Saturday, February 28, 2009

Poetry Time

I'd hate anyone to think I'm some sort of political activist, based on my last post. So I'll paste a Phillip Larkin poem today, just to balance everything out. (And next week I'll have to get back to medical posts lest anyone think I'm the effete poetry guy all of a sudden.) I like this one, though.
We met at the end of the party
When all the drinks were dead
And all the glasses dirty:
'Have this that's left', you said.
We walked through the last of summer,
When shadows reached long and blue
Across days that were growing shorter:
You said: 'There's autumn too'.
Always for you what's finished
Is nothing, and what survives
Cancels the failed, the famished,
As if we had fresh lives
From that night on, and just living
Could make me unaware
Of June, and the guests arriving,
And I not there.

Friday, February 27, 2009

Era of Responsibility?

I'm sorry but I'm having a hard time concentrating on anything other than this budget travesty. We'll get back to medicine soon enough. But, my God. What just happened this week? President Obama just got done spending over a trillion dollars of money he doesn't even have yet.

But the thing that pisses me off is the faintly scolding tone to his rhetoric. We hear about how now is the time to rectify past sins, now is when we will atone for the profligate ways of the "rich" over the past 10 years. Listen to his words:
"There's nothing wrong with making money," Obama's budget document said, "but there is something wrong when we allow the playing field to be tilted so far in the favor of so few."

Now what exactly does this mean? What is the implication here? That the unequal distribution of wealth in the United States exists because of nefarious, unfair tax codes? Really? In all seriousness? You mean the disappearance of the American middle class has nothing to do with de-industrialization and the failure of our nation to come up with some sort of transitional paradigm that would replace those steady, well-paying blue-collar factory jobs that got shipped off to Mexico or Asia? That all we have to do is take more chunks of money from those lucky enough to find themselves in the upper echelon of earning potential and everything will be just fine?

President Obama, despite all his avowed intellect and perspicacity, is making an irrational leap of induction that goes something like this: since we have entered a down cycle unlike anything we have seen in this country since the 1930's, capitalism must be fundamentally flawed and the solution is now to transition as quickly as possible to a nanny state and an unabashed redistributionist tax policy. The crisis we face is presented in overly simplistic, either/or terms-- either you are an avaricious, selfish champion of the sort of capitalism practiced by Americans for a hundred years and obviously led to our current dire straits or you now see the light and realize that only the federal governement can protect you, only the federal government can judiciously decide how we allocate our capital. For all of Obama's supposed "nuance" and "pragmatism", this sort of presentation isn't nuanced or complicated at all; it's pure propaganda for a leftist state.

Read through his opening remarks on the 2009 budget. After breezily running through examples of the intransigence of individuals left to their own devices he says, "at this particular moment, government must lead the way", as if there are no other options. You screwed up America. Now Daddy is here to put us all on the right path. Daddy will figure it all out, don't you worry. And the brazenness with which he brandishes his Big Government entreaties is utterly shocking.
We need to put tired
ideologies aside, and ask not whether our Government
is too big or too small, or whether it is the
problem or the solution, but whether it is working
for the American people. Where it does not, we
will stop spending taxpayer dollars; where it has
proven to be effective, we will invest. This is the
approach, for example, we have begun in allocating
funds to education, health care, and national

Again, he disengenuously presents himself as Pragmatist (i.e. "whether it is working..."), and then follows it up with actions that are ideologic rather than truly pragmatic. Read the second two sentences in the above blockquote again. The implication is that this regime will spend and spend and keep spending and later on, when the results trickle in, maybe they'll stop throwing around tax payer coin on those things that didn't work out so well, come what may. That's astounding. He's saying, "we're going to throw billions of your money around, some of it may stick, some may be wasted, we'll just have to see", and calling himself a pragmatist while he does it. What the hell, it's your money anyway, he seems to be saying. It's false and misleading and if you disagree with him, then you'll be held accountable for the impending "catastrophe" (which apparently is avoidable only if you fall into line with the Plan).

Listen, I'm not a Sean Hannity/Rush Limbaugh-esque conservative. I hate those guys. I'm not old enough or curious enough to know how a Conservative is "supposed" to act and think. All I can do is interpret the events of my life and form political opinions based on some sort of fusion of subjective and objective data. That's how I function. The Bush Presidency was an unqualified disaster on many fronts and certainly bears a large share of responsibility for our current state of affairs. I'm not advocating for The Republican Party. My stance on most social issues leans rather leftward. The neo-cons and the flapping jaws on FoxNews who have seized the mantle of "Conservative Gatekeeper" have alienated so many younger, upwardly mobile people from my generation who, from a fiscal standpoint, would seem to represent the future of the GOP, but are turned off by a party now fronted by Rush Limbaugh and Sarah Palin and Ann Coulter. It's sad, really.

With wealth comes great responsibility. Obama is correct on that count. Society falls apart if life degenerates into a relentless, Hobbesian battle for the spoils between competing individuals and factions. We need schools and safety net health care and adequate roads and a strong national defense and our federal government is best suited to provide them. But why is it that this administration equates a man's obligation to society with how much he gives to the federal government. It's a "New Era of Responsibility", he says. By giving more, the rich will finally fufill their responsibilities. Why is this the only option? Why would anyone in their right mind think that the federal government is best suited to efficiently and cost effectively solve all the problems of mankind? Where in history is this evident?

What about the "rich" man who is a doctor in the community and provides free care to all the late night ER admits that end up on his service. Or the local attorney who gives thousands of dollars to the public library for the creation of a new children's reading room? Or the bank vice president who endows the local symphony? How will charity and local endowments be affected by this new tax code? You want to arbitrarily define "obligation" as 40% of what I earn, fine; but let me at least direct 10 percent of that to a charity or needy cause of my choice. Sending more to fund this wasteful morass in Washington DC is simply imtolerable.

You see, this isn't just a tax hike. What's happening now is epochal. It's societal reconfiguration. It could potentially change us on an ontologic level for generations, in terms of how we define success and obligation and our relationship to the at-large society. I know, that sounds like outlandish hyperbole. But listen to the content of the words coming out of Washington. Insidiously (and I say insidious because our President was elected under the guise of being the 'pragmatic centrist'), this brand new Administration has launched an all-out assault on the very form of capitalism that allowed this country to ascend to its heights of power, wealth, influence, and innovation. We're going all in with Keynesian economics. There's no turning back after this budget. Time will tell if it's justified.

Thursday, February 26, 2009

Comparative Effectiveness vs. Innovation

Peter Orszag is President Obama's Director of the Office of Management and Budget (OMB) and he has emerged as the architect of the fiscal aspects of healthcare reform. He is known as an expert on the concept of Comparative Effectiveness Research. This is simply a wonkish term for using best available evidence to guide decision making; in particular, using evidence based medicine to determine the most cost effective treatment guidelines (without sacrificing efficacy). For example, if the science demonstrates that generic pills are just as good as newer, more expensive combo-pills at controlling high blood pressure, then it would be reasonable to implement restrictions that would preclude physicians from prescribing the more expensive medication.

The Dartmouth Atlas Project, very much the hot new thing in the medical blogosphere this year, is a long term study of health care markets in the US measuring variations in health care resources and their utilization by geographic area. Basically, it showed that clinical outcomes are not necessarily related to the amount or cost of care provided, and that there is an incredible variation in practice patterns depending on what part of the country you examine. The message is clear: standardize the delivery of health care according to Comparative Effectiveness Research protocols and we can save boatloads of money in the health care sector. And this sort of thinking is Peter Orszag's baby. This is the underlying theory (along with redistribution of wealth) behind President Obama's health reform agenda. And it seems to have substantial validity.

