Thursday, March 31, 2011

Over Treatment

With utter dismay I've been following President Obama's unconscionable usurpation of limitless executive power with regards to the War in Libya. And let us clear: The bombing of Libyan ground targets, the arming of rebels, and CIA presence on Libyan soil (in an advisory capacity, so they say) all represent aggressive acts of war. This is a third war we have now embarked upon in a Muslim country. Absurdly, once again, American missiles are being fired at a country that poses absolutely zero threat to our national security. And this time our Commander in Chief has committed us to war by executive fiat. No congressional approval. No meaningful debate. Not even a symbolic vote by the legislature to at least give the pretense of abiding by the dictates of Article I of the US Constitution. Everything this man campaigned on---- hope and change, the dawn of a post-partisan era, the end of the Imperial Presidency-----all a complete fraud.

I'm no foreign policy guru. I'm not there in the Situation Room. I don't presume to think that my feelings wouldn't be different if I had access to all the relevant information that the national security council has. But such a monumental decision cannot be contingent on personal feelings. It's one thing to help avert a potential slaughter, such as at Benghazi (although such rationale appears to be somewhat arbitrary; otherwise why aren't there bombs raining down in the Ivory Coast, Yemen and Bahrain?) It's quite another to unilaterally assert the right to bomb the bejeesus out of a foreign land. We are not a nation of Great Benevolent Men. We are rather a nation of laws. Believe it or not, even the President of the United States must abide.

I see parallels in this current military overreach with what is happening in healthcare. We spend 30% of a person's lifetime Medicare outlays on care provided during the last year of his or her life. We spent $50 billion of Medicare dollars last year on dying patients' last two months of life. Why are we doing this? Why has that 30% number remained unchanged for almost 30 years? Why do I continue to see consults on demented 89 year olds in the ICU who are intubated and unresponsive and suffering from multiple organ failure? And they linger for days and days. And the chart contains consults from numerous highly trained specialists, all dutifully offering the best that American health care can provide.

Is it greed? In our procedure-oriented, profit-driven health care culture, you eat what you kill. Why spend an hour doing a thorough history and physical examination, talking with family members and concluding that no further treatment is warranted when you can send your PA to do a quick consult, sign her note, and schedule the patient for a lucrative procedure the next day. Are we in Libyan merely to protect Italian oil interests? Are we there just to safeguard British Petroleum investments? Or is it truly a "humanitarian" venture?

Do we do it just because we can? Hey, we have a pulmonologist on staff. That 94 year old is dying of congestive heart failure. Send him down to the ICU, consult the pulmonologist who then orders the patient intubated based on an ABG that the nurse gives him over the phone. Then get the interventional cardiologist involved. And did you know, the hospital just recruited a new endocrinologist. The patient has a blood sugar of 356. Consult the new guy so we can tweak his insulin dosage. And on and on. Similarly, here we are sitting on the greatest military arsenal the world has ever seen. American military spending in 2010 was over $650 billion. That's 7 times more than the second highest national military budget (China). All this ordnance and materiel that, which each passing year, becomes more and more obsolete, necessitating even more spending in the future---might as well use it whenever a vaguely justifiable reason develops somewhere in the world, right?

Is it our arrogance? As doctors, do we presume to be the arbiters of life and death? Has our power to save and extend life been corrupted by an overweening sense of infallibility and righteousness? Has the American Hegemon unequivocally declared itself the Exceptional, Indispensable Nation? Do we truly believe we know what is "best" for every other group of human beings scattered across the expanse of the globe? Has the condescension of the White Man's Burden been passed on to 21st century America?

It's probably a combination of all those reasons, to some extent. Fundamentally something is rotten at the core of our nation. We define things in superficial terms. We demonize with catch phrases and sound bytes--- i.e. "death panels" and "they hate us for our freedom". We dare not look under the surface into the complexity and confusion and unpredictability of reality. We close our eyes to the discomfort of uncertainty and nuance. We would rather wear flag pins and dress up like 18th century New Englanders and sing God Bless America and publish papers on the effectiveness of colon surgery on nonagenarians. Death and decline prey upon us all---individual and nation as a whole. Nothing lasts forever. Clinging to a platitudinous nationalism, a jingoistic pride, a sense of professional omnipotence---these are all forms of an incipient dishonesty that threatens our collective soul. Death and decline are not to be feared. We can't save all patients. We can't rule the world forever. There are limits to human achievement. There is nothing shameful about recognizing futility. It's time we summoned the courage to look a little deeper, to find a sliver of humility through self analysis, and to reconcile ourselves to our ineluctable imperfection in this fallen world.

