Wednesday, July 29, 2009

Wingnut Lies

This pisses me off. I have a few right wingers in my family who like to forward me the latest FoxNews/Sean Hannity/Rush Limnaugh spewage via email. Making the rounds right now is the meme that page 425 of HR 3200 (Obamacare) contains a provision that will "lead to government encouraged euthanasia of the elderly". First of all it's a false accusation. Second, what sort of sick twisted world do we live in where honest dialogue between opposing political ideologies is not only rejected, but proscribed as a source of weakness? Why does the truth always have to be manipulated to meet a political agenda?

Here's the truth. There is a provision in the bill that would require Medicare to cover an end-of-life consultation between a palliative care specialist and an elderly individual. In other words, if you are in the twilight of life, but still of sound mind, you have the option of consulting with your geriatrician or palliative care specialist about things such as living wills, DNR status, and asserting your durable power of attorney. This a good thing. Any hospital-based physician who works in this country would welcome reform that better prepares patients mentally and legally for their inevitable decline. I can't tell you how many times a month I find myself seeing a demented patient in the ICU on pressors, intubated, gorked out, sustained solely by machines and no one knows what to do, no one in the family is prepared to "make the big decision" because no one ever thought to ask the patient when she was lucent: what do you want us to do when you're deathly ill and are unable to make decisions for yourself?

Close to 30% of Medicare spending on the elderly occurs in the last six months of life. And it's all wasted. These are futile cases, invariably. But it goes beyond the pure cost. The suffering and emotional angst of family members is immeasurable, as they watch a loved one transformed into something unrecognizable.

This bill is not about euthanasia. It rather represents an initial attempt to confront our mortality on our own terms, while we still have the intellectual capacity to articulate what it is we want done prior to the onset of the inexorable decline of our minds and bodies. Death is not something to run from. We ought to stop ignoring it, putting it off until it's too late. If anything, I think the language in the bill is not strong enough. We need to mandate the legal documentation of our end-of-life wishes. As soon as one contracts a terminal illness, or hits age 65, then make it law to file official DNR, durable power of attorney, and living will documents. It's the socially responsible and humane thing to do....

The Cost of Obesity

The WSJ health blog discusses the added cost of morbid obesity on total American health care expenditures.
The estimated annual medical costs due to obesity nearly doubled to $147 billion in 2008 from $78.5 billion in 1998, as the obesity rate rose 37% during the period, according to an article published online today in the journal Health Affairs and highlighted during the conference. Obese individuals incurred an average of 42% more in medical expenditures — about $4,800 for per person per year — compared with normal weight individuals, who incurred an average of about $3,400 in such expenses.

Individual accountability in health care reform has been curiously downplayed. If anything, the mandates for prohibiting denial of coverage of individuals with pre-existing conditions suggest that personal accountability will be buried. Reckless behavior and overindulgence has a societal price. Certainly care for those who are more of a burden on the national health care ledger (due to self determined circumstances) ought not to be denied coverage or made to pay exorbitant premiums, but shouldn't they be incentivized in some fashion to change those behaviors that contribute to the cost burden?

Taxes on cigarettes keep getting raised (not to fund health care projects, mind you, but to rather construct shiny new baseball stadiums for rich athletes to play in while the surrounding urban infrastructure crumbles) and now the prevalence of cigarette smoking is trending downward in this country. No one has a problem with this. Why isn't there similar momentum for a "sin tax" on fried foods, candy, and fructose-laden beverages? All revenues collected then could to be directed toward the health care kitty. The penalty will be a self inflicted wound rather than an arbitrary decree mandated by the federal government. Maybe I'm missing something but that seems reasonable to me....

Tuesday, July 28, 2009

The Cost of Innovation

Matthew Yglesias today writes about the effect that innovation in the medical industry has on health care costs. There is a driving force in the United States to push the envelope. New drugs. New diagnostic modalities. New procedural techniques. And with the latest innovation comes a heftier price tag. At some point, the benefit of ground breaking technologies is outweighed by their prohibitive costs.

In surgery specifically we are seeing this with regards to minimally invasive surgery. Robotic surgery programs are cropping up in academic centers across the country. NOTES (natural orifice transendoscopic surgery, i.e. "incisionless" surgery) has captured the attention of some surgeons and just recently, the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) announced that the first multicenter human trial on incisionless gallbladder surgery has been approved. These developments, although exciting, are not cheap to implement (especially the million dollar Davinci robotic system).

But an important consideration is omitted when enthusiasm builds for these newer surgical techniques. What value do patients derive from these innovations?

Gallbladder surgery used to require an unsightly slash incision under your right ribcage. Most people would be kept in the hospital for 3-5 days. Pain was not insignificant. People would be off work for 4-6 weeks sometimes. Complications such as wound infections and hernias occured in perhaps 10% of cases. The laparoscopic innovation completely altered this paradigm. Nowadays, patients are discharged from the hospital on the same day. Incisions are neatly hidden in the belly button. Activity is resumed as soon as possible. Pain is negligible after a few days. In this case, the innovation has inarguably justified its increased cost.

