Christie Gets a Band

I had blogged a while ago about New Jersey governor Chris Christie's angry response to a former White House physician's opinion that he needed to think about losing some weight.  Christie basically told the doc she needed to mind her own business.  My take was that, morbid obesity being a risk factor for coronary artery disease, stroke, and early death, Christie's weight would be a issue I considered if and when he decided to run for the Presidency in 2016.  In order to be reassured that he could withstand the stress and pressure of being the leader of the world's only superpower, I indicated that I would need to see recent stress test/cardiologist bill of good health records before I even considered casting him a vote.  The blog was cross posted at KevinMD and subsequently set off a firestorm of conflicting opinions.  Many commenters felt strongly that it was a form of bigotry to even mention his weight when considering him for higher office. 

Again, I have no doubt that an obese person could be an excellent US President.  But I would be more likely to vote for him if I knew he wasn't necessarily a ticking time bomb for a major heart attack.  And publicized stress test results (just as melanoma survivor John McCain published his records from his oncologist when he ran for office in 2008) would go a long way in setting my mind at ease.

And now we find out that Mr Christie recently underwent Lap-Band weight loss surgery.  Why would he do such a thing?  I thought obesity was irrelevant to the discussion of higher office?  According to the governor:

 “For me, this is about turning 50 and looking at my children and wanting to be there for them."
 

I see.  Sooooo, weight loss is.....good?  I don't want to be a bigot. 

But why did the dude get the Lap-Band?  Doesn't he have a coterie of advisers and lackeys?  The Lap-Band results in less long term weight loss than a gastric bypass and the complications/annoyances that develop over the long haul with the Bands often necessitate their eventual removal. 

Anyway, best of luck to the Governor in in weight loss endeavors.

Defensive Medicine and the Drone Wars

From my interview with Andrew Thompson the other day, the issue of a medical malpractice crisis was raised.  Mr Thompson averred that such a concept is pure myth, a spook story older docs tell young interns around the campfire at night.  And he may be right.  In a paper from the Journal of Healthcare Quality, researchers at Johns Hopkins demonstrated, using data from the National Practitioner Data Bank, that "catastrophic claims" (those awards in excess of $1 million) totalled about $1 billion per year, a figure that represents just 0.05% of total national healthcare spending in this country. 

Now one could retort that "catastrophic claims" account  for only 36% of total claims over the time period (unduly neglecting the effects of smaller claims up to $1 million) or that the study doesn't include the settlements made with hospitals and healthcare corporations, only individual physicians.  But the data are eye opening nonetheless.  Total number of med mal cases have been dropping precipitously over the past ten years.  The costs of waging a medical malpractice case are prohibitive for most law firms (discovery, expert witnesses, contingency based fees, physicians win 70% of cases that go to trial, etc).  So why is tort reform still the linchpin piece of alternative national healthcare reform plans?  Why do the GOP and physicians organizations continue to shout from the rooftops that medical malpractice represents the single biggest threat to American healthcare?  Why has the refutable become dogma in the minds of otherwise intelligent people?

World Class

This is what can happen when a private practice surgeon refers a complicated colon cancer patient to a medical oncologist affiliated with a certain multinational, gigantic world-famous non-profit health care system.