Tuesday, March 29, 2011

Dentists: Patient Advocates

From the New Haven Independent 3/24:

State dentists could get a monopoly on the lucrative business of teeth whitening pending action by a commission they control.

The State Dental Commission held a hearing in December to review whether teeth whitening should be classified as "dentistry" - a move that would result in the procedure being done only under a dentist's supervision. The commission is set to vote on the issue at its May 11 meeting. If the panel rules that it is dentistry, others who provide the service in shopping malls, salons and spas could be put out of business.

You think this is unreasonable? You think this is just a craven power play by a State Commission to monopolize a lucrative side business flimsily related to dental health? You see a conflict of interest in that the Dental Commission is comprised almost entirely of...dentists? Are you crazy? Just wait till you see what is coming down the pike in other fields:

The American Hand Surgery Commission is considering a resolution that defines all finger nail clipping as "digital-related surgery". Early drafts of the bill would require Americans to obtain finger nail clipper licenses from a Hand Surgeon-approved weekend instructional class. (To be renewed every three years.)

Rumors have it that the American College of Dermatologists are hoping to define the application of any SPF lotion above 30 as "practical dermatology" thereby mandating a visit with your local dermatologist and a prescription prior to that summer trip to the Outer Banks.

Working its way through subcommittees is a resolution from the State Board of Pediatrics that would try to re-classify classic remedies for your kids' colds as "rudimentary pediatric medicine". So no more over the counter Vicks to your kids' scrawny chests. No more TLC. No more ginger ale without a prescription. And the only chicken soup you can administer your kid is the the leftover slop that your pediatrician fed her family the previous night.

The Bariatric Surgery Commission is close to an agreement that would deem any form of exercise as a "bariatric intervention", to be monitored by highly trained obesity specialists. GPS monitors would be placed on anyone with a BMI of over 30 to ensure that nobody obese is moving faster than a crustacean without first seeking advice from a friendly local bariatric surgeon and informed of the harmless, easily tolerated surgical options in the War on Obesity.

Finally, the American Society of Pulmonologists and Critical Care Intensivists is lobbying to regulate the way Americans breathe. It isn't just a gasp or a sigh or a mere inhale. No sirree. Just because you breathe involuntarily doesn't mean that a highly trained sub specialist shouldn't be lucratively involved in your own personal world of O2/CO2 exchange. A mechanism that complex requires close surveillance. If enough votes are garnered, citizens will be forced to see a pulmonologist every 6 months for a full assessment of his or her "respiratory mechanics".

Chart of the Day

Thursday, March 24, 2011

Hedge Funds for Lawsuits

This is awesome. As if there aren't enough shady financial instruments out there for nefarious money making purposes. We now enter the era of the hedge fund- financed medical malpractice lawsuit.

I get it. Mounting a malpractice trial is expensive. You have to spend hours upon hours (at $500-800 per) taking depositions. You have to pay off, er, compensate whores, er, I mean, expert witnesses for their time. For a garden variety med mal case, trial attorneys can expect to spend upwards of 100 grand of their own stash. Given that physicians end up winning 70-80% of med mal cases that go to trial, this anticipated outlay of personal funds prior to a verdict can be somewhat discouraging to the less testicularly fortified litigation firms.

And this is part of the reason why malpractice lawsuits have declined over the past ten years. It doesn't have anything to do with the merits of cases; it's just simply too damn expensive to take a complaint to trial. This is the moral hazard that dissuades too many "frivolous" lawsuits. But it also hurts patients. Patients who have been injured through possible negligence may find that there are fewer firms willing to acept the case.

So what to do if you're a med mal lawyer without a fat bankroll? Contact one of these rapacious "lending firms" to front the costs of the litigation. You then pass the burden of the exorbitant interest payments on to your client. Awesome! So if you win the case, the first chunk goes towards your fee (did you think otherwise?). The second chunk pays off the interest on the loan. And whatever is left goes to the patient/client. And you aren't required by law to inform your client that you have leveraged the costs of the litigation. What a country!

Saturday, March 19, 2011

Yeats for March Madness: Who Goes With Fergus

I forgot to post this on St Paddy's Day. Go Bucks. (And yes, Drackman--- Jim Tressel is an embarassing phony).

Who will go drive with Fergus now,
And pierce the deep wood's woven shade,
And dance upon the level shore?
Young man, lift up your russet brow,
And lift your tender eyelids, maid,
And brood on hopes and fear no more.

And no more turn aside and brood
Upon love's bitter mystery;
For Fergus rules the brazen cars,
And rules the shadows of the wood,
And the white breast of the dim sea
And all dishevelled wandering stars.