But medicine doesn't like to be categorized. Although it would seem intuitive that we ought to always practice according to guidelines established by the "evidence", the reality is that we often go off the reservation in medicine. The history of medicine is full of doctors who went against the grain, despite available evidence, and ultimately ushered in new eras of innovation. The history of organ transplantation is absolutely fascinating. (Check out Joseph Murray's Nobel speech.) A small cadre of surgeons in the 1960's basically hammered out the principles of immunology and, through trial and error (and what was in essence human experimentation) were able to hone and standardize the transplant process over just a decade. Dr. Murray's first three kidney transplant patients (not including the initial transplants performed between identical twins) all died. By 1965, his group had achieved a 1 year allograft survival rate of 65%. Nowadays, there are people walking the streets with 30 and 40 year old donor kidneys. We are transplanting livers and pancreases and cataracts and lungs and even hearts. These pioneers were not guided by "best available evidence". It was completely ad libbed and improvised on the fly, until some modicum of success was attained and could be systematized.

Laparoscopy developed in a similar vein. There were no randomized controlled trials comparing open with laparoscopic cholecystectomy when the minimally invasive approach swept across this country in the early nineties. The data came later. The actual practice of surgery, however, developed independently of CER. Likewise, we don't currently have any level one evidence supporting laparoscopic appendectomy as being superior to open appy. But ask any general surgeon today and more and more are opting to treat appendicitis laparoscopically because of the superior wound infection rates, better cosmesis, faster recovery, and an increasing comfort level with performing the procedure itself. Eventually the "evidence" will confirm what is already apparent.

You see, medicine is a constantly evolving and developing field of science. Evidence based decision making is an excellent method to assess what has been done in the past, and help guide us through the complex process of deciding which treatment option is most prudent in terms of both cost and efficacy. But it doesn't help us figure out new paradigms for unforeseen challenges in health care. Innovation and risk-taking and aggressiveness are fundamental to advances in medical knowledge. We don't have a transplant program in this country if CER determined the allocation of funding in the 1960's. Laparoscopy was significantly more expensive in the early days of minimally invasive surgery because the equipment costs and length of OR time outweighed the benefits of a shorter hospital stay. Things have changed.

Let's just hope the brainy Peter Orszag has made allowances for innovation somewhere in his complex mathematical manipulations. The next quantum leap in medicine is always just around the corner; let's make sure that leap isn't hamstrung by too much government red tape and bureaucracy....

Initial Thoughts

President Obama has begun his health care reform crusade. Today, he will release a proposal that details a funding plan for what he has in mind. Over a ten year period, $630 billion dollars will be raised via the "restructuring" of the American tax system. This is only the initial salvo. Several thoughts:

1) Everyone speaks of how "bold" and "courageous" the President is for taking on health care reform at a time when the nation teeters on the verge of financial collapse. From a metaphysical angle, I find this quite interesting. I think it says something about the American soul that we don't hesitate to question the wisdom of forking over a trillion dollars of public money to greedy/stupid corporate entities/banks/brokerage houses (within a matter of months), but health care, something tangible, universally acknowledged as a public good, health care is the last "national emergency" addressed and the costs of addressing it will come not from the current national coffers but rather from the pockets of "wealthy" Americans over the course of a ten year period.

2) The "plan" (if that's what you want to call it) is frighteningly devoid of any real details or specifics. Harry Reid hopes to have a plan cobbled together by the end of the year. Really? Nobody has any concrete ideas for a solution but we're going to make money avilable for that eventual plan nonetheless? Again, the discourse remains in the lofty plane of Principles and Aims. Aim for universal coverage. Aim for cost containment. The only thing concrete is the moolah that will be steadily emptied from my pocket over the next ten years. And is this even enough? $650 billion over ten years? I realize this is just a "down payment" (current Obamaphile jargon), and Congress/state governments will be forced to come up with at least another 30-40 billion/year (i.e. new taxes), but I think we know enough about the federal government by now to realize that its ability to make long term cost predictions is shaky at best.

3) There are so many facets of American health care that need addressed, it's hard to imagine how we will be able to navigate out of this morass. It like deciding to have a neighborhood baseball game and everyone shows up naked. Certain factions clamor for gloves. Others are demanding clothes/uniforms. The catcher contingent won't play unless protective cup are purchased. You're the manager and everyone is yelling and screaming and you just don't know where to begin. Here's just a sample rundown:
- 48 million without insurance. What is the plan to cover them? Nationalized Medicaid/Medicare? A combination of private and public insurance?
-Who is going to be providing all this government-subsidized care? There's already a shortage of primary care docs. Cutting Medicare/Medicaid reimbursements at the same time that you're increasing the workload for physicians is a sure way alienate the very people (doctors) any reform plan needs in order to assure a smooth transition and funtionality.
- How exactly are costs going to be cut? Rationing? Government bureaucracy dictums on when/how/where a physician can order a certain test/procedure?

4) It seems to me that a tiered system of health care is inevitable. Those who depend on the public dime will receive coverage that necessarily differs from that of those who work fulltime and contribute to their own health plan. This ought not to be shameful or controversial. We can agree that food, shelter, and health care are fundamental tenets of a dignified human existence. One ought not to have to go without food. A family of four should not have to sleep under a highway underpass. An elderly woman should be able to have her breast cancer treated without worry of declaring bankruptcy. But if you're receiving food stamps or WIC aid you shouldn't be able to eat out at Olive Garden or buy a three pound tenderloin with your public assistance. A homeless person shouldn't be able to move into the Ritz Carlton until he gets his affairs in order and is able to rent an apartment. Similarly, those who cannot afford private medical care will have to utilize the expanded County/public hospital system which may mean long lines, waiting longer for elective surgery, denied MRI procedures for chronic back pain, and an overall higher level of inconvenience/irritation.

5) The burden for this is going to obviously fall on the backs of a minority of Americans. The highest tax bracket will return to 39.6% (incidentally, I love how this is called "rolling back tax breaks" as if giving 35% of your income instead of 40% to the federal government is some sort of scam that needs to be rectified). The AMT will be adjusted for inflation. Again, our federal government just got done doling out a trillion dollars to Wall Street, the automotive industry, mortagage lenders, and AIG. But health care is apparently different. Apparently health care reform depends on taking more money from people like me, who already pay a substanial percentage of earnings into the public kitty. Now all I need is for Max Baucus to push through "budget neutral" reform and further Medicare cutbacks on lap chole/hernia reimbursement and I'll drop into a lower tax bracket. I can't wait.

Tuesday, February 24, 2009

Eat Me (My name is calcium)

Hey look, the NY Times is touting a recent study published in the Archives of Internal Medicine that suggests an inverse relationship between one's calcium intake and risk of colorectal cancer (just for women, not men). Isn't that terrific? Just start pounding the Oscal and you'll be home free, right?

Of course, articles like this are absolute junk. It's the equivalent of retrospectively reviewing all the baseball games you've watched over the past five years and noticing that your favorite team seemed to be more likely to win whenever you ate exclusively hot dogs while watching the game rather than an amalgam of hot dogs, chili dogs, nachos, hot pretzels et al and based on that observation, deciding that, in the future, you will eat only hot dogs, sans chili, at live baseball extravaganzas in order to optimize your chances of cheering on a win. It's absurd.

But these are the kinds of articles that ALWAYS end up in the health/lifestyle sections of local and national newspapers. Eat more calcium! Broccoli will cut your prostate cancer risks by 60%! Snack-sized vanilla pudding is significantly more efficacious at lowering gastric cancer risk versus daily consumption of a vat of whole milk chocolate pudding! Simply biting off the head of your Flintstones daily vitamin will decrease childhood oral cancer rates just as much as those children who chow down the whole body (but not as efficacious as sweet toothed kids who sneak a second Wilma after Mom goes upstairs to put her curlers in)!