But what do you get for your incisionless cholecystectomy? You go home....maybe on the same day (but doubtful, at least at first, given how most surgeons tend to be pretty conservative when early on the learning curve). Pain perhaps could be incrementally less (proven via complicated calculus equations using some contrived Patient Vitality Pain Survey as the "data"). But hey! No incision! Looky! See how your tiny barely noticeable incisions from your primitive lap chole totally stand out and make you look hideously ugly compared to me!

Yglesias writes:
The current market creates strong incentives for people to develop “better and more expensive” methods of treatment, but almost no incentive to develop “as good but cheaper” methods of treatment. Both kinds of innovation, however, are extremely valuable. The world’s resources are limited, and the development of cheaper methods of treatment would allow for more overall treatment and thus better outcomes.

He's absolutely right. At some point in time (like when health care in America isn't in full crisis mode) it may be advisable, even desirable, to see innovations like NOTES and robotic surgery gather momentum as acceptable alternatives to the standard of care. But we aren't there yet. And it isn't just medicine. There are lots of worthy scientific advances that lay dormant due to financial considerations. The United States certainly has the wherewithal and technical expertise right now to make a manned space flight to Mars. But the cost of such a noble endeavour would bankrupt us.

The old surgeon's adage of "the enemy of good is better" is apropos here. American surgery operates pretty well as is. If we temporarily abandon costly innovations that provide only subtle benefit, I think we'll nevertheless be all right. It's not like we'll suddenly revert to the days of the surgeon-barber slapping an ether soaked rag over your face while he unsheathes his cleaver.

Saturday, July 25, 2009

The meaning of life

The Happy Hospitalist took aim at my post from last week on the spry 92 year old lady with metastatic breast cancer who needed a Mediport for her adjuvant chemotherapy. As anyone who reads the Happy Ho would expect, he comes down hard on the decision of myself, the patient, and the oncologist to proceed with aggressive chemotherapy on someone obviously in the twilight of life. He writes:
So I have to ask the question. Does this 92 year old have the right to consume the resources used to treat an incurable, fatal and futile disease if it means we wont have the money required to treat another disease that is neither incurable, neither fatal and neither futile?

Unsurprisingly, HHO treats this case as yet another flagrant example of the profligate waste we see in everyday medical practice in America. Health care dollars and resources are a limited commodity (like oil and soybeans?), he avers---we cannot afford to waste them on the extreme elderly.

Now I think his heart is in the right place. Happy isn't a preternaturally evil person. Most of what he writes is at least reasonable. Besides, when you are an anonymous blogger, sometimes you write things you don't necessarily mean, with a stridency that you wouldn't normally use in everyday discourse. Who knows, maybe in real life HHO is a giant softy, one of those docs who brings his patients warm blankets and a cup of hot tea every morning. But on this particular topic, I think he's way off the mark and a little out of his depth.

I'm going to veer of course for bit, if that's OK. Notice first the ponderous, pretentious title of this post--- "the meaning of life". What the hell is that all about? Is this going to be another rant about Baudrillard or Kundera or DFW, you ask? Well, sort of. Just bear with me. Much of what happens to us in life is unimportant and ultimately forgettable. The traffic jam on the way home from work. Saying hi to people you pass in the hall. Pumping gas. Watching television. Reading the sports section. The lost moments of time that slip through our fingers every day. But every once in a while moments arise that demand our attention. These are the moments that either force us to step up and make good on the ideal conception of the sort of person we think we are (adversity, ethical quandaries, etc) or force us to stop and re-evaluate the very foundations of our notion of being. No matter who you are, it's important to accept these challenges when they present themselves; otherwise life is a random, arbitrary mess that ends much too quickly. My 92 year old breast cancer patient was, for me, such a moment. As a physician, and this may come off as a bit arrogant, I think I am thrust into situations that demand this sort of introspection more often than the average Joe. This is both a privilege and a burden.

A physician's raison d'etre is arguably to alleviate suffering, to improve a patient's quality of life, and to, in some cases, work to extend the duration of the life of an ill patient. Life is the common denominator. Our purpose, our meaning is driven by the concept of "life"--- making it better, richer, less intolerable. If we admit this, then we are obligated to define what we mean by "life", because that is the fulcrum upon which we operate. What is life? What is it exactly that we are trying to save, to alleviate, to improve?

Now this is purely my take and I'm just some yahoo like all the rest of you so don't get too upset if you disagree. I see our temporal time on Earth as having two distinct components. On the one hand is our contingent, a priori self that thrusts itself upon us, the part that deprives us of our autonomy. I was born in the late 20th century. I could not choose my parents. My genome is unalterable. I was raised a certain way by my mother. This is our contingent life. It didn't have to be like it is, but it is, and there isn't anything we can do about it. And it doesn't end at birth. The contingencies of life continue until we die. Events occur beyond our control that exert pressures upon our being. Wars. Economic depressions. Pestilence. The tragic untimely death of a loved one. A car that runs a redlight as you drive home from your daughter's wedding. We cannot control them. There is no escape from the weight that they bring to bear. But we are not condemned to let contingency define us. There is another side of Life, the side of free choice and alterability. Jean-Paul Sartre wrote about the being for itself (etre pour soi) that exists fleetingly in the instantaneous moment when we are free to decide, to choose to be, to push back against the weight of our contingencies, to create ourselves, fresh and new. Heidegger's dasein (being in time)is a similar concept. We aren't always doomed to serve out the sentences of our contingencies; every moment in time brings with it an opportunity to change, to rectify, to make better. We don't have to accept defeat. Those moments that interminably rush toward us with each waking second of consciousness afford us the chance to get back up off the canvas. And this is the aspect of Life that I find far more interesting.