Thursday, March 17, 2011

Mr. Obama, What Are You Doing About the Torture of Bradley Manning?

Bradley Manning may have broken the law. He allegedly is the source of the "Collateral Murder" videotape wherein an American Apache helicopter was filmed gunning down innocent Iraqi journalists. But he certainly may have violated military codes by leaking classified information. These allegations warrant an investigation. But Bradley Manning has been held in solitary confinement for 23/24 hours a day for ten months. He is now being forced to sleep nude. He is watched by military personnel throughout the night and is awakened roughly if his face is not visible to the surveillance cameras. Most concerningly, he has yet to be convicted of a crime.

Glenn Greenwald has been an invaluable thorn in the side of the US government's apparent mission to bring down Wikileaks and intimidate whistleblowers who dare to question military/executive branch authority.

His article on what exactly Wikileaks revealed to the world in 2010 is here.

Posts on the inhumane treatment suffered by PfC Manning can be found here and here.

Further embarassing are the brig psychiatrists who are signing off on the forms that deem Manning a "suicide risk", thereby providing the US government with the legal cover to continue its torture of a lowly private. Maybe one day the kid will simply break down and implicate Julian Assange and Wikileaks as co-conspirators. Surely, that's not what our noble, godly military/executive leaders had in mind all along is it??

Why did Manning do it? For money? Because he's a traitor to his country? In his own words:
well, it was forwarded to [WikiLeaks] - and god knows what happens now - hopefully worldwide discussion, debates, and reforms - if not, than [sic] we're doomed - as a species - i will officially give up on the society we have if nothing happens - the reaction to the [Baghdad Apache attack] video gave me immense hope; CNN's iReport was overwhelmed; Twitter exploded - people who saw, knew there was something wrong . . . Washington Post sat on the video… David Finkel acquired a copy while embedded out here. . . . - i want people to see the truth . . . regardless of who they are . . . because without information, you cannot make informed decisions as a public.

Hospital Royalty

This article from the Times did not surprise me in the least. In this era of exponentially increasing health care costs, to an extent that the very solvency of our nation could hang in the balance, we have identified that one sacrosanct budget item that will not go under the knife--- hospital CEO salaries.
At Bronx-Lebanon, a hospital that exists only by the grace and taxed fortunes of the people of New York State, the chief executive was paid $4.8 million in 2007 and $3.6 million in 2008, records show. At NewYork-Presbyterian, a hospital system that receives nearly half a billion dollars annually in public money, the chief executive was paid $9.8 million in 2007 and $2.8 million in 2008.

Is anyone surprised? I know, it's so cliched to begrudge someone what the market will bear to pay them. I'm sure there are manifold reasons for a hospital CEO to pull down 7 figures, even at "non-profit" hospitals. But when you have states chopping Medicaid left and right, when Congress faces an imminent debate on the inevitability of entitlement cuts (i.e. Medicare) in order to achieve some semblance of fiscal sanity, is it altogether justifiable for appointed leaders of non-profits to be so generously compensated?

We live in an age that deifies the famous and powerful. No one blinks an eye when Kendrick Perkins signs a $36 million extension. Tom Cruise's $20 million/per picture demand is met with a collective yawn. Sarah Palin commands 100 grand speaking fees. And now celebrity culture has infected the business world. Wall St. collapses and yet, within a year, all time-high bonuses are handed out to the very same idiots who contributed to the financial catastrophe. We expect our leaders, our winners if you will, to be obscenely compensated. They deserve it. This is the American Dream. This kingly submission to the "winners" in the capitalist game is what ultimately holds the entire house of cards together.

Shifting Appendectomy Consensus

An interesting article from Archives on the optimal treatment of children who present with perforated appendicitis. Previous dogma dictated an initial non-operative approach---- dick around with IV antibiotics, CT guided drains, etc--- and then bring the child back in 6-8 weeks for an "interval appendectomy". This article demonstrates that getting the kid into the OR ASAP leads to better outcomes and a faster return to normal activities.

I've advocated for this approach before. Explore the kid laparoscopically, evacuate any abscess collections, leave a drain in certain cases, and take the damn appendix out. I would even extrapolate from the pediatric population and apply such management to all patients with complex appendicitis.

Saturday, March 5, 2011

The Best

Now that ESPN has been showing more soccer, don't miss a chance to watch Leo Messi play when Barcelona is on during the final stages of Champions League play. He's the best I've ever seen.