This particular article is buried in the back of Archives of IM. It isn't even featured on the on-line table of contents. And that's because the editors of A. of IM know it's complete junk. So why is this garbage the one article from the medical literature that the NY Times feels the need to highlight?

Obviously, every newspaper in this country now has a "Health" section and something has to fill that space. I understand that part. But choosing to print faux science like the calcium paper for a wide audience is an act of contempt directed against that audience. It's incredibly condescending and demeaning, if you think about it. There's plenty of material for health page editors to choose from. But they feel this need to dumb down the discourse to the level of vague dietary admonishments. Eat your vegetables! You'll get tumors otherwise! There's this underlying implication that our purveyors of journalistic excellence believe that the American public cannot handle anything more complex. It's like opening the sports section and reading about how basketball is this new sport where you bounce a ball and the object is to "shoot" it through a basket-like apparatus. Or flipping through the business section and getting a primer on the fundamental differences between a dime and a nickel (in bullet-point form, color graphics included, of course).

I browsed through this months AofIM and there's some decent material in there. A randomized controlled trial on determining ways of improving colorectal cancer screening. A 25 year cohort study on risk factors for end stage renal disease. The relationship between male infertility and testicular cancer. None of it overly complex. Certainly a professional journalist ought to be able to utilize sources/research in order to break down the gist of the articles in layman's terms. I think the American public just might appreciate the effort. Let's leave the fluff pieces on magic calcium ingestion to US Weekly and Cosmo. Newspapers still have some lingering prominence in the realm of American discourse, right?


I deleted AdSense from my blog. I think I earned something like $3.12 over the past 4 months from it. But besides that, I was tired of seeing ads for "Trace Curry MD, Bariatric Surgeon Extraordinaire" and "Have you been injured after your inguinal hernia surgery" and sundry other appeals by litigation attorneys. It was depressing. I mean, what is the existential point of writing these medical blogs anyway? To make money? If my goals were so prurient I would be better off simply doing more surgery, taking moonlighting jobs, etc, and cutting back on the amount of time I spend clacking away on the keyboard. Making money off this modest endeavor ought to be the least of my concerns. The concept of using my ramblings as a basis for attracting readers to little red limned boxes that promote the merchandise and/or skilled handicraft of various corporate/private enterprise concerns thereby enticing said readers to click on the aforementioned red-limned boxes is rather sad, in my opinion. So there won't be any more ads on good ol' Buckeye Surgeon. It will be continue to be highly unprofitable and obscure and I'll continue to write about whatever I want, whether it's a case study or a cool CT scan or 5,000 words on hospital atriums (atria?) or even triplet strippers. So there you go.

Monday, February 23, 2009

The Pride and Joy of Cleveland

Well, this is heartwarming. In the Plain Dealer today, there's an article that details the travails and ambitions of the Satterfield triplets of Elyria, Ohio. These delightful local blondes apparently were in Playboy magazine together in 2003 and 2007. Are they satisfied? Embarassed? Hell no.

So being in Playboy was everything they wanted?

"No. We're not centerfolds," Vicki said. "If we become centerfolds, then it would become a dream come true."

Vicki said the mansion was "like a pretend world" that included parties, swimming pools and stars.

Becoming centerfolds has been the triplets' ambition since they were 15. They began stripping four years later, with the goal of heading to Los Angeles for Playboy. Rachel Satterfield said the magazine is a class organization and used tasteful photos. She is hardly ashamed.

"I think I look better naked," she said.

The sisters have few other career goals. They just may keep dancing together at Club 57, a business off the Ohio Turnpike, until they get the call from Hef.

Makes me proud to call myself a Clevelander. And I'm sure their parents must be just tickled pink.

OR Dictations (Apologies to the estates of E. Hemingway and S. Beckett)

Laparoscopic Cholecystectomy:
The patient was wheeled in the room. The room was cold. My God it was cold. I shivered. I noticed others shivering. I shook my head. The lights were bright. It was a clean, well-lighted room and I could see everything clearly. There was no talking. I grunted at a nurse. I beckoned. I pointed. The patient was shifted from the cart to the OR table. I was pleased. It was good and I nodded at the old man. I washed my hands. I used powerful solvents. I washed them thoroughly. I scrubbed until the palms were raw and pink. I scrubbed until they were just on the verge of spontaneous hemorrhage. I dried off. I ruminated about my orchids. There was a late frost that morning. I left them out overnight. Damn the weather. The damned frost. I gowned and then draped everything sterilely. It was a clean and sterile working area. It smelled of the early morning. I was pleased. I asked for the knife. Some useless woman pressed a scalpel into my meaty palm. I will have my way with her later. I began to cut. It was an old but true blade, and these are the blades I use. It was sharp. I sliced. I made the flesh bleed. I pushed in my ports. I moved smoothly and efficiently. I was good. There was perfection. I made everyone recognize it. I dissected with smooth and precise movements. The organs were all brown and pink and glistened in the fiberoptic light. The gallbladder gave itself up. I pulled it out. I yelled at the nurses. I yelled loudly and firmly. I made myself heard. It was out. The gallbladder lay brown, broken, and defeated on the blue towel. I looked at it. I went to lunch. I drank grappa. End of dictation.

Right Colectomy
I entered the room. Who is the this I? Am I the surgeon? How shall I label myself. Who is this patient asleep on the OR table with a breathing tube hanging out his slacked jaw? Why is everyone looking at me? Am I here? Where am I? Someone is making me put on clean blue scrubs and sterile gloves. I allow it. It isn't me that does it. I cannot stop them. Maybe it was Krakow. Krakow would know. I begin. I must begin. If not I there is no one else whether I want it or not, rather, wanting to start, to cut, to operate, to begin, to start, the scalpel in my hand I incise, that is to say I make a long midline incision, it does not hurt, the patient is asleep presumably, assuming adequate anesthesia, I ask, just in case, the anesthesiologist, yes, it is ok, to begin, I begin and the blood starts to ooze and it oozes and in some places squirts and I ask Krakow for a cautery, is it Krakow who is here, is it rather Karkov, no matter, someone please hand me the cautery, regardless, I staunch the flow of unnecessary blood and the fascia opens up, I unzip the fascia, yes, yes, unzipped and the guts come spilling out, bulging, that is to say they spill out of the patient's abdomen, evicted almost, metaphorically speaking and I know this, I see it, I will speak of this again, shall I speak of it now, this me, this surgeon I am, the intestines bulge from my inflicted wound, i am sure the wound was from me, I hold the scalpel, the knife, after all, indeed, yes, and large metal retractors are placed, Balfour and Richardsons and I look and this is not me but the patient and I am inside, for the first time, is it the first time, have i been here before, surely I would remember, one would think, as I think and try to remember, I am encouraged to make progress by my assistant, Karkov/Karkow I cannot remember which I incise the lateral peritoneum and liberate the ascending colon, mobilizing it medially and the terminal ileum and gastrocolic ligament is divided between clamps and yes I have been here before, not explicitly here, but Here, in this spot, in this anatomical configuration, in the abdomen but not this abdomen, not specifically, not here, it was me, it was here, I was here, as long as I am honest, the point is not this patient but patients in general, the point being yes I have been here yes, I remember, and Krause is handing me a stapler and verbalizing hateful thoughts toward me and we divide the colon and then the terminal ileum and that didn't take long, how long have we been here, how long, where were we, where was I when I was I in this here before long ago which time it was I cannot remember, and I see Karkov clamping and tying the mesentery as I watch and I am thinking I ought to help if only I can remember, if I start, if I watch long enough, if I am the surgeon, if this would only have a name, if I start, if i remember, scissors and cutting, yes, of course, that is to say, snipping, trimming the sutures, and the colon is free, plopped into a metal pan, and then gone, I know not where, I am tracking it with my eyes, where is it going, people are shouting, crazed, angry looks on the nurse's faces I'm not sterile they scream, it's gone, the colon is gone, was it ever there to begin with, what have i done, did I do anything, was that which is now gone, namely the colon, is that which is gone, was it ever really there to begin with, I cannot recall, I ask Krakow and he is anastomosing the ileum to the transverse colon in a way I recall from ages ago, that is to say, from a time last week when I was doing something, let us call it an operation, in a similar fashion, may I call it an operation, is that being too presumptuous, do i presume to know, I cannot say, it's all going too fast and I look and again I'm snipping sutures, scissors I assume, it may be something else, perhaps metzenbaums, how is one to know, how is one to label, it doesn't matter, the sutures are shorter, the object is achieved, if that is indeed the object, is it the object, deargod what have I done, the sutures are shorter if that is the object, if only I knew the object, can someone tell me the object, Krakow or Karkov I would feel better, in other words I would sleep better, rest, recharge, knowing the object was in fact the shortening of tied sutures if this was clear and there was no possibility of other objects I would feel better, sleep, unconscious, undisturbed, better, yes, I would sleep better if this was clear, this object being the shortening of sutures yes and the fascia is mysteriously closed I looked down and the skin is coming together with staples and I have to assist I'll never know I have to go on I cant go on I must go on....