Let's say the surgeon is asked to see a patient with a large bowel obstruction.  Perhaps the colonoscopy demonstrated a high grade constricting lesion in the distal sigmoid/upper rectum and the CT scan revealed a massive, locally infiltrating mass invading into the bladder and a possible liver lesion.  Perhaps the patient has lost 30 lbs recently and has noted foul smelling material in her urine.  The surgeon is concerned about diffuse tenderness on exam, possibly due to impending cecal ischemia.  He books the case for the OR and curbsides a med oncologist on treatment options.  Should I just divert?  Would there be a role for neoadjuvant chemoradiation?  Or best to just try and resect now with possible pelvic exenteration?  The med onc guy isn't too certain.  Whether there is liver involvement or carcinomatosis is key.  But no time to determine that now given presence of an acute abdomen.  He thinks the case ought to be presented to the tumor board and perhaps a multidisciplinarian consensus could emerge.  The surgeon thinks this seems reasonable.  He performs a laparoscopic diverting colostomy and places a mediport.  CT guided liver biopsy is scheduled as an outpatient.  She recovers from the surgery and is discharged home.  Her instructions are to follow up with a med oncologist from the world-famous healthcare conglomerate close to her house, in addition to seeing the surgeon. Arrangements are made for the case to be presented at next week's tumor board.  Patient's parting words to surgeon are: whatever you guys decide, I want you to do the surgery.  I trust you

Gitmo Force Feedings

In response to over a decade of indefinite detention without charges or trial, with no foreseeable hope of ever being repatriated home, with no hope of ever seeing wives and children again, over 100 inmates at the American Gulag in Cuba are now participating in a mass hunger strike.  Of the 100, our medical personnel in Guantanamo are now force feeding 21 of them using silastic nasogastric tubes.  (The above image is the chair at Gitmo used to restrain prisoners while the tubes are forcibly inserted.)

The American Medical Association (AMA) has again gone on the record condemning the practice of forced feedings.  In a letter to Defense Secretary Hagel, AMA President Dr. Jeremy Lazarus wrote:

  “Every competent patient has the right to refuse medical intervention, including life-sustaining interventions,” Lazarus said, adding that the AMA took the same position on force-feeding Guantánamo prisoners in 2009 and 2005.

“The AMA has long endorsed the World Medical Association Declaration of Tokyo, which is unequivocal on the point: ‘Where a prisoner refuses nourishment and is considered by the physician as capable of forming an unimpaired and rational judgment concerning the consequences of such a voluntary refusal of nourishment, he or she shall not be fed artificially.’”

Interview with the Lawyer

My interview series continues, this time with local vampire litigation attorney Andrew Thompson, Esq.  The topic this time is medical malpractice.  I asked him a bunch of questions.  He answered.  See what you think. 

Background on Andrew Thompson:

I attended Syracuse University Newhouse School of Journalism, transferred to CWRU and received a BA in Political Science in 1996. I obtained my J.D. from CWRU School of Law in 1999 and passed the Ohio Bar Exam. In addition to Ohio, I have handled cases in courts in Pennsylvania, New Jersey, Florida, and West Virginia.

I was an Associate at Chattman, Gaines & Stern in Cleveland until that firm dissolved in 2001. I moved with a partner from CG&S to Stege & Michelson Co., LPA, and became a partner at that firm a few years later. In October 2010, I left that firm to start a litigation firm in Beachwood -- Dubyak Connick Sammon Thompson & Bloom, LLC. The firm has a focus on litigation, and my practice concentrates on railroad law, labor/employment and personal injury matters mostly from the plaintiff’s side, including medical malpractice. Every firm that I’ve worked at has handled medical malpractice cases.

#1: In your opinion, is there a medical malpractice crisis in this country?

No. This is not even a close issue. The concept of a “crisis” or dramatic increase in the number of medical malpractice cases is a fabrication created by the U.S. Chamber of Commerce and the insurance industry. High-priced public relations firms have been hired to disseminate this message to the general public to generate support for tort reform bills. For the most part, the effort has been successful. The average person firmly believes there is a crisis, and tort reform bills have been passed in many States, including Ohio in 2003.

Complications and Profits

This paper from JAMA had the health blogosphere in a tizzy recently.  The Boston Consulting Group reviewed surgical discharge data from a 12-hospital system in the southern US to see if there was a "relationship" between surgical complications and hospital profits.  Their findings were obvious and unsurprising:

When a privately insured patient experiences one or more complications -- such as blood clots, stroke, infection, septic shock, pneumonia or cardiac arrest -- hospitals' profit margins are 330% higher compared to a patient with no complications, the report found.