Going back to my old lady with breast cancer. Her situation is fraught with contingency. She has incurable cancer. The chemotherapy may do more harm than good. She's old as hell. She's seemingly crushed by the cold hard weight of pure contingency. And she knows it. She knows she is going to die, that the cancer will ultimately vanquish her. But in that dark moment of impending, irrevocable mortality, she exercises her right to push back against death for the sake of her unmarried grandchildren and whatever else--- one more spring bloom, one more Thanksgiving, one last morning snow in December. Who are we to deny her that possibility?

This goes beyond charges of ageism. It's far more important than that. What we're talking about is a woman's dignity and free will. This was an intelligent, lucent, fully informed woman who has decided etre pour soi to mount one last counterattack against the ravages of time and human fallibility. It's as simple as that. To me, the succor of life is in those moments that challenge our preconceptions of who we really are, that force us to re-assess whom we wish to become. The full life, the life bursting at the seams with effervescence, is the one where one continues to make those big decisions as long as one can, independently, without meekly capitulating to the forces of time and contingency. To see it in a 92 year old woman is not grounds for condemnation; it's a reason to celebrate. To want to live so much, to have such appreciation for the rising of another sun, to thirst so much for the chance to make it all last just a little bit longer.... man it's just beautiful. The minute we start to ration care based simply on someone's age or some other convoluted bureaucratic formula, we start to lose something indispensable about what it means to be a human being, let alone for what it means to be a doctor.

Happy says: "Being 92 and functional is, in my opinion, not a good enough reason to abuse patients in their last few months of life, while we choose to ignore the economic realities all around us."

I feel bad for the guy. He's missing something crucial about being a physician. The "economic realities" of society will plague civilations long after we've all shuffled off this mortal coil. But if we cede the terms of our existence to pure contingency and ignore that powerful force of dasein that lurks deep within us all, then we might as well close up shop now because that's not the sort of world I want my grandchildren to live in.

Anyway, that's what a scrappy 92 year old lady, who will probably be dead this time next year no matter what she does, taught me last week....

Thursday, July 23, 2009

Presser continued....

I missed this. It was near the end of the press conference and I may have been distracted changing Little Buckeye's diapers. But Dr. Wes catches it. Here's our President:
We wanted to make sure that doctors are making decisions based on evidence, based on what works. That's not how it's happening right now. Doctors are forced to make decisions based on a fee payment schedule that's out there. So they're looking... if you come in with a sore throat or your child comes in with a sore throat, has repeated sore throats, a doctor may look at the reimbursement system and say to himself, "I'd make a lot more money if I took this kids tonsils out." Now that might be the right thing to do, but I'd rather have that doctor making those decisions based on whether you need your kids tonsils out or whether it might make more sense to change, uh, maybe they have allergies or something else that would make a difference. So part of what we want to do is free doctors, patients, hospitals to make decisions based on what's best for patient care.

Yeah, that's how the President of the United States thinks American doctors go about the business of medicine. They ask themselves--- "how can I make more money" when trying to make clinical decisions. Because, you know, he read this one article in the New Yorker about it a few weeks ago. That's a good enough reason to disparage the integrity of an entire profession right?

Just an irresponsible, off the cuff load of garbage....

The President's Presser

Pretty weak performance last night, I felt, by our Commander in Chief. If you're going to use the bully pulpit, then you need to bring along some substantive arguments to support what you propose and articulate those arguments in such a way that the public will understand. At the conclusion of the one hour presser, I still don't understand the gist of what Obamacare entails and how it's going to be funded.

It isn't enough to cite anecdotal sob stories about "average Americans" who wrote letters to him about their own personal health care tragedies. Trillions of dollars are at stake. We needed specifics from the President last night and all we got were platitudes and generalities. A missed opportunity indeed...

Wednesday, July 22, 2009

Tough Decisions

Sometimes our medical oncologists will us ask us to place Mediports on their patients ASAP so that chemotherapy can be started promptly. A lot of times my office will just add the patient onto the day's OR schedule and I'll meet the patient for the first time an hour or two prior to the procedure to discuss things. The other day I picked up the chart of a lady who needed a port and the first thing I noticed was that she was 92 years old. I must admit, my first thought was: what the hell are we doing here? She had metastatic breast cancer with lesions seen in her lungs and liver. I was all ready to march into the room and have an honest, heart to heart talk with the patient and the family about futile care and cost effectiveness etc etc.

