protocol and compliance will be monitored, whatever the changes are, the rate of compliance with hand washing will increase.

In summary, the authors have turned an abysmal colon surgery SSI rate into a merely bad one by observing it. Medical news sites reported the findings without questioning any of the conclusions. One wonders why the paper is receiving any attention at all or even why it was published.

Vague radiology reports: Can anything be done?

Possible mild peri-appendiceal inflammation. So states a CT scan reading I received the other night.

Here’s another. The findings are concerning for appendicitis.

And another. The appendix is dilated and mildly thick walled with suggestion of mild surrounding inflammatory change, although there is air within the lumen. There is an appendicolith at the base of the cecum. The findings are suspicious for mild acute appendicitis. Clinical and laboratory correlation are recommended. [Digression: You can't diagnose appendicitis with lab tests.]

Even radiologists are questioning the way their colleagues dictate reports. From an editorial in the journal Applied Radiology: The report might say “there appears to be a nodule in the right lower lobe.” If you’re wrong, and there isn’t a nodule in the right lower lobe, you’re covered because you never actually said there was a nodule, only that there appeared to be a nodule, and we all know that nothing is ever as it appears.

Some Stanford researchers looked at radiology reports and found that the most frequent terms used to modify conclusions were probable, consistent with, consider, likely, suggestive, no definite evidence, suspicious, cannot exclude, not likely, maybe and possible. They surveyed radiologists and clinicians and found wide variations in what these words meant to each physician regarding the specifics of whether a hypothetical lesion should be biopsied.

An editorial in the journal Radiology scorned the use of the often-seen phrase if clinically indicated.

I could go on.

Do you know of similar examples of radiologic ambiguity?

Is there a solution to this problem?

A version of this post appeared on Sermo yesterday with interesting comments. About 2/3 of those who voted said there is no solution to the problem. Some commenters said the radiologists are just describing what they see.

Distractions in the OR

More research that we didn’t need (with needlessly inflammatory headlines)

Last week was not a good one for the advancement of surgical research. I’ve already blogged about two studies that attempted to mystify the teaching of laparoscopic surgery.

On Thursday, MedPage Today devoted over 700 words to reporting on a study from Archives of Surgery called “Realistic distractions and interruptions that impair simulated surgical performance by novice surgeons.” It was an interesting experiment which looked at the effects of common types of operating room distractions, like cell phone ringing, questions about floor patients and a dropped metal tray, on the performance of simulated laparoscopic surgery. The subjects were all second and third year residents.

The performance of the 18 residents was tested with and without the interruptions. When distractions were present, 8 major errors in the simulated surgery occurred vs. only 1 major error in the non-distracted series, p = 0.02.

An unexpected finding was that all of the major errors occurred in the afternoon, which was also statistically significant. Fatigue, a very subjective characteristic, did not seem to play a role, although one could speculate that residents might be more tired in the afternoon.

The authors mentioned several limitations of the study including that it wasn’t carried out in a real operating room and only novice surgeons were tested.

The research was cleverly done and obviously could not have taken place in a real OR with a patient. It accomplished the number one goal of any study, which is to get published.

However, I take issue with the way it was reported. Here’s the MedPage headline: “Distractions in OR Make Errors More Likely.” That is grossly misleading since it fails to mention that the errors were made by junior residents, who were the only subjects of the experiment. This is important because even in my day, JUNIOR RESIDENTS NEVER OPERATED WITHOUT SUPERVISION!

Not until the sixth paragraph does the MedPage report point out the important disclaimers that “the authors said the results should not be interpreted as representative of operating-room (OR) experience in general” and that “these results should not be used to infer that almost half of all surgical procedures with distractions and interruptions are expected to have major surgical errors."

The paper was also covered by Medwire news with the headline “Surgical distractions could have disastrous consequences.” The story did not explain that second and third year residents do not operate by themselves.

Personally, I do not play music in the OR. During a difficult case, I am so focused on what I am doing that I don’t know who has come in or gone out of the room, nor do I hear extraneous conversations.