For Medicare patients with complications, hospitals' profit margins are 190% higher, according to the report...
 

So if a patient develops a medical condition that requires further medical treatment with utilization of resources and involvement of other specialists then we are supposed to be astounded that the resultant costs will be higher?  This may sound controversial but who cares?  Why is this an issue? The problem is being painted as one of doctors expecting to be paid for doing the hard work of managing a surgical complication.  Complications are part of medicine, especially surgery.  A major part of what makes a good general surgeon is his ability to manage a difficult case, including the judgment as to when to return a patient to the operating room.  Anastomotic leaks in Crohn's patients on steroids will happen.  Bile leaks from the liver bed will occur at a fairly regular statistical probability.  Old ladies who undergo major abdominal resections will develop post op pneumonias despite the best preventative measures.    Sometimes you have to try to make a chocolate cake out of mud and stones.  You do the best you can.  Success is not measured in terms of cost overlays but as to whether or not you can get the patient from the ICU to a rehab bed in a safe, timely fashion.      

Barry Rosenberg MD sort of tip toes around the implications:

Hospitals make more money the longer a privately insured or Medicare patient stays, said Rosenberg, a partner with BCG's health care practice. As a result, they may lack financial incentives to take steps to reduce surgical complications, he said. 

 "Insurers are rewarding hospitals when there are complications," he said. "This is not the type of incentive you want ... in the healthcare system for your family."
 

So what do you mean by that Barry? 

MRCP: Stop Already.

A typical general surgery scenario plays out like this.  Patient comes into ER at 1AM with RUQ pain, gallstones on US, elevated WBC and mildly abnormal LFT's.  The patient is admitted, hydrated and started on antibiotics with the plan to re-assess in the morning.  I see my ICU patients, do a 7:30 case and then check the overnight admit's morning labs.  The WBC is now normal and the bilirubin is slightly improved (down to 1.4 from 1.9).  I go to see her but she's gone.  I query the nurse.  Nurse says she's off to MRI.  I sit down in patient's room, watch TV for a bit, perhaps eat one or two of the sausage links off the plate of her sleeping roommate.  No, I don't do that.  I just go drink some more sour free coffee and see other people, silly.

I tell the nurse to text page me when she gets back.  She does so.  I race back between cases.  The patient "feels much better".  Her abdominal exam is rather unremarkable.  We shoot the shit for a while re: biliary pathophysiology (involving crudely drawn anatomic diagrams on the back of patient satisfaction survey forms; I like the way I draw the stomach but my gallbladder/biliary ductal rendition looks rather like the way a kindergartner would draw equine procreation).  There's an opening in the afternoon.  She doesn't want to ever experience the sort of pain she had last night.  I commiserate.  I can imagine, I say,  although I can't, having never experienced a gallbladder attack myself so to reproduce empathy I imagine that one time I spilled lye on my leg working at a metal treatment plant in the summer and the lye ate through my jeans, my epidermis, the dermis and bits of the subcutaneous fat.   

Ten Years

The picture above is from the height of the Iraqi insurgency in 2006.  Click on the picture and magnify it.  What it shows is a dead boy, 3 years old perhaps, with half his head blown off after an American raid in Baghdad.  The flap of translucent scalp catches the sun's rays.  His grandfather carries him from the morgue.  All of us have an obligation to spend a few minutes staring at that picture.  It is one of thousands.   

This is what we did.  That was a child we exterminated.  WMD.  Liberate Iraq.  The one true incontrovertible crime of the 21st century so far.  Aggressive war.  Pre-emptive war.   False pretences.  It has been ten years since we charged into disgrace.  Perhaps this ought to be a time for national reflection and collective shame.....   