But I composed myself. Every situation is different. I asked questions. I listened. Her breast cancer had been treated 15 years ago. This was an unusually late recurrence of disease. And the patient sure as hell didn't look like the typical 90 year old I know. She was robust and charming and full of zest. She was one of those old ladies who are always winking at you at the end of sentences. She kept telling me that I'd better not screw up the procedure. Her daughter sat next to her and smiled supportively.

I asked her if Dr X. had gone over the side effects of the proposed chemotherapy. She said yes. She understood it was not going to be easy. But she was ready to endure it. She had two grandchildren who hadn't gotten married yet. Anything to give her just a little more time. She winked again.

Dr X. is a respected oncologist in our community. She had been seeing him for over 10 years. He is an employed Cleveland Clinic doc, so he wasn't going to make any more money based on whether she chose chemotherapy or not. Assuredly this had been a difficult decision for him, recommending such an aggressive course. I was just meeting this woman for the first time. Who was I to presume to dictate to her what was reasonable? She had a long-standing relationship with a physician who undoubtedly was very honest with her about her options. The decision they made, it really wasn't any of my business. The port went in uneventfully.

These are the scenarios we see all the time in the real world practice of medicine. It isn't always cookbook-easy. But who do we want making these sorts of tough decisions: doctors/patients or some faceless bureaucracy in Washington DC that mindlessly follows an arbitrary algorith? Legitimate arguments can be made for both sides...

Tuesday, July 21, 2009

The American College of Surgeons supports HR 3200

Why is Dr. Thomas Russell coming out in support of the 1000 page health care reform behemoth? Has he read it? Is the ACS just trying to upstage the AMA?

It's very simple, actually. Medicare is due to cut physician reimbursement fees next year by 21.5%. This bill averts that. Furthermore, as most general surgeons will attest, any reform package that increases the number of paying customers (i.e. reduces the uninsured) is a win-win situation. You do enough appendectomies and perfed colons at 3 in the morning on self pay patients (that you'll never see a dime out of) and those piddly remunerations from medicare/medicaid start to seem like Publisher's Clearing House jackpots, giant fake check included....

Monday, July 20, 2009

Nancy Pelosi looking out for HENRY's?

We're all aware of the recent proposal to fund Obamacare by assessing a new surtax on the wealthy. Those married couples making more than $350,000/yr will chip in an extra 1% into the health care kitty. Seems fair right? I mean, why shouldn't 1% of the population fund the greatest expansion of federal power since the New Deal? Who needs the $300 billion a year the government could get by rolling back the tax deduction on employer-provided health insurance when you can just squeeze the "rich" a little bit more. Who cares if you raise their effective tax rates to near 50% of their income. Level the playing field dammit!

But here comes Nancy Pelosi, of all people, to the rescue. She wants to increase the threshold to $1 million/yr. Since when did Nancy Pelosi start giving a damn about upper middle class, two income households? Oh, that's right, she depends on rich California liberals for her campaign contributions. I forget sometimes, these people are all corrupt, soulless cretins without any principles whatsoever. It's a dark day when I start cheering for Nancy Pelosi....By the way, what are the odds anyone in Congress actually reads all 1000 pages of HR 3200?

Sunday, July 19, 2009

An old school doc says goodbye to Cleveland

Dr. Jack Rzepka wrote a letter to the Cleveland Plain Dealer that was published in today's Sunday edition. Here's the entire piece:
In these days when general internal medicine is barely extant, I write to say goodbye to my beloved patients, whom I treated for the past 21 years in Cleveland. The first 19 years were in private practice, and for the last two years I have been an employee with the Cleveland Clinic (Southpointe Hospital).

I always tried to do my best for my patients, starting my rounds at 2 a.m. in the hospital and opening the doors to my office at 6 a.m. I did not earn much money compared to my specialist colleagues, but I felt fulfilled knowing my patients were being attended to. I was able to make a living and support my family. Now I am told that, to remain a practicing physician in Cleveland, I must stop seeing one or two patients an hour and see three to four patients instead. This is not something I can conscientiously do, nor do I advise that any complex internal medicine patient be treated this way by a physician or by a mid-level practitioner.

I will move on to Phoenix, where I have secured a position in which seeing one or two patients an hour is still highly valued.

I will miss all my patients here in Cleveland.

Jack Rzepka, M.D., Warrensville Heights

I don't know Dr Rzepka personally. But it seems to me that this is the essence of the problem with American health care. We have committed, selfless physicians like Dr. Rzepka who are not allowed to practice medicine the way it ought to be done, either because of personal financial pressures or pressures brought on by giant, for-profit medical organizations like the Cleveland Clinic.

The more patients you have to see, the less thought, the less effort you can afford to expend on any one patient. So the specialist consult train starts and we never get off it. Next thing you know, all your type II diabetics are being managed by endocrinologists, your chronic GERD patients by GI guys, your asymptomatic anginal patients by cardiologists, with all the attendant excess testing and procedures that come with them.... Good luck to Dr. Rzepka.

Saturday, July 18, 2009

Capitation in Massachusetts?

Megan McArdle at the Atlantic looks at the unforeseen consequences of "universal health care' in the state of Massachusetts. Believe it or not, expanding the public net of coverage has the effect of driving up health care costs. Imagine that. Coupled with the fact that there aren't nearly enough primary care doctors to provide care for the massive influx of new patients, a financial and public-relations disaster is brewing in the old Commonwealth.