Distractions can be a problem. But this paper and the way it was reported by medical news agencies do nothing but heighten the anxiety of an already skittish public when it comes to fear of medical errors. I don’t see how proving that novice surgeons can be easily distracted adds anything toward the enlightenment of mankind.

Why do malpractice claims take so long to be resolved?

Two recent papers have prompted me to ask myself the question, “Why do malpractice suits take so long to be resolved?”

One was by a group from Harvard, USC and the RAND Corporation. They looked at more than 10,000 closed malpractice cases for all specialties and found the average length of time it took to close a case was 19 months, with litigated claims taking a little over twice as long as non-litigated claims, 25.1 vs. 11.6 months respectively. Claims that were resolved at trial took much longer averaging 39.0 months for defendant verdicts and 43.5 months for plaintiff verdicts.

The second study was by a group headed by a surgeon based at a Johns Hopkins affiliated hospital. They reviewed 187 closed surgery claims at four university hospitals in New York. Using a different method of calculating the length of time, they noted a mean time until resolution of all claims of 4.5 years. Cases closed with no payment took 3.9 years, while those won or lost at trial took about 5 years.

I’ll give you a minute to see if you can guess why it takes so long to resolve these claims.

Here’s my theory. I think it might have something to do with the involvement of lawyers. We all know that plaintiffs’ attorneys get a large percentage of the take from any case settled with payment or plaintiff’s verdict with damages.

But defending cases can be expensive too. Since defense lawyers are paid according to their billable hours, it seems to me that it is in their best interest to make a claim last as long as possible. Have you ever been deposed or read a deposition? Lawyers object to every other question, which accomplishes nothing. The question still has to be answered. They also ask the same questions over and over leading to the old “Objection, asked and answered” response. Often the questions seem to have nothing to do with the alleged negligence.

Let’s do some math.

A paper that appeared in the journal Health Affairs in 2005 addressed the legal costs associated with malpractice claims. The study found that “legal costs average $27,000 per claim in the United States, which adds approximately $1.4 billion in costs to the $4.4 billion paid in settlements and judgments. The costs of underwriting insurance against malpractice claims are estimated at an additional 12 percent, or $700 million. The cost of defending U.S. malpractice claims, including awards, legal costs, and underwriting costs, was an estimated $6.5 billion in 2001—0.46 percent of total health spending.”

Yes, it’s less than 1% of total healthcare spending. But as the old and possibly apocryphal saying attributed to the late Senator Everett Dirksen goes “A billion here, a billion there, pretty soon, you're talking real money.” And don’t forget the emotional toll that being the target of a lawsuit takes on the defendent doctor while the case is meandering through the process.

A version of this post appeared on Sermo yesterday. All who commented thought the process took too long.

A simple mistake?

If you pay attention at all to news about medicine, you must have heard about the tragic death of a 12-year-old boy who was seen and discharged from the emergency department of the prestigious New York University Medical Center. He had developed sepsis from what appears to have been a small cut and the diagnosis was missed. When he eventually returned to the ED and was admitted, it was too late and he died. Read more details here.

Many have commented on this sad story. The good people at ProPublica, some of whom I follow on Twitter, wrote about this and other types of medical errors in a piece entitled “Why Can’t Medicine Seem to Fix Simple Mistakes?” I will grant that some of the errors they mentioned, such as wrong-site surgery and reusing syringes, are indeed simple mistakes and should be 100% preventable.

But the death of young Rory Staunton, admittedly caused by medical errors, was not the result of “a simple mistake.” The ProPublica story says, “The hospital's emergency room sent Rory Staunton home in March and then failed to notify his doctor or family of lab results showing he was suffering from a raging infection.” Specifically, he had a number (said to have been five times the normal value) of immature white blood cells called “bands,” which is a sign of the body reacting to an infection.

While human errors were made, this event also fits James Reason’s “Swiss cheese model” of a complex series of occurrences that will take more than a new policy about notifying ED MDs about abnormal lab results to fix.