Robot Rebuked

Once again, a paper has come out evaluating the efficacy and cost effectiveness of daVinci Robotic surgery.  From Diseases of the Colon & Rectum comes a retrospective review assessing elective robotic vs laparoscopic colectomy from 2008-2009 (over 12,000 procedures):

Patients undergoing robotic and laparoscopic procedures experienced similar rates of intraoperative (3.0% vs 3.3%; adjusted OR = 0.88 (0.35–2.22)) and postoperative (21.7% vs 21.6%; adjusted OR = 0.84 (0.54–1.30)) complications, as well as risk-adjusted average lengths of stay (5.4 vs 5.5 days, p = 0.66). However, robotic-assisted colectomy resulted in significantly higher costs of care ($19,231 vs $15,807, p < 0.001). Although the overall postoperative morbidity rate was similar between groups, the individual complications experienced by each group were different.

Alone

We have this book of children's poems I've been reading at night to my daughter.  Most of them are stupid, nonsense-type verse about magpies and talking cows and little boys who wish for things that always come true but then there are a few from people like Shel Silverstein that are actually pretty decent.  The other night we came across an e.e. cummings selection I remember reading in high school called "Maggie and Milly and Molly and May":

maggie and milly and molly and may
went down to the beach(to play one day)

and maggie discovered a shell that sang
so sweetly she couldn't remember her troubles,and

milly befriended a stranded star
whose rays five languid fingers were;

and molly was chased by a horrible thing
which raced sideways while blowing bubbles:and

may came home with a smooth round stone
as small as a world and as large as alone.

For whatever we lose(like a you or a me)
it's always ourselves we find in the sea

After I read it she said to me, "daddy when we're alone, where does everyone go?" and I said "that's a very good question, sweetheart" and I got very sad but also proud; happy because she was able to identify the essence of a complex poem from a master of the form, and sad because maybe she is starting to realize that life is sometimes hard and lonesome and not everything stays the same and that there isn't always going to be someone around to tell you where to go or what to do.  I didn't have an answer right away.  She turns four this week.  I hope to be able to speak with greater wisdom when she is older....

Costs

Ezra Klein writes:

There is a simple reason health care in the United States costs more than it does anywhere else: The prices are higher.  That may sound obvious. But it is, in fact, key to understanding one of the most pressing problems facing our economy. In 2009, Americans spent $7,960 per person on health care. Our neighbors in Canada spent $4,808. The Germans spent $4,218. The French, $3,978. If we had the per-person costs of any of those countries, America’s deficits would vanish........We spend less time in the hospital than Germans and see the doctor less often than the Canadians.  “The United States spends more on health care than any of the other OECD countries spend, without providing more services than the other countries do,” they concluded. “This suggests that the difference in spending is mostly attributable to higher prices of goods and services.”
 

But.... but.....I thought the problem in this country was that the ranks of doctors were filled with profit motivated dickheads like those in McAllen, Texas?  I thought the sole problem was our fee-for-service reimbursement system that rewarded more and more interventions and allowed doctors to game the system in order to enrich their coffers?  I thought the solution was to convert all doctors into salaried employees, to completely disincentivize them from any profit-maximizing motivations and allow the Good, Noble giant healthcare conglomerates like Mayo or the Cleveland Clinic be in charge of carefully doling out just the appropriate amount of healthcare services this country needs? 

Klein goes on:

Too Many Scopes

Colonoscopy is overdone in this country.  This is an observable fact.  I see patients every single day who get scoped every 2-3 years for no discernible reason.  I see inpatient 90 year olds who present with "GI bleed" (really just a little coffee ground emesis from dehydration/mild peptic ulcer disease) who end up getting black tubes snaked through their mouth and anus before they are returned to the nursing home from whence they came.  This happens constantly.  A study from Archives of Internal Medicine elucidates this phenomenon:

The colonoscopists with percentages significantly above the mean were more likely to be surgeons, graduates of US medical schools, medical school graduates before 1990, and higher-volume colonoscopists than those with percentages significantly below the mean.
A large percentage of colonoscopies performed in older adults were potentially inappropriate: 23.4% for the overall Texas cohort and 9.9%, 38.8%, and 24.9%, respectively, in patients aged 70 to 75, 76 to 85, or 86 years or older.
 

