Can Glass in Soft Tissues Be Visualized on X-ray? Yes.

A cleverly written post on the blog “Polite Dissent” uses a Superman comic book to make a point that most types of glass cannot be seen using plain x-rays. I beg to differ.

Despite evidence to the contrary, the myth that glass cannot be seen on x-ray persists. Back in 1982, a radiologist named Dan Tandberg performed a simple, but elegant experiment. He embedded 66 different kinds of glass in the muscles of chicken drumsticks. He used pieces of chicken because it is similar in tissue density to human fingers and feet. In all 66 cases, the glass could be seen with a plain x-ray. The paper was published in the Journal of the American Medical Association.

My clinical experience has confirmed Tandberg’s findings.

But a word of warning is necessary. Just because glass can be seen on x-ray doesn’t mean it will be easy to find when trying to remove it. X-rays from various angles, insertion of needles to help establish the location of the glass and even fluoroscopy may be required.

More on whether 10,000 hours makes an expert surgeon

Last week I blogged that I didn’t think 10,000 hours of residency training would make one an expert surgeon [or any other type of physician]. As I explained, and someone who commented on the post explained even more clearly, residency training is not like practicing the piano or swimming. Residency is an amalgam of many skills as well as significant hours of non-productive work that does not approach 10,000 hours of doing only one task.

The concept of the so-called “10,000” hour rule as espoused by Malcolm Gladwell is also open to debate. Another commenter shared a link to a sports science blog that totally debunks Gladwell’s premise, at least as it pertains to athletic ability.

In my previous blog, I pointed out that despite surgical residency training lasting over 19,000 hours, many residents feel the need to take fellowships. The extra year of training not only gives them an edge in the job market, it also helps bolster their confidence.

Three days after that blog was posted, a paper was published in Archives of Surgery confirming what I had suggested. The authors, from Yale University and the American Board of Surgery, surveyed all surgery residents in 2008 and 4136 (77% of all residents) replied, an excellent percentage of response for any survey.

The most interesting finding was that 26% of all respondents were concerned that their operating skills were not appropriate for their level of training and that they would not be confident enough to operate independently upon completion of their residency training.

More residents in university hospitals and those in large programs felt less prepared than residents from community hospital and smaller programs. [Disclosure: I was a community hospital residency program director for 24 years. This paper confirms my longstanding bias that community hospitals produce surgeons with more experience and skills.] Women trainees were somewhat less confident in their abilities than men.

Of course the paper has limitations common to most self-reported surveys. The residents were assured that the survey would be anonymous, but it is possible that the number of residents lacking confidence in their skills may have been under-reported. Confidence is difficult to measure and too much confidence can be as bad or worse than too little. But a distressing finding of the survey was that the residents who were less confident were also less likely to ask an attending surgeon for help in the operating room or when managing a patient.

It is disconcerting to learn that 26% of all surgery residents are uneasy about operating independently.

I hope this paper is read by all surgical program directors and the people who run the American Board of Surgery and the Residency Review Committee for Surgery. I wonder what they will do about it?

Many patients do not know what meds they are on

The other day I tweeted the following:

“How can a patient, who does not know what meds she is on or why, seriously participate in ‘Shared Decision Making’?”

I apparently struck a nerve with several followers who replied with tweets accusing me of not educating the patient, wondering why she doesn’t know, wondering if she might be on too many meds [ya think?], etc. One response was from a software developer who likened doctors to technology professionals, patients to computer users and computers to medications. None of those who confronted me is a physician. I am not sure what types of front line experience with patient care they have had.

Let me clarify a few things.

I am certainly not against explaining things to patients. I believe they should understand what treatments they are agreeing to. My point was I think a substantial number of patients do not really understand things even when they are explained at length.

I was seeing the patient as a consultant. I am not her primary care physician [PCP]. The problem of patients not knowing what medications they take is very common. An informal poll of some of my physician colleagues reveals that as many as 50% of the patients we see in our emergency department do not know what meds they are taking, why they are taking them and they do not have a written list of current meds in their possession.

Many studies show similar results. Researchers at the Mayo Clinic found that patients discharged from the hospital had significant problems recalling the names of any new meds prescribed or their dosages. A study of patients seen in the emergency department at UCSD showed, “Only 48% of patients could recall or produce a list or the actual bottles of all of their medications, 39% knew the times they take their medications, and only 24% knew all the dosages.”

