Ortho Corruption

This story about orthpedic surgeons not disclosing financial ties to the medical device manufacturers in their scientific papers is nothing new. Lack of transparency plagues the medical literature, especially in lucrative, product-driven fields like ortho and cardiology. What struck me were two points.

One, over half of orthopods who accepted over a million dollars from device companies in 2007 did not disclose this information in articles they published in the subsequent year. That's astounding. And illegal according to anti-kickback laws.

The medical device industry's practices were so flagrant that they prompted an investigation by the Justice Department. Indeed, the payments reported in the new study appear in Internet listings set up by five big orthopedic device makers — Zimmer, DePuy Orthopaedics, Biomet, Stryker and Smith & Nephew — as part of a September 2007 settlement that capped a federal inquiry of company kickbacks to doctors. Zimmer, DePuy Orthopaedics, Biomet and Smith & Nephew also paid the government $311 million in penalties.

Secondly, the amount of money is just staggering. The study from Archives of Internal Medicine indicates that 41 orthopods were paid a total of $114 million, with pay outs varying between $1-$8 million to each surgeon. My God, I chose the wrong specialty.

The good news is that there is some law that will go into effect in 2013 whereby a government database will keep track of doctor gifts/payments of more than $10 bucks. So we have that going for us. Which is nice.

Get Rid of the 4th Year of Med School

A poorly kept secret amongst recent med school grads is the fact that the last year of medical school is a complete joke and waste of time. Most 4th years will do rotations in July and August in the specialty they hope to match in, for the purpose of cozying up to attendings for recommendation letters. But after that, it's a 6 month vacation until match day. I did a surgical ICU rotation in July and then followed that up with a stint on cardiothoracic surgery. I spent the rest of the year half assing my way through rotations like radiology, anesthesiology, and pathology case studies. Most days I got to the gym around noon for a 4 hour session of pick up hoops. And oh yeah, I borrowed about $35,000 to finance that lifestyle.

There are two main reasons to reorganize medical school education along the lines of a three year program. One, it's a waste of loan money and squanders a year of earning potential. Two, it just may be a contributing factor in driving more students out of internal medicine, primary care, and general surgery.

Let me explain. If you eliminated the fourth year, students wouldn't have the oportunity to rotate through subspecialties like dermatology and radiology and cardiology and orthopedics. Hence, less chance to be brainwashed into thinking that general medicine and surgery were beneath them. The third year curriculum would expand the exposure to internal medicine and general surgery and family practice. Someone who really really wanted to do a cardiology rotation could do so, but would have to eliminate either OB/gyn or psychiatry. As it is now, the entire fourth year is built around the idea of winning praise from subspecialist academic physicians. Is it any wonder that medical students look down upon the "mere generalist" professions?

NSQIP Appendicitis Data

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database has yielded some great ammunition to my preferred side in the ongoing open/laparoscopic appendectomy (OA/LA) debate. In this paper, over 17,000 cases of appendicitis were reviewed from 2008. Interestingly, over 14,000 of the appendectomies were performed laparoscopically, indicating a sea change in OR strategy on a wide scale. Pertinent findings:
*Shorter OR time for LA
*Lower incidence of superficial and deep surgical site infections with LA
*Shorter hospital stay for LA
*Significantly lower mortality in the LA group

Finally, the surgical literature is catching up with the facts on the ground. For the life of me, I just don't understand why any surgeon would want to make a McBurney incision anymore.

Surgical Buy In

Pauline Chen had a post in the Times last week about surgical informed consent. Informed consent is an important part of the surgeon/patient communication transaction. Surgeon reviews the proposed operation, the rationale behind it, and the possible complications. For example--- a patient comes in with biliary colic. We describe the anatomy and pathology. We aver that surgical resection will lead to cure. The operation (laparoscopic cholecystectomy) is described in detail. Potential complications are addressed (bile leak, CBD injury, bleeding, infections, cardiopulmonary morbidity, etc.) Patient is informed that although complication rates are low, there is still a statistical probability that her procedure will encounter such problems. Given all this information, patient then decides what she ultimately wants to do. Informed consent.