So now a commission appointed by the governor is exploring the political feasibility of capitation as a solution. Capitation means that an arbitrary cap is placed on the amount of health care one can receive over the course of a year. Once you hit your limit, you're out of luck. It's an awful proposal, of course, representing the worst of human commodification and rationing.

I find it interesting that when we discuss the issue of cost in the health care debate, everything always boils down to the potential abuses of a fee-for-service system where proceduralists are incentivized to do more, inject more, excise more, radiate more. It is the greedy doctor's fault. And the solution is simply to cap the amount that can be spent on individual patients. Certainly you're going to deleteriously effect a proceduralists income by capitating, but you're also potentially compromising individual patients. What about the diabetic fifty year old who suffers from incapacitating biliary colic, needs her gallbladder removed, but has already exceeded her spending limit just from her expensive medications and other health care needs? Who's going to electively do her lap chole for free, with all the inherent risks?

Peter Orszag et al (along with articles on McAllen, Texas practices) have successfully demonized physicians as the source of the cost problem. But if something is expensive, why in health care do we attribute that cost simply to the utilizers (doctors/patients)? What about the producers who stand to gain the most profit from the current system? Where is the outrage against Big Pharma and the medical equipment industry (Stryker, Medtronic etc)? Why are caps set on the amount of (cheaper) prescription drugs that can be imported from foreign countries? Where is the populist rage about $3,500 MRI's? Could it be that political clout carries the day in contemporary American politics? That it's easier to go after the fractured, disunited physician lobby?

Friday, July 17, 2009

Laparoscopic Gastric GIST resection

This patient, during a routine EGD for epigastric discomfort, was found to have a small submucosal mass in the gastric antrum (you can see it on the above CT if you look closely). A subsequent endoscopic ultrasound suggested that there was some invasion of the muscle layer of the stomach as well. The surgery went well. A combination of endoscopic staplers and laparoscopic suturing closed the resultant gastrotomy. The patient went home on day #3. The final path confirmed a low grade GIST (gastrointestinal stromal tumor) with clean margins.

Laparoscopy for gastric stromal tumors is a reasonable alternative to the traditional open approach. Here's a link to a paper by some smart guys down in North Carolina on the topic. Best outcomes are seen when the tumor is small, has a low mitotic index (i.e. rate of growth), and when the surgical margins are clean. Check, check and check on my guy. He ought to do just fine.

Thursday, July 16, 2009

Diagnosis: Fail

This poor older guy had been going to urgent care centers and ER's over and over for 6 weeks complaining of "back pain". He was diagnosed with shingles. Valtrex was prescribed. One day he passed out at work and was brought into the ER hypotensive and septic. I drained about a gallon of pus from his fluctuant, erythematous, tender back. General surgeons get all the glory....

Sunday, July 12, 2009


Welcome to another tardy edition of SurgeXperiences! It's been a killer week for me so this is probably going to be a little substandard. Apologies will be forthcoming. Operating three nights in a row after 2AM while your partner is out of town will do that to you. So excuse the spelling errors, the fractured syntax, the incoherence, the lack of any semblance of organization. Which seems to fit perfectly in the context of the former Alaskan governor's rambling resignation speech....So here it goes, just follow the damn links.

We'll start with the heavyweights.

Ramona Bates has a nice post on "Sausage Fingers", aka macrodactyly. Here's another on the prevention and treatment of skin tears. I love how she includes a bibliography at the end of all her posts. Such meticulousness is the sign of someone who knows how to close a wound beautifully. The idea of doing that myself, however, causes acute psychic pain.

Bongi had an excellent week of blogging. Grab a Castle Lager, kick back, and enjoy reading this, this, and this.

Old man Sid Schwab re-joined the fray (at least for the time being) with a couple of new posts. He reflects on trauma here and geriatric surgery here. Nice to see him dabbling in the medical blogosphere again.

Bard-Parker gives us his thoughts on Atul Gawande's New Yorker piece here on his blog Cut to Cure.

Over at Make Mine Trauma, our favorite first surgical assistant gives us her thoughts on calling doctors by their first names. I get called Jeff and Dr. Parks. I haven't ever requested one or the other. I respond to both. Whatever you're comfortable with I say...

Dr. Alice
is now a big shot thrid year resident! Read her well written diary-style blog here.

Via Kevin MD, a video on robotic surgery. The cost effectiveness gurus are going to love this robot business! Here's more on robots here from Ducknet.

From Medgadget---- a story about the largest kidney swap, involving 16 patients. Pamela Paulk blogs about the experience (she's donating to a co-worker) here.

Here's a link to a new nursing blog about carpal tunnel syndrome.

Dr. Bruce Campbell has a beautiful post here. A must read.

And you know what? That's all I can do. To all those submissions that were basically glorified ads for nursing schools and fitness instructors..... in the words of the great Alaskan stateswoman, "thanks but no thanks". Which just means I'll probably link to the them in the next Surgexperiences.