Tuesday, February 17, 2009

Journal Rundown

Another scintillating peak into the surgical literature. This week we do the February 2009 issue of JACS.

1)Laparoscopic Appendectomy—Is it Worth the Cost? Trend Analysis in the US from 2000 to 2005
Emanuel Sporn, Gregory F. Petroski, Gregory J. Mancini, J. Andres Astudillo, Brent W. Miedema, Klaus Thaler

The Issue: Another episode in the ongoing laparoscopic vs. open appendectomy wars.
Design: A retrospective review of patients from the Nationwide Inpatient Sample (2000-2005) who were treated for acute appendicitis with either open appendectomy (OA) or laparoscopic appendectomy (LA). A trend analysis was then performed to assess length of stay, costs, and complications.
Results: LA results in higher costs and increased morbidity!
The Bottom Line: Obviously, I'm a major proponent of the lap appy and this paper seems to suggest that I'm totally off track. But it's not such a great paper, frankly. It's a retrospective review of patients from a national database and it only looks at in-hospital costs and complications. It's not a randomized controlled trial. It doesn't consider post-hospital costs and complications (like the post op day #5 wound infection that you get in open appies and has to be opened and packed in the office setting). And I just don't think it's appropriate to make defining proclamations on open vs. lap appy based on accumulated data from 9 years ago. When I was a resident, I would say that 90% of the appendectomies I did were of the open variety. The only guys doing lap appy were the Pediatric surgeons and a couple of the bariatric guys. Nobody was comfortable with it. It's like trying to decide if the forward pass is a suitable form of offensive football strategy based on completion rates from the Knute Rockne era. In 2000, the laparoscopic appendectomy was still a bit controversial and a majority of academic surgeons simply were not comfortable doing anything other than making a McBurney's incision in the right lower quadrant. Now that lap appy is a 10-15 minute case in experienced hands, the discrepancy in accrued costs due to lengthy OR time ought to narrow. Now is the time to conduct a multi-institutional RCT directly comparing lap vs open. A paper like this one doesn't have any real purpose. It's not good science and it doesn't correlate with what happens in the real world.

2)Impact of Obesity on Perioperative Morbidity and Mortality after Pancreaticoduodenectomy, 18 December 2008
Timothy K. Williams, Ernest L. Rosato, Eugene P. Kennedy, Karen A. Chojnacki, Jocelyn Andrel, Terry Hyslop, Cataldo Doria, Patricia K. Sauter, Jordan Bloom, Charles J. Yeo, Adam C. Berger

The Skinny: Obese patients who undergo a Whipple have a slightly higher complication rate. Or do they:
There were 103 (42.9%) normal-weight, 71 (29.6%) overweight, and 66 (27.5%) obese patients. There were 5 perioperative deaths (2.1%), with no differences across BMI categories. A significant difference in median operative duration and blood loss between obese and normal-weight patients was identified (439 versus 362.5 minutes, p = 0.0004; 650 versus 500 mL, p = 0.0139). In addition, median length of stay was significantly longer for BMI (9.5 versus 8 days, p = 0.095). Although there were no significant differences in superficial wound infections, obese patients did have an increased rate of serious complications compared with normal-weight patients (24.2% versus 13.6%, respectively; p = 0.10)."

Obese patients undergoing PD have a substantially increased blood loss and longer operative time but do not have a substantially increased length of postoperative hospital stay or rate of serious complications."

Um, I'm confused. Anyway, it's a single-institutional, retrospective review. Not so useful. Plus, every other paper on Whipple and obesity seems to suggest that complications are higher the fatter you are. Which makes sense.

3)Operations for Intrahepatic Cholangiocarcinoma: Single-Institution Experience of 158 Patients
Hauke Lang, Georgios C. Sotiropoulos, George Sgourakis, Klaus J. Schmitz, Andreas Paul, Philip Hilgard, Thomas Zöpf, Tanja Trarbach, Massimo Malagó, Hideo A. Baba, Christoph E. Broelsch

The Bottom Line: Cholangiocarcinoma has historically been associated with grim outcomes (median survival <1 yr after diagnosis). This paper reviews the work of a group of surgeons at a hospital in Germany and their experience with cholangiocarcinoma. 53 cases were prospectively evaluated. Basically, they found that R0 resections (when you are able to remove the whole tumor with clean margins, i.e. no residual microscopic disease) led to 1-,3-, and 5-year survival rates of 71%, 38%, and 30%. That's outstanding. But to get these R0 resections, the German surgeons had to perform complicated anatomic liver resections in many of the cases. These are not operations you want your local surgeon doing. Liver transplant surgeons need to be doing these complicated liver whacks. This paper further supports this idea.

4)Effect of Short-Term Pretrial Practice on Surgical Proficiency in Simulated Environments: A Randomized Trial of the “Preoperative Warm-Up” Effect, 04 December 2008
Kanav Kahol, Richard M. Satava, John Ferrara, Marshall L. Smith

The Bottom Line: This one is great. The idea is to test the hypothesis that "warming up" prior to an operation will improve a surgeon's performance. So participants were randomized to various warm-up cohorts: calisthenics, hatha yoga, jumping jacks, an hour of Super Mario Brothers on Playstation and they were then evaluated based on subsequent dexterity and surgical skill performance. Actually that's not true. I'm being an ass. The "warm-up" consisted of performing some desultory maneuvers with laparoscopic tools and pegs and rubber beads and moving those beads from one spot to another. What they found was that warm-up "does positively affect proficiency during postcall condition characterized by fatigue and sleep deprivation. " That's interesting, but what are we supposed to do with the information? Morning stretches before rounds and cases? Do we make Peyton Manning perform a series of bureaucratically designated exercises prior to taking the field? I mean, we're all professionals here. We all know what we need to do to get ready for an operation. You're not going to catch me moving a bunch of rubber beads on a laparoscopic simulator before my next gallbladder any time soon.

Monday, February 16, 2009

The 2009 Zagat's Guide to Doctors

According to the NY Times:
The ubiquitous Zagat guides are known for an assortment of mostly leisure-related topics including hotels, spas, golf courses, movies and nightlife. Now the editors are asking people covered by one of the country’s largest commercial insurers to post reviews of their doctors and rate them in categories like trust and communication.