Stomach Partitioning

There are two articles in the latest Archives of Surgery that compare different techniques of bariatric surgery in terms of long term efficacy. (If you're interested, the more complex gastric bypass seems to lead to better diabetes control and quality of life compared to other techniques.) One paper was from Taiwan, the other from Wisconsin. I didn't realize Taiwan had such a problem with Chalupas. But it's true, apparently Taiwan has seen an increasing rise in obesity over the past two decades (that's what you get for aligning with America over the Chinese mainland!). Wisconsin, well, that's where all the Cheeseheads are.

But it's amazing to me the number of bariatric papers that get churned out every year by major surgical journals. It's really difficult to read Archives or Annals or JACS on a month to month basis without seeing at least one paper devoted to bariatrics.

Is this a good thing? Is this science on the march? Are we monthly witnesses to the ineluctable forward thrust of the scientific method in human endeavor?

The bariatric lobby has won the war I suppose. You no longer read dissents that question the philosophical nature of the "disease" of obesity and the appropriate steps a society ought to take to remedy it. The more papers they can manufacture touting the efficacy of chopping your stomach up into various new shapes and forms, the more they can avoid the fundamental question of means and skip ahead to ends. Obesity surgery works. But we've stopped asking why obesity exists to such a grave extent. The ontological nature of obesity has been buried under an avalanche of teleology.

Are we so resigned to the epidemic of morbid obesity that we no longer hope to change human behavior or the way we provide food on a massive scale? Have we become passive reactants to a national health scourge, offering only the option of anatomic rearrangement?

I've always felt that bariatric surgery ought to be an esoteric, poorly understood specialty, where patients were only rarely referred due to underlying metabolic or genetic abnormalities. I never thought it would flourish, sustainably, like the way it has. Surgery departments at major tertiary centers all have their own bariatric programs. The casual prevalence of such a development ought to astound us all.

Friday, March 4, 2011

Serena Williams and Anticoagulation Complications

Serena Williams was in the news recently. Apparently she was diagnosed with a pulmonary embolism last week. These typically arise from blood clots in the leg or pelvic veins that break off and propagate into the pulmonary arteries. Patients present with shortness of breath, chest pain, blah blah blah. You can also die from them. I'm not going to spend all morning writing about why you get them; the thought of doing that is excrutiating to me. Google it if you like.

I bring the story up because it sounds like Ms Williams had to undergo an emergency operation this week, several days after the original diagnosis of PE. All the news organizations are writing headlines like "Serena has emergency operation for Pulmonary Embolism". That strikes me as odd. Treatment of PE is typically not a surgical problem. Treatment involves placing one on the blood thinner coumadin for 6-12 months. Because coumadin takes several days to "kick in", a lot of docs will bridge the anti-coagulation therapy with either a heparin drip (inpatient) or subcutaneous high dose Lovenox (can be administered as an outpatient). In rare cases, such as when the patient presents in extremis, an emergency embolectomy is performed via a sternotomy while the patient is on cardiopulmonary bypass. Catheter directed fibrinolysis has also been described as an option for these very sick patients.

So in general, surgical intervention for a PE is a sign of impending doom--- it's unlikely Serena Williams had her chest cracked open. More plausibly, she required invasive intervention for a complication of the anti-coagulation therapy that all patients with PE's are administered. Spontaneous bleeding from the retroperitoneum spaces is a known, not uncommon, complication of lovenox or heparin induced anti-coagulation.

The pictures above demonstrate the extensive retroperitoneal hematoma of a lady I took care of several months ago who had been started on high dose lovenox and coumadin for a heart arrythmia. Initially you try to correct their coagulopathy and transfuse packed red cells because most of these spontaneous bleeds will eventually tamponade. This lady kept bleeding. I think she received something like 12 units of packed red cells, 10 units of plasma, and several transfusions of platelets and cryoprecipitate. Furthermore, the massive hematoma was starting to compress the right kidney, leading the renal consultant to believe that its very viability was compromised.

Reluctantly I took her for surgery. These aren't fun surgeries. Outcomes are generally pretty poor. Often, you never pinpoint the source of bleeding. You just scoops giant handfuls of gelatinous purplish-black clot into shiny metal bowels, coat the raw surfaces with thrombin/topical clotting agent and hope things don't get out of control. For some reason, just evacuating the hematoma can help halt the death spiral of sustained fibrinolysis that evolves in the setting of large in-situ clots. Anyway, she did allright and went to a nursing home.