I apologize for the half assed effort. It's my third time hosting and I promise the fourth will dazzle you. That's right, dazzle.

Have a great summer.

Monday, July 6, 2009

Profoundly Ignorant

Former Treasury Secretary Paul O'Neill (no, not the unlikable retired New York Yankee outfielder, although both have about the same credibility when it comes to health care reform opinions) has a curious op-ed in the NY Times today. According to Mr. O'Neill, we don't need more entitlements to fund health care reform. The financing solution is simple; just make those damned doctors eliminate all hospital related infections and errors, the bastards!

The president says he likes audacious goals. Here is one: ask medical providers to eliminate all hospital-acquired infections within two years. This is hardly pie in the sky: doctors and administrators already know how to do it. It requires scrupulous adherence to simple but profoundly important practices like hand-washing, proper preparation of surgical sites and assiduous care and maintenance of central lines and urinary catheters. With these small steps, we would no longer have the suffering and death associated with infections acquired in hospitals and we would save tens of billions of dollars every year — money we should have in hand before new health-care entitlements are enacted.

These are the shark-infested waters we swim in these days. We're either greedy or careless. Either way, kill all the doctors (in the revisionist, postmodern Shakespearean rewrite).

Sunday, July 5, 2009

Excuse me?

Here's a good op-ed from Charlotte Allen in the LA Times.

In Barack Obama's June 24th town hall meeting on ABC he was asked by one Jane Sturm, whose 99 year old mother had received a pacemaker and is now thriving at age 105, if consideration ought to be given to a patient's "spirit" for life when making those hard cost effectiveness medical decisions. Here's what he said:
"I don't think that we can make judgments based on people's spirit," Obama said. "That would be a pretty subjective decision to be making. I think we have to have rules that we are going to provide good, quality care for all people."

Um, excuse me Mr. President but that's what doctors do. We make clinical decisions based on a multitude of factors: best evidence, cost, and suitability of the particular patient in question for the treatment strategy. Arguably the most important factor is that human being sitting across from us in the exam room. You cannot divorce the individual patient from the decision-making process. I'll choose to operate on the hale and hearty 85 year old WWII veteran who walks his dog three miles a day over the obese, diabetic 52 year old with a history of angina every single time. Subjectivity is of paramount importance when trying to determine the best course of action. We act on subjective hunches all the time (Mr. X looks "sick", Mrs. Y just "doesn't look right", etc). That subjective clinical judgment develops with experience and time. And those who ultimately acquire it are the ones who make the best doctors; or at least the sort of doctor I want taking care of my family.

Once again, we see the Obama administration trying to railroad through an overintellectuallized, hyperrational alternative to healthcare reform as policy. It's like Obama/Orszag are an elite consulting firm doling out advice on how to streamline operations of an inefficient business enterprise. This isn't a fortune 500 company though. These are real people we treat, gentlemen. Save your models and bureaucratically designed algorithms for the banks and auto industry...

Gawande Responds

Atul Gawande paid a visit to this humble blog the other day to respond to some recent posts I've done regarding his notorious expose' piece in the New Yorker on McAllen, Texas. Here's what he wrote:
As a Buckeye surgeon myself (I grew up in Athens OH), I felt I should respond. I don't actually disagree that the story of what causes overutilization is multifactorial, complicated, and bound to vary from community to community. McAllen's has a strong revenue-driven component. Besides payment incentives, habit and fragmentation of care play a role in almost every community, as well. I agree the malpractice system is a mess too and have written and researched at length on this (although it is a much smaller factor -- nowhere with caps or other restrictions have seen lower cost growth).

But I don't think we in medicine acknowledge the revenue-driven component nearly as much as we should. This is a powerful factor. It reinforces leadership that treats medicine as a business. It also discourages leadership to organize care with greater collaboration and time for patients to produce less overtreatment and undertreatment when such work reduces revenues. Reform needs to reward and protect communities that nonetheless achieve success with lower cost and high quality. I gave a lecture recently at greater length on the value of studying and emulating communities that do this differently: I don't think we disagree on the fundamentals here.

See, isn't nice to be able to collegially exchange ideas and thoughts? The internet sure is neato! Atul, as I suspected, realizes that health care reform is an extraordinarily complex endeavour. The McAllen piece highlights one aspect of the problem; i.e. when physicians have too much financial benefit at stake. In that regard, his piece was a masterful strike, a call to arms to look at ourselves, as physicians, in the mirror. The problem is that our Washington DC health care gurus have desperately latched on to this as the be-all end-all of health reform tactics: go after the greedy doctors! Hence my incessant (annoying?) ranting the past few weeks....

Friday, July 3, 2009

Gawande Rebuked?

For a while there I thought I was the lone voice of dissent on the Atul Gawande New Yorker article which determined that the profligate spending patterns seen in McAllen, Texas was almost entirely due to the "culture of money" that had infected its physicians. In three posts over the past two weeks I have countered Dr. Gawande's deductive leap of faith with an alternative interpretation--- that the etiology of overutilization is instead multifactorial (defensive medicine, patient expectations, lack of thinking, laziness, overemphasis on testing/algorithms in medical training etc.). In response to those posts I basically heard crickets. The viral spread of Gawande's article through the blogosphere and up to the steps of the White House had ingrained the tenets of the article into the national consciousness as the conventional wisdom. I can't tell you how many respected bloggers/columnists I've read over the past month who have called the article "the best piece of health care policy I've ever read". The medical community had apparently already made up its collective mind.