As in other Zagat guides, the responses are summarized and presented as scores that, in this case, are edited by the insurance company WellPoint. They can be viewed only by WellPoint customers. The reviews are being introduced online to millions of WellPoint’s Blue Cross plan members across the country.

A sampling:

Robert Mixxon MD (Pediatrician)
"Dr Mixxon is just ok. I mean, I liked his waiting room (lots of coloring books and toys and cute little mini-chairs for the kids and a giant aquarium, although I did notice a couple dead goldfish floating at the surface). But he's not exactly a world class charmer. I mean, where's the silliness? Would it kill him to make a few exaggerated facial expressions? Would it be putting him out too much to maybe tickle little Joey a couple times? Couldn't he like wear a clown nose or have a pen with a little mini-stuffed animal attached to the cap? Overall, the effect was rather a little too desultory; utilitarian but ultimately unsatisfying."
-Reviewed by LourdesNYC

Sussanah Pledget MD (Internist)
"This chick is hot. Smoking hot. I'm a healthy guy but I'm going to have to find new excuses to make another appointment. If you're heterosexual, I strongly suggest smoking, overeating, and using a lot of hard core drugs so you can get in to see Dr Pledget as much as possible."
-Reviewed by StanTheMan

Anil Patel MD (Gastroenterologist)
"I like Dr Patel. His skin is an eclectic mix of caramel and chocolate, but tastes more like expensive aftershave (I would not recommend trying to lick his fingers like I did; awkward!) He's a great physician. Very handsome. He drives a red BMW so if you wait in the McDonald's parking lot across the street you can follow him home."
-Reviewed by LooonyLorrie

Kyle Stoffer MD (Dermatologist)
"What a disaster this guy is. He comes in, looks at my hideous rash, writes me a prescription for some 'special cream' and then he's gone. I'm like, don't you want to see my blood sugar trends for the past 6 months, but he'd already slammed the door in my face. And my ankles were especially swollen that morning and he didn't even press on them. And I've been so tired lately, it's like if it isn't my fibromyalgia acting up, I can hardly get out of bed. Dr Stoffer is not my idea of a compassionate physician!"
-Reviewed by Phyllis_Lunddun

Joseph Manheim MD (Surgeon)
"Bad teeth, bad breath, and a chilly demeanor. And he wears paisley ties with striped shirts. I'd rather have my dog's vet take out my gallbladder."
-Reviewed by Connie_in_Poughkeepsie

Theresa Knowles MD (Family Practice)
"I'm not a doctor (admittedly) but sometimes I wonder if Dr Knowles knows what in the hell she's doing. I mean, look at my skin. It's all saggy and wrinkled and hideous and she says there isn't anything she can do about it. All she wants to talk about is my goddam blood pressure. Meanwhile, I have these swollen blackened sacks under my poor eyes and she says there's no medicine that will make it go away. Is she stupid? Doesn't she realize I can Google these things? Hello? Don't they teach doctors about sliced cucumbers anymore in medical school? I highly recommened seeking your medical advice from someone else."
-Reviewed by Dolores_Astor1932

Friday, February 13, 2009

Kitsch and Kundera and the Hospital Atrium

This link (via KevinMD) from the Freakonomics blog highlights the beautification phenomenon sweeping American hospitals. Here's what I'm talking about: You walk into a renovated hospital atrium and you have to pause because your breath get sucked right out of your essence; you gaze up at 50 foot ceilings and brass rail fittings and sparkling waxed floors and luminescent lights and 30 footer Christmas trees decorated with gold limned angels and red gleaming placards proclaiming area businesses who have donated a certain minimum and the hi-def muzak and nice looking people in Prada and Brooks Brothers bustling around and Starbucks just to your right and your little old granny is tucked away in a wood floored, heavily lacquered expansive room with a private bathroom and the butler, er orderly, arrives ringing a little silver bell to announce the hour of feeding, Wolfgang Puck platters and a half carafe of red wine (tannins exemplary examples of underutilized natural health products, according to the brochure that accompanies admission) and massage/spa options depending on your insurance and a botanical garden wedged between the parking garage and the boiler room with brick lined paths and rhododendrons and hyacinths and guide books for the horticulturally inclined. This is the new trend. This is the modern American hospital. Part utilitarian bastion of higher medical provision; part weekend getaway spa package. And the latter, alas, has become just as important as the former in terms of how we assess our "hospital experience". According to the article cited, "Hospitals as Hotels":
From the patient perspective, hospital quality therefore embodies amenities as well as clinical quality. We also find that a one-standard-deviation increase in amenities raises a hospital’s demand by 38.4 percent on average, whereas demand is substantially less responsive to clinical quality as measured by pneumonia mortality.

You see, this is how our hospitals respond to economic stress; by building bigger parking garages and painting the walls and replacing old carpeting with fake wood flooring and making the rooms WiFi accessible and constructing fabulous new "wound care centers" or "wellness gyms" and putting in a bunch of gigantic indoor vegetation in the well-lit main atrium and assigning each patient a personal masseuse. (Maybe not the last one). Meanwhile, the unglamorous aspects of a hospital are neglected. Laparoscopic equipment from the mid nineties aren't upgraded but million dollar DaVinci Robots are purchased. At one of the hospitals I cover, employees received a standardized mass email from the Director informing them that there would be no raises this year because of "economic turmoil". Moreover, families were informed that "sitters" (usually a nurse's aide who sits with a patient {typically an older, possibly demented patient who needs to be watched during the night lest he/she yank out all his/her IV's and tubings}) would now only be provided at an additional cost to the patient, i.e. either sit with grandpa overnight yourself or fork over some cash. Meanwhile, a massive construction project is ongoing (in response to a rival hospital system's plan to construct a new hospital on the east side, aiming to cut into that lucrative east suburban Cleveland insurance coin) with new OR's and more parking and an expanded ER on the docket.

There is a word for what is happening in suburban and tertiary care American hospitals and it is kitsch. Kitsch is the forgotten other disease afflicting the American soul right now (the other being unbridled irony) and its effects are just as insidious, just as damaging. Kitsch is the aesthetic ideal of the soggy, weighted-down heart. It is the apotheosis of dripping sentimentality. It is the enemy of subtle beauty and nuanced aesthetic worth. Kitsch is Thomas Kinkade paintings and Yanni soundscapes and Nicholas Sparks novels and "This is my country" pickup truck ad campaigns and patriotic American flag lapels and faux Irish pubs in strip malls and the miniaturized versions of Paris and New York and Egypt on the Las Vegas strip. Kitsch lulls us into the misapprehension that we're participating in something cultural and sophisticated. Our hearts are warmed by the fact that, yes, we too can appreciate "culture", just like everyone else and it's right there, mass produced, easily accessible and understandable, not elitist and obscure like so much of what is considered high brow and cosmopolitan. Why slog through Joyce's Ulysses when you can have intelligent discussions in your weekly book club on the relative merit and artistic value of The Devil Wears Prada? Why buy a bunch of unglamorous wheelchairs for patient transport that no one ever sees or appreciates when you can budget instead for brand new carpeting in the front atrium? Kitsch is reassuring because of its widespread appeal. Look, everyone else is doing it. I'm not alone, you think. But it is this very popularity and pervasiveness that makes it so dangerous (and unconscionably profitable). Kitsch may masquerade as real art and capture the mass public's imagination but deep down, it knows better. Deep down, kitsch is an unscrupulous scam, capitalizing on our collective longing for order and meaning and uncomplicated beauty. Which, I think, is sort of sad and melancholy.