Dr. Chen talks about this concept called "surgical buy-in" where the patient is prepared for worst case scenarios prior to the operation. When a case goes bad, we surgeons have a tendency to implement the full court press, whereby we try anything and everything to get our patients back on course, even when the situation begins to look futile. It's our ingrained sense of responsibility and duty to try to reverse the deterioration. But sometimes these last gasp maneuvers are not what the patient would have wanted.

There's an article in Critical Care Medicine from March that talks about this buy in. For complex elective operations (Whipples, liver resections, transplants, rectal surgery) surgeons would negotiate with patients prior to the surgery the extent to which both the surgeon and the patient were willing to labor if things took a turn for the worse. In other words, the surgeon would say something along the lines of: "If you leak from your pancreaticojejunostomy and get septic would you be willing to be reintubated? Taken back for revision? If you were unable to be weaned, would you consider a tracheostomy? What about CPR? Is there a time limit you would restrict aggressive intervention to, i.e. if you weren't improving by 6-8 weeks of intensive therapy, then palliative measures would be undertaken?"

It's a great idea. As long as we restrict the protocol to those complex operations. I'd hate to put my patients through such a terrifying question and answer session prior to a lipoma excision or a breast biopsy.

Obstetric Trauma on Healthbeat

An interesting thread developed last week at Maggie Mahar's Healthbeat blog regarding a guest post by one Jordan Grumet, an internist in Chicago, writing about an experience he had while a medical student rotating through OB/gyn.

He writes about a patient in the third trimester of pregnancy who arrived in the trauma bay bleeding profusely from a stab wound to the neck. As the trauma team fought to control the bleeding, Grumet's chief resident donned a gown and grabbed a scalpel. The woman's blood pressure dropped. The fetal monitor showed deccelarations in the baby's heart. I'll let Dr. Grumet describe the rest.

My chief cleared her throat: "Okay, guys, we're gonna lose the baby if we don't do something fast!"

Without taking his eyes from the patient, the trauma surgeon said authoritatively, "We can't. If you cut her, she'll die. Give us a minute."

"It will take a minute-and-a-half to have this baby out," said my chief. She got no answer.

She stood poised over the patient's abdomen, arm raised, scalpel in hand and ready to pounce.

The patient's blood pressure dropped even faster, and the baby's heart rate plummeted.

"It's now or never," said my chief. Then the cardiac monitor began beeping.

"Ventricular fibrillation!" The ER physician grabbed the cardiac paddles and shouted, "Clear!"

With a sweep of his arm, the trauma surgeon moved everyone away from the table, then stepped back--and crashed into my chief. She fell to the floor, extending her arm to avoid slashing anyone with the scalpel.

Dramatic, no? I especially like the image of the resident bravely controlling the scalpel so as not to "slash" anyone as she toppled to the ground. The writers on ER couldn't have scripted a better scene.

My initial comment on the post was this:

I work as a trauma attending. In obstetric trauma, the mother always takes precedence----the single biggest determinant of fetal survival is mother survival. This is Trauma Surgery 101. Once the mother progresses to unsalvageability, there is some evidence to suggest that post mortem delivery of the baby can lead to meaningful survival, albeit at meager rates of success.

Maggie Mahar responded by averring that such guidelines "must be a mistake". I then posted a second comment, politely reminding her that simply disagreeing with the evidence based, algorithmic approach to major trauma purely on emotional grounds is not a credible argument. I even posted a power point presentation I give for CME at one of my hospitals on obstetrical trauma. Pay particular attention to slide #15.

Maggie then posted a final comment where she basically just reiterated her contempt for established trauma practice. She gave no indication that she reviewed any relevant literature or even the power point link that I provided.

If the mother is hypotensive, the baby also is not getting enough blood flow. Hence oxygen exchange is compromised at the placental level. In layman's terms, if the mother is unstable, the baby is in just as much trouble. The fastest way to improve a baby's condition is to make the mother better. Maggie is seemingly unaware of the fact that a c-section requires an actual incision in a mother's belly. Furthermore, anticipated bleeding from a c-section, even in ideal circumstances, is generally expected to be around a liter. So not only would trying to perform a c-section in a hemodynamically unstable, actively bleeding pregnant woman be negligently unwise, it would arguably venture perilously close to the realm of criminal assault.

