The checklist from hell

This one-page form illustrates much of what is wrong with medical care today.

Just imagine the amount of time it would take to complete all 11 steps. Wouldn't you love to hear what goes on in a "post Fall Huddle"?

Thanks to @anish_koka for tweeting the form.

Antibiotics vs. surgery for appendicitis: Critique of a meta-analysis

A meta-analysis can be useful when looking at a topic that has been studied by several different groups of investigators. The pooling of data from different published papers can sometimes bolster a conclusion about the effectiveness of a treatment.

However, a meta-analysis is only as good as the studies it includes, and the biases of those performing the meta-analysis can color the results.

Last month, a meta-analysis concerning antibiotics vs. surgery for the treatment of uncomplicated acute appendicitis by investigators from Nottingham University Hospitals was published in the World Journal of Surgery.

The authors concluded that “antibiotic therapy represents a safe, efficacious and viable treatment option for the treatment of uncomplicated acute appendicitis.” I disagree.

Five randomized trials involving 1430 subjects were included in the meta-analysis. After one year of follow-up, the efficacy of treatment for those receiving antibiotics was 62.2% compared with those undergoing appendectomy whose treatment efficacy was 88%. Depending on the inclusion or exclusion of a particularly weak study there was said to be a 39-52% risk reduction for complications in the antibiotic group.

This meta-analysis has so many problems that it is hard to know where to start.

Changing pre-med requirements and med school curricula

Ezekiel Emanuel, the University of Pennsylvania physician and ethicist, has written an opinion piece suggesting many changes in both pre-medical education and the medical school curriculum.

He would do away with many of our hallowed medical school prerequisites such as calculus, physics, and organic chemistry, feeling that those subjects are simply used to "weed out" certain students. I confess I once believed that such subjects were worthwhile. However, Emanuel makes a convincing argument that rigorous college courses in more relevant disciplines such as statistics, genetics, ethics, and psychology with a special focus on human behavior would suffice.

Regarding medical school, Emanuel points out he was taught the Krebs cycle on four different occasions in college and medical school and never used it once in practice or research. I have made a similar observation in a previous blog post.

He considers pathology, cytology, and pharmacology to be largely irrelevant to medical practice but concedes that some may disagree.

Does wearing jackets over scrub suits prevent infections?

I always enjoy papers that reinforce my biases. Here’s one called “The Impact of Perioperative Warm-up Jackets on Surgical Site Infection: Cost without Benefit?”

If you’re a regular reader of my blog, you undoubtedly know the answer. Wearing jackets over scrub suits doesn’t prevent infections and adds costs.

Investigators from the University of Minnesota looked at infection rates one year before the institution of a mandatory warm-up jacket over scrub suit policy and one year after.

The rate of surgical site infection for the 13,302 cases done in the year before jackets had to be worn was 2.42% compared to 2.67% for the 12,998 cases done during the year after. The difference was not statistically significant with a p value of 0.1998.

Operative risk and surgeon decision-making

Should it surprise you that surgeons might have differences of opinion about whether or not a patient should have an operation?

It doesn't surprise me, but apparently a lot of people were taken aback by an Annals of Surgery paper published online last week stating just that.

The authors gave 767 surgeons four brief complex clinical scenarios and asked whether they would operate on each patient. The vignettes were purposely designed to not have "correct" answers.

In response to the question would you recommend an operation, the surgeons could choose one of the following responses: very likely, unlikely, neutral, likely, or very likely.

If you were in the emergency department with mesenteric ischemia, would you want a surgeon who responded "neutral"?

Why the authors selected five possible choices is puzzling. In real life when you are faced with a difficult decision in the middle of the night, you don't have five options. You have only two—operation or no operation.

Deciding whether adverse events are preventable or not

Adverse events and poor outcomes are not always preventable. Deciding whether an adverse event is preventable or not can be difficult.

"To Err is Human: Building a Safer Health System," the original Institute of Medicine report in 1999, stated that  between 44,000 and 98,000 deaths each year were caused by preventable medical errors.

That report was widely cited and spawned a number of studies and reviews claiming that anywhere from 250,000 to 440,000 preventable deaths occur in the United States every year.

I was critical of the 440,000 deaths paper as well as the most recent of these estimates—the one claiming 250,000 deaths due to medical errors per year.

It's not widely known or perhaps simply forgotten, but the 1999 Institute of Medicine report also came under fire. In 2000, two researchers from Dartmouth, Drs. Harold C. Sox Jr, and Steven Woloshin, published a critique called "How many deaths are due to medical error? Getting the number right."

When bad research is not critically reported by journalists

Yesterday I posted a critical review of the study "Medical error—the third leading cause of death in the US."

I did not have time to address the media coverage of the paper, but fortunately the website HealthNewsReview did.

Their post started with "Seemingly all the major outlets carried the story, with headlines so alarming that they’d have any conscious hospital patient demanding an immediate discharge."

They called attention to headlines which included the word "now" such as these:

CBS: Medical errors now 3rd leading cause of death in U.S., study suggests
Washington Post: Researchers: Medical errors now third leading cause of death in United States
Nature World News: Medical Errors Now the Third Leading Cause of Mortality in U.S.

They pointed out that the headlines were similar to the title of a press release issued by the PR department at Johns Hopkins and that using "now" in the headline implies that the incidence of deaths caused by medical error has increased.