Milan Kundera talks about the totalitarian aspects of kitsch in his great novel "The Unbearable Lightness of Being". He describes kitsch as the "total denial of shit". For example, the Soviet May Day parades were a rebuke to anyone who dared to claim that the communist system was going to hell. The massed crowds and the orderly marching and the smiling apparatchiks and the patriotic hymns were proof, don't you see, that all was well behind the Iron Curtain. In another passage, he describes a Czech emigree in America with her lover, and they watch children scrambling through a sunny field. The American says, "now that's what I call happiness", and he smiles the same glazed, self-satisfied smile of the Communist honchos of the May Day parades. What does he mean by that phrase and that smile? Kundera replies:
How did the senator know that children meant happiness? Could he see into their souls? What if, the moment they were out of sight, three of them jumped the fourth and began beating him up?
The senator had only one argument in his favor: his feeling. When the heart speaks, the mind finds it indecent to object. In the realm of kitsch, the dictatorship of the heart reigns supreme.
The feeling induced by kitsch must be a kind the multitude can share. Kitsch may not, therefore, depend on an unusual situation; it must derive from the basic images people have engraved in their memories: the ungrateful daughter, the neglected father, children running on grass, the motherland betrayed, first love.
Kitsch causes two tears to flow in quick succession. The first tear says: How nice to see children running on the grass!
The second tear says: How nice to be moved, together with all mankind, by children running on the grass!
It is the second tear that makes kitsch kitsch.
The brotherhood of man on earth will be possible only on a base of kitsch...

Can you see how this kind of attitude is dripping with a lazy smugness? It is a refusal to acknowledge anything that detracts from the Platonic Ideal of the Whole, a refusal to look under the covers at the seamy underside of our complex reality. Kitsch demands conformity to Universal Truth and Beauty, whatever that means. It simplifies and softens rough edges and buries anything unsavory beneath a veneer of polish and gleam. Theodore Adorno puts it this way: "Kitsch or sugary trash is the beautiful minus its ugly counterpart". And there's the rub; kitsch does prick at something hopeful inside us, fuzzily arousing vague feelings of love and nostalgia for something that we can't, or dont have the intellectual courage, to try to define for ourselves. It defines the essence of what it means to be human, but in simplistic, juvenile terms. And we allow it, for a variety of reasons. That's the tragedy.

Kitsch seeps into our souls because it's easy and eliminates the need for critical analysis. It decides for us what we require, what is important. And so now we have the American hospital; clean, sparkling, almost luxurious. You will eat well and get exercise and return to a higher state of wellness than that which necessitated your admittance. Commit to this paradigm. Support this investment of dollars and public resources. Ignore the actuality. Ignore the smell of shit and melena and vomit and the corpsish spectres lingering down in the ICU's and the blood and pus soaked bandages and the late night delirium old people moaning, street names and ex-girlfriends from the Prohibition-era, and the mediciney smell of gauze and gowns and sharing a room with a stranger in a moment of absolute vulnerability separated by a thin drape and not eating when you want and waiting and waiting for the nurse to bring your pain meds when you really need it. None of that gets addressed. But at least the atrium is awe inspiring and the meals are world class and there's a piano that plays on Thursday evenings and when you wonder about the weather outside you can simply check via your complementary WiFi account. Make a commercial about those things. Come to our hospital! You won't want to leave! The rest is edited out of existence. And sadly, that's apparently just the way we want it.....

Thursday, February 12, 2009

Emphysematous Cholecystitis

This isn't something we get to see every day. I saw an elderly gentlemen in the ER recently who complained of 24 hours of right sided abdominal pain. Other than a history of mild HTN, he was a pretty healthy old dude. No diabetes. Nothing in his history to suggest an immunocompromised state. He was certainly tender on exam, exquisitely and rather diffusely so. His WBC count came back over 30k and I was actually initially worried about ischemic bowel. But we sent him for a CT scan and the above image is the money shot.

What you see is a pathognomonic picture of emphysematous cholecystitis. (Notice the air in the wall of the gallbladder). This is a very severe form of acute cholecystitis where anaerobic bacteria, such as clostridial species, invade the gallbladder wall and produce gas. It's rather rare (only about 1% of cases of cholecystitis) but it can be lethal, carrying mortality rates of 15-25%.

Emphysematous cholecystitis depends on one or both of following: vascular compromise of the gallbladder and systemic immunosuppression. Anaerobic bacteria don't exactly thrive in tissues that are well oxygenated with good blood flow. Advanced cholecystitis, where the perfusion pressure of the capillaries is overcome by the edema of the inflammatory process, can lead to cystic artery occlusion and hence, a dead gallbag. Enter your anaerobic species, stage left. Immunocompromised patients (diabetics/transplant patients/HIV) are also susceptible to this virulent form of cholecystitis (for obvious reasons).

The treatment is surgical. Call the OR. Book the case. I took this one out laparoscopically, but sometimes you have to open because the wall of the gallbladder can often be about as sturdy as wet toilet paper (single-ply, like in bus terminal restrooms) and everything tears and spills and it's just a horrible mess.

Monday, February 9, 2009

Organ Donor for Hire

An interesting essay from Sally Satel advocating the controversial position that organ donors ought to have the option of being remunerated for their generosity. With 78,000 people on the kidney transplant waiting list, there is clearly a shortage of available organs. Currently, a big part of the screening process of potential living donors involves a thorough assessment of donor motivations. Why are you doing this? Any suggestion of financial incentive would usually disqualify a potential donor from consideration. Donation has been defined as an act of pure altruism. The gift of life. Anything extraneous or compensatory betrays the dignity of the donor/recipient relationship, according to contemporary medical ethics dogma....

But is altruism ever truly "selfless"? Intangible benefits of organ donation certainly exist; the sense of moral rightness (even superiority), a sense that you alone are responsible for the well being of another can be an intoxicating high. Moreover, the tyranny of the gift can be a burden that ties a recipient to his/her donor for life. This sense that one owes another person something of such value, a gift that was completely unsolicited and philanthropic, can be an overwhelming burden to bear for the recipient.

So what if we offered compensation for donors (either tax breaks or lifelong free health insurance or cold hard cash) and commodified the act of organ donation to some extent? Would the organ shortage be solved? Would the recipient be liberated from this stifling sense of indebtedness? Would poor people rush to sell their organs for pure financial benefit, risking their own lives? The consequences are not all entirely foreseeable but I think it's important to at least consider the possibilities of compensated donation. As Satel concludes:
To be sure, these skeptics have a right to their moral commitments, but their views must not determine binding policy in a morally pluralistic society. A donor compensation system operating in parallel with our established mechanism of altruistic procurement is the only way to accommodate us all. Moreover, it represents a promising middle ground between the status quo—a procurement system based on the partial myth of selfless altruism—and the dark, corrupt netherworld of organ trafficking. The current regime permits no room for individuals who would welcome an opportunity to be rewarded for rescuing their fellow human beings; and for those who wait for organs in vain, the only dignity left is that with which they must face death.

Sunday, February 8, 2009

More Pneumothorax

In medical blogging, I've found that patience is usually rewarded. I had a craving to write about pneumothorax and when Gerald Wallace was crunched by by Andrew Bynum, I jumped all over it. But it turns out that all I had to do was wait a week and a situation would develop in my own practice. I was covering for another surgeon who had a patient in the ICU on the vent. The patient had severe COPD and seemed to suddenly decompensate; low BP, dropping oxygen saturations, etc. So I ordered the usual workup, i.e. CXR, ABG, cardiac enzymes, et al. And the above picture showed up on my home computer. So I hustled into the hospital, slammed in a chest tube and the subsequent CXR made everyone feel more better. (Special thanks to the state trooper who inexplicably didn't pull me over as I zoomed by at 90 MPH on I-271).