I post about this because, although the main problem with rampant, out of control healthcare expenditure in this country occurs at the macro-level via the health-industrial complex of hospitals, Big Pharma, the insurance carriers and the medical device industry, it doesn't excuse unscrupulous physicians acting like greedy assholes and the role individual doctors play in driving up costs.  Whether it's cardiologists performing unwarranted cardiac stent procedures or general surgeons taking out robin's egg blue gallbladders, we have to be able to shine the light on such behavior and shame those who betray basic medical ethics. 

HRT for Menopause?

This article I saw on Yahoo News is an example of why patients ought not to go scouring the Internet for all their medical information.  The title of the article "Doctors Clear Up Confusion Over Hormone Therapy" is rather misleading.  Hormone replacement therapy (i.e. supplement estrogen and progesterone pills) has long been known to be the best intervention for refractory menopausal symptoms.  Unfortunately, a Women's Health Initiative study from a decade ago demonstrated that subsets of post-menopausal of women who took hormonal replacement therapy (HRT) medication increased their risk of developing breast cancer by 25%.  Afterwards, enthusiasm for HRT sort of tapered off.  As you could imagine.  This new statement avers that:

...while the therapy comes with risks, its benefits generally outweigh the harm for women under age 60, or those who've been in menopause for fewer than 10 years. The increased risk of breast cancer also appears to disappear a few years after treatment is stopped......doctors recommend low doses of HRT for women whose menopausal symptoms are limited to vaginal dryness and pain during intercourse. HRT is not recommended for women who've had breast cancer
 

So if you're under 60, have had symptoms less than 10 years, never had breast cancer,  and your symptoms are limited to vaginal dryness and dyspareunia, then HRT is for you.  I'm a little wary myself.  Curiously absent from the "consensus statement" are doctor's groups such as the American Medical Association, the National Cancer Institute, the American Cancer Society, the American Society of Breast Surgeons, and the American Breast Cancer Foundation.  The Asia Pacific Menopause Society, which I'm sure is a fine organization, just doesn't have the carry the same cache for me.... 

Cardiac Outcomes

Alice Park reviews David Jones' counter intuitive new book on the history of cardiac surgery and coronary angioplasty in most recent issue of Harvard magazine.  Jones, also a physician, is a professor of medical history at Harvard.  His latest book explores the rise of interventional cardiology and cardiac surgery since the 60's and how much of the rationale for such a procedure-dominated treatment strategy is undergirded by some surprisingly shoddy data. 

The first randomized clinical trial of bypass surgery’s efficacy, using data from a collaboration of Veterans Administration hospitals, was not published until 1977. Such trials were then becoming the gold standard of medical research (and still are). “Surgeons said trials were totally unnecessary, as the logic of the procedure was self-evident,” says Jones. “You have a plugged vessel, you bypass the plug, you fix the problem, end of story.” But the 1977 paper showed no survival benefit in most patients who had undergone bypass surgery, as compared with others who’d received conservative treatment with medication.
 

It's funny, coming from the perspective of surgical training, I don't recall ever hearing from disgruntled cardiac surgeons the actual reasons why bypass surgery had started to fall out of favor during the nineties and oughts.  All I heard was that fellows were having a hard time scoring jobs because bastard cardiologists were snaking all the cases.  Never did we discuss studies outlining the lack of survival benefit from CABG.  It seems obvious now that such an inquiry was a trip down the existential rabbit hole--- no one wanted to find out that the profession one had spent a third of one's lifetime preparing and training for was, in the end, no better in terms of providing survival benefit than simply telling someone to stop smoking, to eat better, and to get off the couch. 