The PCPs and hospitalists where I practice take great pains to educate their patients on the need to know their illnesses and medications. They have all been instructed about the importance of this and the need to carry a list of their medications at all times.

They simply do not do it. Why not?

I don’t know but I have some ideas. I practice in the real world. Most of my patients are nice people who are very down-to-earth types. Some are on too many meds. Some are old. Some are confused as a result of their illnesses and/or their meds. Some are anxious. Some are mentally ill. Some are “all of the above.”

But [you won’t like to hear this] many just do not want to take responsibility for their own health. I think they don’t know their meds for the same reason they eat too much, smoke too much, drink too much and don’t exercise.

Go ahead and blame us doctors for not educating the masses. I say, keep trying, but don’t be disappointed when half of them don’t comprehend the importance of what you are trying to do or possibly just don’t care.

While I’m on shared decision making, I have this final comment. Physicians should not present three options with lengthy dissertations on the myriad side effects of treatment and no real advice as to what would be best for the patient. You cannot teach someone the anatomy, physiology or the nuances of medical care in a shared decision making discussion. How can a patient make a rational choice without guidance from the physician?

The 10,000 Hour Rule: Does It Apply to New Graduates of Residency

Hospital inpatients taken care of by older doctors have a higher mortality rate, a recent article in the American Journal of Medicine concluded. The authors investigated 6572 admissions cared for by 59 different physicians at Montefiore Medical Center in New York. They suggested that older MDs might benefit from remediation to improve their skills. They also speculate about why this seeming non-intuitive finding occurred.

Maxwell S. Kennerly, an attorney blogging on the KevinMD website, proposed that maybe recent graduates of residency programs, having spent more than 10,000 hours as residents, are already “experts” as defined by Malcolm Gladwell’s 10,000 hour rule. That is an intriguing thought. Let’s see if it is plausible.

One must first agree that 10,000 hours of practicing something would lead to an expert level of skill. In his book Outliers, Gladwell gives several examples to try to prove his point. The Beatles played music 8 hours/day and 7 days/week for the better part of three years when they first started. Bill Gates programmed “practically nonstop” for 7 years. The best musicians at the Berlin Academy of Music practiced for more than 10,000 hours as they progressed through the school while the merely average musicians only did 4,000 hours. These anecdotes, while not scientific, bolster Gladwell’s theory. Not mentioned are the negative results. How many people do something for 10,000 hours and never get better? For example, that might be true of my tennis game.

What about internal medicine residents? They train for 3 years less about 4 weeks of vacation/year. If one takes the remaining 144 weeks X 80 hours of work/week, the result is 11,520 hours. That makes them Gladwell-anointed experts, right?

I don’t think so. Unless they underwent particularly rigorous training, they must have slept for some parts of their 80 hour week. They very likely were on overnight call only one or two days/week and sleeping an average of at least four hours/night. Even if they were awake for 70 of the 80 hours/week they worked, they were not practicing medicine the entire time. There are massive amounts of paperwork. There are educational conferences. There is “scut work” [medical jargon for menial tasks] like looking up lab results, calling to arrange x-rays, calling consultants and many more. There are lunches, dinners, snacks and even occasional down time.

Medical residents participating in a study in 2000 said that they were not comfortable performing four of seven basic procedures [central venous line placement, knee joint aspiration, lumbar puncture, and thoracentesis] despite achieving minimum numbers set by the American Board of Internal Medicine.

Even surgical residents, whose training lasts five years [19,200 hours], feel somewhat uneasy at the prospect of working on their own. A study of surgical residents’ work flow revealed that more than 20% of their work time involved non-educational activities. That is the equivalent of one year of their training.

Another recent study showed that for 61 of 121 procedures thought to be essential by surgical residency program directors, the most common number [mode] performed by graduating surgical residents was “0.” After residency, they often take an extra year of training [fellowship] to increase their level of experience before assuming attending surgeon status.

Similarly, Canadian thoracic surgery residents were queried about their level of comfort in performing 18 core thoracic surgical procedures. The residents responded that they were not comfortable performing any of the 18 operations and even the faculty answered that at the end of their training, they were comfortable performing only 7 of the 18.

Assuming that practicing anything for 10,000 hours makes one an expert [a leap of faith at best], I do not think any new graduate of residency training qualifies.

Kennerly’s other theory is that maybe newly minted attending MDs have what is called a “beginner’s mind” and are more open to new ideas and other diagnoses. Although he presented no data to support this and I, of course, am close-minded about it, it is possible.