Friday, February 6, 2009

Friday Surgical Journal Review

I've decided that it might be fun to write up a quickie review of one of the main surgical journals as a weekly feature. And I use the word "fun" in a very broad and all-encompassing sense. I've always found that trying to stay up on my surgical literature is about as much fun as watching a Grey's Anatomy repeat on Telemundo while stranded in a motel in Guadalajara. The journal arrives in the mail all glossy and colorful, jam packed with scholarly insight and innovative new science and then maybe you set it aside for "later" but every time you open it up, you end up just skimming through a couple of the abstracts that seem vaguely interesting and as the weeks go by, the glossiness of the cover dulls and crinkles and is pocked by circular coffee cup stains and residua from spilled food. So I will break down a journal once a week (except those weeks when I don't feel like it) for the edification of myself and my sparse but loyal readers. Enjoy.

Journal of The American College of Surgeons (JACS): January 2009

1) Human Polymerized Hemoglobin for the Treatment of Hemorrhagic Shock when Blood Is Unavailable: The USA Multicenter Trial

What's the deal?: Synthetic hemoglobin (PolyHeme) as an alternative to packed red blood cells. This is a cool development. In the study, trauma patients who were hypotensive in the field were randomized to 2 resuscitation arms; saline/red blood cells vs. intital infusion with PolyHeme.

Conclusions: Similar outcomes in patients resuscitated with PolyHeme vs saline/blood products.

Usefulness: Good to know that level I trauma centers can use this stuff in a pinch. Perhaps EMS first responders can be equipped with Polyheme so that resuscitation with oxygen carrying compounds can be implemented in the field. But the cost and availability of PolyHeme is not addressed. I don't foresee places other than major Level I trauma centers even considering this any time soon.

Statistics: They used something called a "dual superiority/noniferiority primary end point". I have no idea what that means. I can only trust that the conclusions drawn are valid.

General enjoyability: Not bad. The statistics and graphs are hard to follow but the case for synthetic oxygen carrying compounds is compelling. Of interest is that previous literature suggested a higher risk of myocardial infarction in patients receiving synthetic hemoglobin. This study intially suggested more MI's as well but a subsequent review by an "independent subcommittee" of cardiologists determined that there actually NOT a higher incidence of MI in the PolyHeme group.

2) Peripheral Vascular Surgery Using Targeted Beta Blockade Reduces Perioperative Cardiac Event Rate

What's it about?: Pre-operative evaluation of patient's needing major vascular surgery.

Conclusions: For low and medium risk patients, it may been unnecessary to do anything prior to surgery other than starting them on beta blockade.

Statistics: I don't know, something about cohorts and multivariate analysis.

General enjoyability: Quite high! Surgical interns across the land can now rejoice. Instead of exhausting themselves wheeling patients all over the hospital to complete their pre-op cardiac workups, this study (along with this one) suggests that perhaps all we need to be doing in select patients is starting them on Lopressor and titrating it to a targeted heart rate of 60-65.

3) Informatics and the American College of Surgeons National Surgical Quality Improvement Program: Automated Processes Could Replace Manual Record Review

What's it about: I have no idea. I couldn't read more than the first 2 sentences.
Conclusions: Something about informatics and how wonderful they can be.
Statistics: Didn't get that far.
General Enjoyability: As close to zero as you can get.

4) Survival in Stage III Colon Cancer Is Independent of the Total Number of Lymph Nodes Retrieved

What it's about: The relationship between the number of lymph nodes harvested and survival in patients with Stage III colon cancer.

Conclusions: In stage III colon cancer (i.e cancer that has spread to the mesenteric lymph nodes), the total number of nodes harvested is not a prognostic indicator of survival. This is in contradistinction to stage II colon cancer where survival is equated with retrieval of at least 12 lymph nodes.

Usefulness: Minimal. I'll explain why. The 12 lymph node threshold for Stage II is critical because if you only get 4 nodes and they're all negative, there's a chance you've understaged your patient. This is important because in colon cancer, we give adjuvant chemotherapy anytime you have N1 disease. If you have less than 12 nodes you can never be certain that the patient is truly stage II. So most oncologists would recommend giving chemo for stage II tumors if an inadequate lymph node sampling is done. Now if you know the patient is stage III he's going to get adjuvant chemo no matter how many nodes you harvest. It doesn't matter how many nodes are positive; all it takes is one. So this study only confirms the importance of chemotherapy in lymph node positive disease. It doesn't make the same comment about the extent or adequacy of the surgery performed like in previous studies on stage II disease because, again, stage III colon cancer gets zapped with chemotherapy no matter what. It's not like you run the risk of understaging the patient. But I still think we ought to always aim for high yield lymph node harvests whenever doing surgery for colorectal cancer.

5) Stored Red Blood Cell Transfusion Induces Regulatory T Cells

What it's about: Um, the search for the mechanism of immunosuppression after an allogeneic blood transfusion and the role that induced regulatory T-cells play.

Conclusions: No comprendo.

Statistics/Design: Something along the lines of supernatants and flow cytometries and test tubes and beakers and cytokine levels.

General Enjoyability: I was stabbing myself in the knee with a steak knife as I read this and I didn't even know it.

6) Effect of Body Mass Index on Short-Term Outcomes after Colectomy for Cancer

What it's about: The consequences of being fat and having your colon whacked out.

Conclusions: Morbidly obese patients have higher rates of wound infections, dehiscence, pulmonary embolism, and renal failure after colorectal surgery.

Statistics: A retrospective review of the ACS-NSQIP database. Pretty straightforward.

General Enjoyability: Obesity is bad. We can never have enough articles in the medical literature to hammer this home.

7) Nationwide Volume and Mortality after Elective Surgery in Cirrhotic Patients

What it's about: The hazards of operating on patients with underlying severe liver dysfunction. A national database of patients with cirrhosis who underwent one of four index operations (lap chole, colectomy, AAA repair, CABG) from 1998-2005 was reviewed.

Conclusions: In-hospital mortality, length of stay, and total hospital charges were substantially higher in cirrhotic patients undergoing elective surgery.

Usefulness: Cirrhosis, strangely enough, is often not identified until a patient comes into the hospital for a "routine" procedure and all hell breaks loose. Even patients without portal hypertension (compensated cirrhosis) had a higher frequency of adverse outcomes compared to the general population. For the average general surgeon, the lesson is: do a thorough history and physical prior to elective surgery. Being able to identify those patients at risk and preparing for the worst is often half the battle....

Thursday, February 5, 2009

Justice Bader Ginsburg

Supreme Court Justice Ruth Bader Ginsburg underwent surgery today for a pancreatic tumor at Sloan-Kettering Cancer Center in New York. The renowned surgical oncologist Dr. Murray Brennan performed the operation. It sounds like her doctors discovered a small (1cm) mass either in the head or the body of the pancreas on a recent imaging study. Presumably, she underwent a Whipple procedure (assuming the tumor was not in the tail). Obviously, our thoughts and prayers are with Justice Bader Ginsburg and her family at this time.

The reason I'm posting on this (not my usual thing to slap up a post on the latest medical current event before anyone else has) is because an anonymous commenter on my last post asked about "a supreme court justice getting routine screening CT scans" with the implication being that they only found this lesion because of privileged medical care available to a SCJ. Well, I don't think any special indulgences were granted in this situation. Justice B-G has a history of colon cancer, successfully treated in 1999 with surgery and adjuvant chemotherapy. Getting a yearly surveillance (rather than screening) CT scan of the abdomen and pelvis (and also checking a CBC, liver panel, and a CEA) would be considered to be a routine standard of care follow up measure. This small tumor was probably discovered incidentally on her last scan. So good for her. Hopefully she survives the surgery and does well long term.

Pancreatic cancer after previous colon cancer would an unusual case report. It will be interesting (for prognostic purposes) to see whether this is a primary pancreatic tumor versus a delayed metastatic colonic cancer.....