Tylenol: That will be $16.95 please

I just have to highlight this.  In the AHA release in response to the Brill article, they address the issue of why it costs $17 for a single tylenol when you're an inpatient:

A dose of Tylenol provides a good example. In order to take medications in a hospital, even over-the-counter medicines, they must be prescribed by a doctor (a little bit of cost for the doctor), that order gets transmitted to the pharmacy (a little more cost), the order gets filled by a pharmacist or pharmacy tech who retrieves just one Tylenol pill and individually packages that one pill (still more cost), the pill gets transported from the pharmacy to the nursing unit where the patient resides (a little more cost), then the pill is retrieved by a registered nurse who personally gives the pill to the patient and then must document the administration of that pill in the patient medication administration record (a little more cost). All of this process to give a patient a single dose of Tylenol in a hospital bed is regulated by agencies that accredit hospitals – a condition of participation in the Medicare program. In other words, this is what hospitals must do to administer a pill in compliance with all pertaining regulations (a little more cost).
 

Apparently this was not written as an intentional parody.  At least I don't think so.  It's always possible that they're putting us on.  But maybe not.  Maybe they really have conducted thorough internal audits on the costs of "transporting the pill from the pharmacy to nursing unit" and "individually packaging a single pill".  Bureaucracies have been known to do worse. 

Profits and Hospital Systems.

The American Hospital Association has come out with a rebuttal to Steven Brill's Time Magazine article.  Brill had claimed that non-profit hospitals operate at a 11.7% profit margin.  According to some internal AHA survey, the actual number may be closer to 5.5%.  In the context of typical corporate profit margins, this adjusted number does not exactly make one weep for the hospital industry.  To wit, according to recent industry trends, even a 5.5% profit margin out-performs private stalwarts like the auto manufacturing industry, major airline carriers, textiles, heavy construction, and even the tobacco industry.     

I mean, the hospitals aren't raking in 25% profits like real estate investment trusts, but 5.5% isn't too shabby.  They do just fine.  CEO's of places like the Cleveland Clinic and Mayo and Johns Hopkins earn well over seven figures.  Even mid-level hospital executives usually take home twice or three times as much as the salaried docs who actually take care of patients and make sure all the billing information is filled out appropriately.

Are we OK with hospital systems who don't pay a cent in federal or local taxes generating bottom lines that American Airlines would take in a heartbeat?  This is not merely a question of pragmatics--- i.e. whether or not, given the exploding cost curve in the health care sector, it is feasible to expect hospitals to remain so profitable with their million dollar robots and Renaissance Hotel-esque entrance lobbies and 42 inch flat screen TV's in every room and outrageous facility fees and $18 charges for two Tylenol pills. 

The question, like it or not, transcends pragmatics.  It is the defining moral question of our time...

Understanding Sub-concussive Head Trauma

The link between Chronic Traumatic Encephalopathy (CTE) and repeated subconcussive head trauma (as in football) has been well documented.  What is less well understood is the pathophysiologic mechanism by which this process occurs over time.  This paper suggests that a disruption in the blood brain barrier (BBB) occuring after sub-concussive head trauma can elicit an auto-immune response, whereby auto-antibody production and infiltration of the brain could potentially lead to the long term cognitive damage as seen in CTE.

This is only the beginning.  Science lurches toward the truth.  And Pop Warner leagues can flip that hourglass over any minute now.  The end of football as we know it is coming, and quickly. 

Matthew Yglesias Thinks Doctors are the Problem

The liberal blogger Matthew Yglesias' take on the Steven Brill's health care crisis tome is a strange one.  Rather than focus on Brill's substantive points about the medical-industrial complex, he elects to point out the one facet of health care spending that Brill downplays; i.e. doctor compensation.  Yglesias, from the Gawandean school of Avaricious Physicians, apparently, feels that we need to crack down even harder on physician reimbursements.  After all, doctors in the United States earn more than doctors anywhere else in the world.  To back such a claim he cites this chart from the OECD:

The Chargemaster and Non-Profit Charity Care

In Steven Brill's article, the main take home message is that pricing for hospital based services is arbitrarily far too high.  The starting point for negotiations between hospitals and the various third party payors (Medicare, private insurance plans) begins from a price listed in the hospital "Chargemaster", an all-encompassing compendium of charges for everything a hospital can bill for (example here).  No one knows where prices listed in the chargemaster originate from.  And so you end up with absurd situations where itemized bills will show that the tylenol the ER gave you for a headache got charged at $18.50 per pill.  Paper surgeon's gown for $32.  IV tubing priced at $125.00.  Troponin lab tests for $199.50.  The CT of your head, several thousand dollars.  Now hospitals themselves don't pay any attention to the chargemaster.  Those patients with Medicare or private insurance don't pay anywhere near the listed chargemaster price.  But if you have no insurance or some sort of shoddy, limited-reimbursement plan, then the bill you receive, when itemized, will include charges on ridiculous items that insurance plans routinely disregard as part of the facility fee, and all the prices will come directly from the chargemaster. 

So yes, those who are least able to pay get charged the most.  And many hospital systems adopt strict non-negotiation stances toward patients who are in financial difficulty.  Unpaid bills are quickly turned over to collections agencies, written off as "free care", or sometimes the hospital will actually litigate to squeeze everything they can from patients already teetering on the edge of financial catastrophe.

Cost Not-So-Conundrum

Steven Brill's long form report on the "cost conundrum" in American healthcare has occupied my free time the past several days.  To say that this is the most important piece in decades explaininge how health care spending occupies 17% of our GDP would be a gross understatement.  Brill's meticulous documentation of the what ails us, both at the macro and micro levels, represents everything that journalism ought to aspire to.  Brill simply exposes the rot that lies at the heart of a system that incentivizes the marketization of a profit-driven American health care infrastructure. 

I need to break down an analysis of the piece over several posts, but for now I just want to draw attention to the radically different conclusion Brill outlines arrives at compared with Atul Gawande's celebrated New Yorker article from a few years ago.  Gawande, recall, spent a week visiting with doctors at a private for-profit hospital in McAllen, Texas who, collectively, accrued higher utilization rates and billing charges than similar sized cities in the area.  His conclusion was that our current fee for service model was flawed and easily corrupted by greedy, profit-driven individual physicians and group practices and that the solution was to transition to a system where doctors worked as employees for large, monopolistic heath care behemoths, incentivized to provide "quality care" at, presumably, much lower costs. 

Robotic Hysterectomy: Everybody's Doing It!

A cohort study done by Columbia University evaluating the rise of robotic hysterectomy from 2007-2010 had some pretty breathtaking findings.

Use of robotically assisted hysterectomy increased from 0.5% in 2007 to 9.5% of all hysterectomies in 2010. During the same time period, laparoscopic hysterectomy rates increased from 24.3% to 30.5%. Three years after the first robotic procedure at hospitals where robotically assisted hysterectomy was performed, robotically assisted hysterectomy accounted for 22.4% of all hysterectomies.... In a propensity score–matched analysis, the overall complication rates were similar for robotic-assisted and laparoscopic hysterectomy (5.5% vs 5.3%).......Total costs associated with robotically assisted hysterectomy were $2189 (95% CI, $2030-$2349) more per case than for laparoscopic hysterectomy.

Buckeye Eviscerated on KevinMD

The medical social media Godfather Kevin Pho will occasionally cross post some of my work on his hugely popular and successful blog KevinMD.  Earlier this week he chose to include my relatively recent post on an article I had read in the Economist last fall about physician assisted suicide (PAS).  I was in one of those moods when I wrote it.  I suppose I was looking to achieve a certain degree of shock value by writing it as a straight satire of what it could mean to be an actual doctor who participated in PAS.  I mused about how a general surgeon might get involved in such a vocation.  This musing involved several proposals for procedures that a general surgeon would have within his skill set to do if requested, including but not limited to...um... bilateral carotid artery ligation, aortic transection, and trachea clamping.  The KevinMD readership did not take kindly to such apparent insouciant treatment of a sensitive issue.