But then I stumbled across a post in the Health Care Blog. The author, Daniel Gilden, does some actual number crunching (rather than make generalized conclusions based on anecdotal evidence) and what he finds is that the patient population of McAllen is the biggest factor in driving up costs. When one accounts for the fact that people in McAllen are fatter and have higher rates of diabetes and heart disease, the difference in spending between McAllen and El Paso or Grand Junction disappears.
McAllen is different from many areas of the United States: it is sicker and poorer. The observed differences in the rates of chronic disease are highest for those conditions rampant in low income American populations: diabetes and heart disease. Further, Medicare beneficiaries in McAllen have significantly higher rates of co-occurring chronic conditions. As a result the costs of caring for McAllen Medicare population appears high in comparison to other areas but not abnormally so. McAllen suffers from a tremendous burden, but it not caused by its physicians: the care they provide leads to costs that are substantially comparable to the other counties in the article once adjustments are made for the magnitude of the health problems they face. The disturbing pattern of physician practices uncovered by Dr. Gawande sounds a warning not because it foretells a McAllen-like future but because it portrays the on-going crisis that affects both McAllen and Grand Junction and it is national in scope. Physician culture is only part of the McAllen story.

Patients with chronic disease, especially those with multiple conditions, are extremely costly to treat. Cost savings will not be realized by denouncing and penalizing medical systems because they treat patient populations with high rates of disease. Instead health care reform must develop policies that support streamlining and coordinating care for beneficiaries with multiple chronic conditions, wherever they reside. Policies that support lifetime continuity of coverage, disease prevention and early treatment, could reduce healthcare costs for populations who now reach Medicare eligibility with a history of under-service. Physician culture has a role to play: Accountable Care Entities are intended to reduce barriers to access by facilitating care coordination. The high costs of care in places like McAllen will not be dramatically reduced by transforming physician ethics and organization if the roots of the crisis are in the interaction between class, demographics and chronic disease.

Amen. Again, there's no doubt in my mind that the Gawande piece (however interesting, well written and provocative it may be) is one of the most dangerous acts of anti-physician propaganda to come down the pipeline in twenty years. We have our President waving it in front of reporters and Congress. Let's at least take 5 minutes and make sure the conclusions reached have a base in reality before we allow our national policy makers to use it as a blueprint for reform, shall we?

Thursday, July 2, 2009

WaPo Inanity

This is just mindboggling. John Bolton (neocon extraordinaire) has an op-ed in the Washington Post today where he advocates that now is the time for a pre-emptive Israeli strike against Iran. Do these people have no sense of shame?
Those who oppose Iran acquiring nuclear weapons are left in the near term with only the option of targeted military force against its weapons facilities. Significantly, the uprising in Iran also makes it more likely that an effective public diplomacy campaign could be waged in the country to explain to Iranians that such an attack is directed against the regime, not against the Iranian people. This was always true, but it has become even more important to make this case emphatically, when the gulf between the Islamic revolution of 1979 and the citizens of Iran has never been clearer or wider. Military action against Iran's nuclear program and the ultimate goal of regime change can be worked together consistently.

That's right, all it's going to take is some sort of mass P.R. campaign (pamphlets? spam mail?) to convince the majority of Iranians that when Israeli fighter planes start dropping bombs on Tehran it's nothing personal--- hey, we just don't like Khanenei! We're on your side!

Yes, this is the same paper that features Charles Krauthammer, refuses to use the word "torture" in reference to the, um, torture organized and implemented by the Bush regime, and that just fired their only left leaning on-line columnist (Dan Froomkin). What a joke. Furthermore, the Iranian people just spent the past 2 weeks courageously rising up against the results of a sham election. The subsequent brutal, totalitarian crackdown has only made the Islamic theocracy more vulnerable and less legitimate in the eyes of its citizens. Unrest continues to foment. And so now is the time to send Jewish F-16's into the heart of Shi'ite Islam????

Zero Sum

Well, it's official. The Obama administration is going to steal from Peter to pay Paul. After months of speculation, the reality is that reimbursement reform will indeed be a zero sum game. From the WSJ:
Under the proposal, Medicare would put specialists' payments for evaluating and managing illnesses on par with those of primary-care physicians starting in January.

That, combined with other changes, would boost payments to internists, family physicians, general practitioners and geriatric specialists by 6% to 8% next year, said the Centers for Medicare and Medicaid Services, the agency that manages Medicare, the federal insurance program for the elderly and disabled.

Payments to cardiologists would be trimmed by 11% overall, but certain procedures they perform would see steeper reductions. Alfred Bove, president of the American College of Cardiology, figured that cardiologists would receive 42% less for an echocardiogram and 24% less for a cardiac catheterization.