Wednesday, February 4, 2009

Vaginal Nephrectomy

At Johns Hopkins last week, transplant surgeons removed a healthy kidney from donor Kimberly Johnson's vagina. And now the internet is abuzz with excitement. It's the new frontier! The natural extension of NOTES!

But several clarifications are needed. Number one, this wasn't really natural orifice surgery. The kidney was dissected and liberated through standard laparoscopic incisions. It was just extracted through the vagina. (And this is not something new anyway.) Instead of a small flank or periumbilical incision, (4-5cm), the kidney was placed in a sterile bag and brought out the vagina through a colpotomy. So the benefit (arguable at that) was one of cosmesis. Secondly, this patient went home the next day. Which is when most laparoscopic kidney donors go home anyway. Recovery is expected to be similar. More concerningly, the threat of bacterial contamination is introduced anytime you pass instruments/donor kidneys through the colonized mucosa of the vaginal vault. And remember, that kidney ends up getting implanted into an immunocompromised patient. So I guess I just don't get it. Why increase the complexity and risk of a completely elective operation when the benefits are chiefly cosmetic (and that's debatable at best)?

I've written about NOTES here and here. I admit I'm a bit biased at this point. Sometimes, in our drive to discover the 'next great thing', we forget about the highly efficacious modalities we already have. Laparoscopic cholecystectomy is an outpatient operation that's minimally invasive and allows patients to return to regular activities/work within a week or so. That's a tough standard to topple. And if we're planning on scrapping it, there better be a more compelling reason beyond the allure of "incisionless surgery" (and not really incisionless anyway) because the cost of the new equipment and the more onerous cost of training an entire generation of surgeons the new technique will be a tough pill to swallow, especially in these already strapped times.....

Monday, February 2, 2009

Compassion Inc.

Pauline Chen MD (from the NY Times) recently highlighted an article from Academic Medicine that promulgates the idea that compassion and empathy can be taught to physicians in whom such sentiments don't come naturally. Here's the gist of the study:
In the study, groups of established physician-teachers from five different academic medical centers met at least twice a month. During the meetings, the doctors either practiced skills designed to enhance compassion, or reflected on their own work through discussion and narrative writing.

After 18 months, residents and medical students at each of the medical centers evaluated the physician-teachers, as well as a “control group” of faculty, on such matters as listening carefully and connecting with others, teaching communication and relationship-building skills, and inspiring the adoption of caring attitudes toward patients.

I imagine the meeting where the participants met with the study designers to review their performances went something akin to the following:

Proctor: So Dr X, it seems that after undergoing the training, your compassion/empathy quotient (CEQ) scores went up substantially.
DrX: Why thank you.
Proctor: There were just a few areas you could work on. Do you mind if we run the tape and talk about some minor deficiencies?
DrX: Of course. Go right ahead.
Proctor: (Clicks the play button) Now here, I like how you've brought a bouquet of flowers with you in the room. The patient seems to really appreciate it.
DrX: They're orchids. Just lovely I thought.
Proctor: Agreed. You see the patient identifies with you as one who appreciates beauty, natural beauty, just like her.
DrX: Yes. That's what I was aiming for. Plus it'll make the room smell nicer.
Proctor: Nevertheless, also arranging for a singing get-well-soon telegram, performed by a scantily attired Chippendale dancer may have been going overboard.
DrX: Agreed. Next time maybe just a clown with balloons or something.
Proctor: Um, or maybe just not doing anything at all of that nature.
(The tape runs)
Proctor: Now here I like how you've invited the patient to join you on a yoga mat you've splayed out on the floor.
DrX: I thought if we sat cross legged, palms pressed together for 20 or 30 minutes it would allow us to connect on a deeper, more spiritual level.
Proctor: But the patient just had knee replacement surgery. She was in no condition for hatha yoga.
DrX: I see your point.
Proctor: Anyway you seemed not to get flustered by her reluctance. But then you crawled into bed under the covers with her.
DrX: I wanted to identify with her. To see what it was like to be in your shoes, literally in her hospital bed.
Proctor: Yes, but....don't you think it a bit weird for a doctor to join a patient in bed?
DrX: I let her have most of the sheets and covers and I basically was on a little sliver of mattress and I must say, those hospitals beds are exceedingly uncomfortable.
Proctor: I see. Anyway, as we learned during the training module, touch is always important in building a patient/physician relationship. We talked about holding a patient's hand, resting your hand on a patient's shoulder...
DrX: I utilized touch...
Proctor: You kept patting the patient's head like she were a puppy or something. Look at what you're doing there. The patient keeps trying to wave you away.
DrX: (Blank faced staring at TV screen)
Proctor: And we talked about the use of facial expressions.
DrX: Yes. I always remembered to stare deeply into the patient's eyes as I spoke, to let her know I was looking into the depths of her pain and suffering.
Proctor: Maybe that was your intention, but in reality you seem to have a lascivious, lustful look on your face, as if your looking into the eyes of a long lost lover.
DrX: Oh. I didn't realize. Is that why security showed up?

Is this really the road we want to travel down? Where compassion and empathy are "taught", packaged into an edifying lecture/power point format, to be "acquired" like any other commodity? Is this what we ought to be doing? In A Supposedly Fun Thing I'll Never Do Again, David Foster Wallace (I know, I know, yet another DFW reference) talks about the rise in American culture (especially in our service oriented economy) of the Professional Smile. We all know this smile. It's the one you get from the check out clerk at Target on a hectic saturday afternoon. Facial muscles visibly quivering from the strain to keep the corners of the lips upturned. The eyes aren't involved, a smile that stops below the nose, the disturbing juxtaposition of dead vacant eyes against strained cheeks and lips and bared teeth. We all know it's phony. We all know that clerk couldn't give a damn if we "had a good day" or not. We all know the clerk only does it because he/she has been instructed to smile and say have a nice day (forced and monotone) to every customer by the corporate honchos because it's good for business to present a friendly, approachable visage to the paying consumers so they feel good about themselves when they leave with merchandise in hand. And the absurd part of all this is that if a service employee doesn't flash you that phony smile, you get pissed off. Like if you are buying gum at the 7-11 and the clerk is chatting on his cell phone, barely acknowledges you as he slides your change through the slot in the glass window, you feel slighted. Where's my smile, you think? Where's my encouraging platitude?

I'd like to think that the doctor/patient relationship is so fundamentally different from the buyer/seller one that any attempt to impose the "rules of engagement" from the latter on the former is doomed to failure. Developing a compassionate bed side manner comes easy to some. For others, it is definitely a struggle, something that takes years to master. And then some docs will never "get it" no matter what they do. But it isn't a "technique". There's no recipe to follow. It's like trying to tell someone how much you love your spouse. Or why you cry when you drop your five year old off for his first day of Kindergarten. There's something inexpressible about it. And I submit that this is a good thing. I don't think we want to be able to break down "physician compassion" into a two week CME class with a syllabus and scientific literature to study and a quick little exam (pass/fail) at the end. We don't need to repackage our physicians in the slick, glossy veneer of used car salemen. What we do as physicans, this relationship is very simple. One human being who is ill presents herself to one who has knowledge of what may be wrong and the possible treatment remedies. The ill one is honest and open and completely vulnerable. The physician processes the data, the physical exam, her professional experience and must render a verdict. But before that verdict, the physician must pause and acknowledge that the data must be coalesced with the actual human being sitting across from her. It is in that pause, that brief sliver of time in a hospital room or an office when compassion will or will not crest to the surface. That's all it is. Some physicians genuinely have it, some don't. What we have to ask ourselves is whether increasing the number of docs who "appear" to have it (via the indoctrination of "compassion school") is necessarily for the best, or if it ends up corrupting the sanctity of the patient/physician relationship.