Maggie Mahar does great work analyzing the intricacies of health care policy and reform but in this particular post she has written irresponsibly. If you're going to use a wide platform like Healthbeat to write about actual medical practice, then you have a journalistic obligation to do so in a much less capricious fashion.

Sunday Quote

Every summer vacation I re-read the Meditations of Marcus Aurelius. It always reinvigorates my heart and prepares my mind for the inexorable vicissitudes of life. A few choice selections:

"Adapt yourself to the things among which your lot has been cast and love sincerely the fellow creatures with whom destiny has ordained that you shall live."

"Loss is nothing else but change, and change is Nature's delight."

"What more do you want, man, from a kind act? Is it not enough that you have done something consonant with your own nature- do you now put a price on it?"

"When you arise in the morning, think of what a precious privilege it is to be alive--to breathe, to think, to enjoy, to love."

"Remember that man’s life lies all within this present, as it were but a hair’s-breadth of time; as for the rest, the past is gone, the future yet unseen. Short, therefore, is man’s life, and narrow is the corner of the earth wherein he dwells."

"Each of us lives only the present moment, and the present moment is all we lose."

"The soul is dyed by our thoughts."

"Perfection of character is this: to live each day as if it were your last, without frenzy, without apathy, without pretence."

Bucks Roll

Just for Drackman.

Quote of the Day

"A democracy cannot exist as a permanent form of government. It can only exist until the voters discover that they can vote themselves largesse from the public treasury. From that moment on, the majority always votes for the candidates promising the most benefits from the public treasury with the result that a democracy always collapses over loose fiscal policy, always followed by a dictatorship. The average age of the world's greatest civilizations has been about 200 years. These nations have progressed through this sequence: From bondage to spiritual faith; From spiritual faith to great courage; From liberty to abundance; From abundance to selfishness; From selfishness to apathy; From apathy to dependence; From dependence back into bondage." - Alexander Fraser Tytler.

(h/t Daily Dish).

Update: Joe Sucher has informed me that the provenance of the above quote is in dispute. See the wikipedia article on the author for the details. Anyway, I thought it was a good quote.

Anachronistic Specialties?

The NY Times has jumped all over a couple of recent scientific articles asserting that certified registered nurse anesthetists (CRNA's) provide equivalent care as MD anesthesiologists. Already, it is legal in 15 states for CRNA's to dispense anesthesia without the overarching supervision of a physician. Furthermore, a study from the Lewin Group in California has demonstrated that CRNA-only models of anesthesia provision are far more cost effective that our current dual profession paradigm.

In the long run, there also could be savings to the health care system if nurses delivered more of the care. It costs more than six times as much to train an anesthesiologist as a nurse anesthetist, and anesthesiologists earn twice as much a year, on average, as the nurses do ($150,000 for nurse anesthetists and $337,000 for anesthesiologists, according to a Rand Corporation analysis). Those costs are absorbed by various institutions and public programs within the health care system.

This is a fascinating debate. And I expect MD anesthesiologists to fight for their interests tooth and nail.

To some extent, MD anesthesiologists have become a victim of their own excellence. Deaths during the administration of anesthesia occur at a paltry rate of 1/250,00 cases nowadays. This remarkable improvement can be attributed solely to technical improvements in the monitoring of patients during a procedure. Things like continuous pulse oximetry, end tidal CO2 monitoring, and fiberoptic-based intubation equipment have almost completely eliminated major morbidity from the profession. This is a good thing. But maybe not so good for anesthesiologists. They practice in a very algorithmic, checklist-based manner. Thus, it was relatively easy to teach their methods to CRNA's during a period when the exponential rise in operative case loads made it necessary to incorporate "anesthesiology assistants" into a practice, thereby allowing one attending physician to cover multiple rooms. That recent studies have confirmed what everyone else in the OR already knew---that it didn't really matter who was behind the drape while a cholecystectomy was ongoing---- is hardly a surprise. The less variability in clinical excellence one sees from certain specialists, there seems to be a commensurate decrease in perceived prestige. In other words, one's individual reputation as a doctor can be paradoxically harmed when the overall complication rate of your chosen specialty is so low. You are seen as a mere "cog in the machine", a cog that could easily be interchangeable with another doctor or, in this case, a CRNA.