Radiologists would see an estimated cut of 20% for imaging services using expensive equipment such as MRI and CT scans, said Bibb Allen, chairman of the commission on economics at the American College of Radiology. That would be in addition to the cuts imposed on radiologists under a 2005 law, he said.

Well it's not a horrible idea. Primary care physicians are certainly undercompensated compared to their subspecialist brethren. They ought to get paid more. Make it financially viable for them to actually spend more than 5 minutes with a complicated elderly patient.

But let's honest about something; these cardiologists and gastroenterologists and rheumatologists are not materializing out of thin air. The radiologists aren't all sneaking into the hospital at night and ordering ridiculous MRI's on all the inpatients. Cardiologists aren't putting ads on Craigslist for cardiac catheterizations. Someone has to order the MRI. Someone is shotgun consulting all the specialists in the hospital. Invariably that someone is the overworked, underpaid internist or family practice doc. So by all means, pay them more. Compensate them in such a fashion that will encourage more comprehensive, individualized care of their patients. But it can't be business as usual. If the reimbursements are going to be shifted toward the primary care docs, then there ought to be a concomitant shift in responsibility for the delivery of care and an increased awareness on the part of the PCP's of the cost of said delivery. No more shotgun consults. No longer ought it to be acceptable to admit patients at three hospitals (running up gargantuan inpatient censuses)in order to drum up revenues and then shunting the responsibility for the care of those patients onto specialists. Pay them more at the expense of consultants/proceduralists? Fine. We've seen this coming. But they're going to have to work harder, not in the sense of longer hours or greater effort, but in the sense of dealing with the practice of actual medicine on their own. That gastroenterologist perhaps isn't going to be as available ten years from now to help you out with that pain in the ass patient with chronic benign epigastric pain. And maybe the general surgeon won't be able to see that patient with a small infected sebaceous cyst stat like before. It sounds nice to better remunerate those primary care physicians who represent the backbone of the American health care system. But it won't come without a cost...

Wednesday, July 1, 2009

Crazier than we ever thought

Todd Purdum's Vanity Fair profile on Sarah "Whackjob" Palin is definitely worth a read. Yes, this woman was nominated by our only opposition party to be a heart beat of 72 year old cancer survivor away from the Presidency.
What does it say about the nature of modern American politics that a public official who often seems proud of what she does not know is not only accepted but applauded? What does her prominence say about the importance of having (or lacking) a record of achievement in public life? Why did so many skilled veterans of the Republican Party—long regarded as the more adroit team in presidential politics—keep loyally working for her election even after they privately realized she was casual about the truth and totally unfit for the vice-presidency? Perhaps most painful, how could John McCain, one of the cagiest survivors in contemporary politics—with a fine appreciation of life’s injustices and absurdities, a love for the sweep of history, and an overdeveloped sense of his own integrity and honor—ever have picked a person whose utter shortage of qualification for her proposed job all but disqualified him for his?

Anovaginal Fistula

An anovaginal fistula is an abnormal communication between the vaginal vault and the anal canal and/or low rectum. There are few diagnoses that cause as much psychological distress and embarassment as an anovaginal fistula. Women present with frequent urinary tract infections, passage of stool when they urinate, and foul smelling, feculent vaginal discharge. Often, there is also a concommitant sphincter injury resulting in fecal incontinence. Patients who suffer from this malady often do not seek medical treatment for years because of the humiliation. Social interactions are compromised. It's a horrible existence.

Anovaginal fistulae are caused by childbirth injuries (such as occur after an episiotomy), cryptoglandular perianal abscesses, Crohn's disease, and malignancies. It's important to define the anatomy prior to definitive treatment. A high rectovaginal fistula (several centimeters above the dentate line in the proximal rectum) usually requires an intra abdominal surgical approach with at least a partial proctectomy. Lower rectovaginal and most anovaginal fistulae are usually more amenable to a transanal approach.

In the CT above, you can see the contrast extravasating from the anal canal to the more anterior vagina (note the thin slip of "white" that connects the two structures). This poor older lady had been suffering from increasingly more debilitating symptoms for years. She hated going out in public. She avoided lunches with her little old lady friends. She kept getting these awful urinary tract infections.

The fistula was easily palpable on digital rectal exam. But I sent her for colonoscopy, CT scan, and cystoscopy to rule out the possibility of an underlying malignancy. The most important factor in determining the optimal surgical approach is assessing the patient's level of continence. An incontinent patient needs a sphincteroplasty in addition to repair of the defect. Fortunately this lady had good sphincter tone.

My approach to a low anovaginal fistula is via a transanal repair. Some OB/Gyns will repair these transvaginally but it makes more sense to me to address the hole from the side of maximal generated pressure. The fistula is identified and granulation tissue is curetted/debrided and then you simply imbricate the circular muscle with interrupted sutures to close it. Then I like to cover the repair with a transanal advancement flap of rectal submucosa/mucosa, mobilized from at least 4cm above the defect. Some have described using well vascularized muscle flaps (bulbocavernosus muscle---Martius flap) to reinforce the repair in cases where the tissues seem a little sketchy. This lady did fine, but long term cure rates run at about 80% for rectal advancement flap repairs....