And as an older MD and a confirmed skeptic, I would like to see the Montefiore study findings replicated before I believe it.

Surgeons Are Not Pilots or Long-Distance Truck Drivers

I have blogged before about the inappropriateness of comparing surgeons to pilots [here and here]. Recently, I have seen some comments that lump surgeons, pilots and truck drivers together. Commenters are in high dudgeon about those three occupations working long hours citing the fact that pilots and truck drivers have strict rules about how many consecutive hours they can work and surgeons do not.

There are several problems with the comparison. Long-distance truck driving involves many hours of boring work. When driving a long distance on a straight interstate highway, most people have had the experience of realizing that they have just covered 10 miles and do not recall a thing about the scenery or the traffic. Except for taking off, landing and occasionally telling the passengers to fasten their seatbelts, flying a modern airliner can be equally boring. The planes fly themselves, hence the name “automatic pilot.”

Being a surgeon has no similarity whatsoever to piloting or driving. When a surgeon is on call for 24 hours, he rarely is awake the entire time. When he is, he is not doing monotonous, sleep-inducing tasks. For example, I might get a call at 2 a.m. to see a patient with appendicitis. I go to the hospital, examine the patient, schedule the surgery, perform the surgery and go back home. None of those activities is boring or repetitive.

Let’s say that while I am waiting for the operating room team to set up the case and have dictated my history and physical exam findings and written admitting orders, I have nothing to do. If I put my head down and take a 15 minute nap, no harm is done. This is not the case if a truck driver or pilot falls asleep on the job. Even if pilots are distracted by other things such as playing with their laptop computers and overflying their destination by 150 miles or receiving oral sex in the cockpit [no pun intended], the plane flies along without incident.

I suppose I am overstating the obvious, but neither of the two activities described above is possible while performing surgery.

So please, stop comparing surgeons to pilots and truck drivers.

Statistical vs. Clinical Significance: They Are Not the Same

MedPage Today featured an article about the beneficial effects of daytime wearing of compression stockings on obstructive sleep apnea. The premise was that increased edema in the neck could be caused by fluid coming from the legs when patients were in the supine position at night. Twelve patients who served as their own controls wore compression stockings for a week and then no stockings for a week alternating. The stockings lowered the amount of fluid in the neck by 60%, a statistically significant difference. So far, so good.

This resulted in another highly statistically significant finding, which was a 36% reduction in episodes of apnea [cessation of breathing] and hypopnea [inadequate breathing]. Sounds good, right? The problem is that the average number of episodes of apnea/hypopnea decreased from 48 per hour to 31 per hour. Patients experiencing more than 30 episodes of apnea/hypopnea per hour are classified as having severe obstructive sleep apnea. This means that the treatment only put the patients in the low range of severe obstructive sleep apnea. They still would require maximum therapy. Is a reduction in apnea/hypopnea episodes that does not move the patient out of the severe category really clinically significant? It does not seem so to me.

Although the MedPage piece did not address that issue, it did mention other limitations of the study including that study was small and brief, it included only otherwise healthy, non-obese patients and it did not look at whether the stockings had any impact of daytime sleepiness.

Another possible problem which I am familiar with concerning patients with varicose veins is that wearing compression stockings is uncomfortable, especially in the summer. They often do not fit well and are not particularly stylish. All of those factors lead to non-compliance.

Bottom line: Although there was a statistically significant improvement in the number of apnea/hypopnea episodes when compression stockings were worn, it does not appear that there was a clinically significant improvement in the course of obstructive sleep apnea.

Twitter MDs Can Change the World. Not so much. Part II

A couple of weeks ago, I blogged that MDs might not be able to change the world via Twitter. My analysis was that even some seemingly influential Twitter MDs really had insignificant numbers of followers compared to the population of the United States. And a cursory look at my own list of followers revealed that about a third were probably following me for commercial reasons.

Douglas Mann of Popular Mechanics magazine took a similar approach. He took a somewhat more thorough look at his followers and those of a colleague and found that anywhere from 20-50% were fake or spam. He cited another study by a company called PeerAnalytics which found that only 35% of the followers of the average Twitter user are real people.

What does it all mean? To me it bolsters my opinion that Twitter is an unlikely vehicle for effecting sea change. Still, some feel that changing even one person's mind about an important issue is worth it. That's fine. But let's keep it all in perspective.