Thursday, March 3, 2011

The "Tyranny" of the Open Breast Biopsy

I found this article via the NY Times. A Florida study assessed the rate of needle versus surgical breast biopsies over a period of five years. What we're talking about here are non-palpable abnormalities that are identified on screening mammography. A mammogram report will come back that assesses the relative risk of an abnormal collection of calcifications harboring an invasive or pre-invasive cancer (staged on a scale from I-V). With such data, one is obligated, as the patient's advocate, to prove whether or not the mammogram represents true or false positive findings. This means doing a biopsy.

Two ways to go about clarifying the cancer/no cancer conundrum: A needle biopsy is scheduled in the department of radiology. The interventional radiologist uses the stereotactic images to advance a specialized needle into the midst of the concerning area and subsequently vacuum aspirate several "cores" of tissue. The technique is not without complications, but is generally very well tolerated without the complications seen from surgical biopsies (bleeding, infection, unsightly scars, etc). The sensitivity approaches 97-99%. A negative needle biopsy, although reassuring, still demands that close follow up is necessary, i.e. re-imaging of the breast within 3-6 months.

The open biopsy is a surgical procedure. And it involves two phases. One, a woman has to go to the radiology suite for directed placement of a wire such that the tip resides in the hot zone of concern. She then is wheeled to the surgical area where she is sedated and anesthetized. The surgeon then makes a 2-5 cm incision in the skin and excises a lump of breast tissue containing the area of concern, using the pre-placed wire as a guide. She goes home the same day. Bleeding and infection complicate 1-3% of these procedures. Sensitivity is 100% and, if a cancer is confirmed, phase one of treatment has already been accomplished (excision of tumor).

This is the conversation, along with the options presented, that surgeons across the country have with patients who are referred to us with an abnormal mammogram. According to the paper cited above, 70% of women opt for the needle biopsy approach, while 30% are undergoing open surgical excision. My personal feeling is that it's always better to start small/less invasive and expand the armamentarium as needed. Acording to the authors of the paper, and other leading light Breast Surgeons, the idea that 30% of breast biopsies in this country are being done via the open approach is a miscarriage of justice akin to the 30 year torture/dictatorial regime of Mubarak in Egypt. (Seriously, some eminent scholar of supreme reknown named Melvin Silverstein, breast surgeon extraordinaire in California, actually compared lowering the 30% open biopsy rate to the recent uprising in Egypt to overthrow Mubarak. I'm not kidding.)

The study found that the open biopsy rate of Academic Breast Surgeons was about 10%. Private practice general surgeons conversely performed open biopsies 37% of the time. The discrepancy was attributed to several factors--- lack of knowledge by podunk non-academic surgeons, and pure greed being the main ones. Because, you know, if a surgeon refers a woman to a radiologist for biopsy of a suspicious lesion, then s/he loses the cost opportunity for an open excision. Only the holy white tower of academia prepares one for a surgical career free from financial incentive, didn't you know?

I love this passage from the NY Times article, again from the esteemed Dr Silverstein:
One way for hospitals to stop excess open biopsies is to ban them, Dr. Silverstein said, unless they are truly necessary, as in uncommon cases in which a needle cannot reach the spot.

“We made a rule,” he said. “If it can be done with a needle, it has to be. We embarrass you if you do an open biopsy. We bring you before a tumor board to explain.”

What a tool. Hey Dr Silverstein guess what? Not every freaking surgeon who takes care of patients with abnormal mammograms lives within two seconds of a giant tertiary care center with experienced, reliable interventional radiologists and pathologists available at all times. We don't all spend our Tues and Thurs morning sipping coffee for three hours in multidisciplinarian breast oncology conferences. Some Americans actually live in the rural midwest and sparsely populated western plains. Furthermore, surgeons who do fewer breast biopsies per year than a dedicated breast oncologist will have inflated stats if a few patients opt for the open approach. Also, some women actually prefer the option of surgical removal. Even if the needle biopsy is negative, the lesion may still show up on a subsequent follow-up mammogram. The report may call it "suspicious" or maybe it will be down- graded to "close follow up recommended". Either way, she must continue to live with it, knowing she harbors something "not quite right", albeit almost assuredly benign, in one of her breasts. Some women, believe it or not, just don't like to have to carry around that secret knowledge. Some women stop you short when you get to discussing the minimally invasive options: "just take it out", they say.

Again, I am a strong proponent of stereotactic needle biopsies for the initial assessment of a concerning mammographic lesion. But this pompous posturing by some in the field of academic breast surgery is simply intolerable. Non fellowship trained surgeons who perform lumpectomies and mastectomies are fully capable of staying up on the medical literature. We are adept at following best treatment guidelines. You don't need a special little framed fellowship certificate on your wall to have an informed, back and forth conversation with with a patient in a very vulnerable position.

Wednesday, March 2, 2011