Anesthesiology represents the easiest target. But don't think that the other specialties are exempt from possible onslaught. The more specialized we become as doctors, and the less we emphasize and reward doctors who focus on a holistic approach to medicine (primary care, internists, general surgeons) the easier it becomes for the federal government to replace those pricey specialists with back door, non-MD options who happen to be much less expensive. Imagine an "certified orthopedist" training program that one could enroll in directly out of college with a bachelors of science. You then spent the next three years doing nothing but learning musculoskeletal anatomy/pathology and practicing the basic orthopod operations in virtual reality and on actual patients. Perhaps actual orthopedic surgeons could be enticed to head up such a training program so that these ortho technician graduates learned their techniques from the best. Further imagine that research papers would be published demonstrating equivalent outcomes no matter who performed your knee replacement, MD or ortho technician.

It isn't difficult to see where all this is heading. The cost of healthcare must be controlled to prevent bankrupting our country. Medical school graduates overwhelmingly opt out of primary care and internal medicine. If you can't force or entice our brightest students to stop applying for derm and ortho and radiology residency slots, then maybe you can at least give them a little competition for that business from non-MD sources....

No Surprises

In the most unsurprising development of health care reform----the Obama iteration that awkwardly tries to fuse private and public coverage plans, thereby preserving the billion dollar health care "insurance" industry---- it has become apparent that the increased costs employers expect to pay for health care have simply been passed on to its employees.

Since 2005, while wages have increased just 18 percent, workers’ contributions to premiums have jumped 47 percent, almost twice as fast as the rise in the policy’s overall cost.

Workers also increasingly face higher deductibles, forcing them to pay a larger share of their overall medical bills. “The long-term trend is pretty clear,” said Drew E. Altman, the chief executive of the Kaiser foundation, which conducted the survey this year with the Health Research and Educational Trust, a research organization affiliated with the American Hospital Association. “Insurance is getting stingier and less comprehensive.”......companies expect that their costs will only go up more under the new health care law because it requires them to provide more benefits, like coverage for preventive care.

Unbelievable isn't it? Who would have thought that for profit entities would do everything in their power to stay in the black. Given the choice to pay the higher health care costs out of a healthy profit margin versus freezing employee wages and earnings, it's hardly surprising that the private sector opts for the latter.

Simply mandating that companies pay for health care without articulating a method of subsidizing it or controlling the escalating cost of health care provision (beyond vague, unspecific programs like the Independent Payment Advisory Board) is not a viable long term solution to the crisis. That is the failure of Obamacare.

Cool Labor Day Tune

Have a great weekend...... LCD Soundsystem.

Making it Easier to Sue!

Rumors abound of a plan to revise the federal tax code in such a way that will benefit those poor, struggling plaintiff's attorneys. A bill introduced by Arlen Specter, currently being bandied about Congress, would allow personal injury lawyers to deduct costs accrued during the pre-trial and trial phases of a claim.

Previously, in contingency cases, attorneys would have to front the costs of a major case themselves, and then hope to recoup that investment with a jackpot jury award. This risk assumed by the personal injury lawyer acted to curb the number of frivolous lawsuits submitted. Allowing the lawyers to deduct these costs shifts the financial burden onto the federal government to some extent. Moral hazard is enjoined.

From the Washington Legal Foundation's Walter Schwartz:

If Senator Specter’s proposed modification of the Internal Revenue Code succeeds, the federal government will, for all intents and purposes, share in the cost and risk of bringing the initial litigation. Under current and certainly potential future tax laws, this could be as much as 40% of the cost of bringing litigation.

That's just fantastic.