To wit, from the comment section:

Roger Goodell: Marlboro Man

Roger Goodell, the NFL commissioner, earned over $29 million in salary and bonuses last year.  The current TV contracts negotiated with NBC, ESPN, CBS, and FOX will guarantee the league's owners over $7 billion to be split amongst themselves. 

Remind me again why anyone would possibly doubt Mr Goodell's sincerity when he says that his primary concern is the safety and well being of NFL players?  Remember his quote from the Bob Schieffer interview:

In fact, we’re all learning more about brain injuries, and the NFL has led the way,” he declared. “We started a concussion committee back in the mid-90s with the players’ association to study these issues and advance science. We’re obviously now learning more and more, and we’re investing more and more. And I think that’s going to lead to answers, even outside of brain injury, even to brain disease.”

What cannot be emphasized enough is that this committee (the Mild Brain Trauma Injury committee) was led not by an independent neurologist or neurosurgeon, but by a salaried rheumatologist named Elliot Pellman.  Now for those unfamiliar with medical terminology, a rheumatologist is a doctor who typically manages auto-immune mediated diseases such as lupus, rheumatoid arthritis, and psoriasis.  The only logical explanation for appointing a rheumatologist to head your ad hoc head injury committee is to guarantee message control.  They may as well have named a dentist to head the committee.  Rarely does one come across such a flagrant example of cynical self interest.  The NFL was so arrogant, so dismissive of player safety that they didn't even feel the need to appoint a stooge specialist within the field of head trauma. 

It's truly astounding. 

And Roger Goodell is laughing all the way to the bank. 

Leaks

This retrospective review from the Archives sheds some light on every surgeon's worst nightmare when it comes to rectal surgery: the anastomotic leak.    This study is a retrospective review of over 70,000 low anterior resections, nationwide, from the years 2006-2009. 

Results The AL rate was 13.68%. The AL group had higher mortality vs the non-AL group (1.78% vs 0.74%). Hospital length of stay and cost were significantly higher in the AL group. Laparoscopic and open resections with a diverting stoma had a higher incidence of AL than those without a stoma (15.97% vs 13.25%). Multivariate analysis revealed that weight loss and malnutrition, fluid and electrolyte disorders, male sex, and stoma placement were associated with a higher risk of AL. The use of laparoscopy was associated with a lower risk of AL. Postoperative ileus, wound infection, respiratory/renal failure, urinary tract infection, pneumonia, deep vein thrombosis, and myocardial infarction were independently associated with AL.

Student Loan Bubble, Continued

From Salon, a stinging rebuke of the student loan racket that threatens to set off another credit-fueled systemic financial crisis:

In effect, the system allows any 22-year-old American University chooses to admit to borrow a sum equal to the average home mortgage, but without a single one of the actuarial controls that are supposed to minimize the risk that homeowners will borrow too much money.

After all, even at the height of the housing bubble, home buyers who got so-called liar loans that misstated their actual income still had to jump through certain hoops to do so. In addition, if they defaulted on their loans, there was a house the lender could foreclose on that in most cases still had some value. Of course, that system proved to be far too unregulated, and led to a financial disaster that would have wrecked the nation’s banking system if not for hundreds of billions of dollars of federal bailout money.

Still, even that system was a model of rationality in comparison to the federal government’s funding of higher education. As long as they are technically “nonprofit” institutions, schools can charge whatever they like, without having to provide a shred of proof that their graduates will be able to pay back the incredible debt loads they will be incurring. And, of course, when graduates default on these loans there’s no house to sell off to cover at least some of the deficiency.

Chris Christie: Very Sensitive

Former White House physician Connie Mariano M.D. set off a firestorm recently by stating the patently obvious fact that New Jersey governor Christ Christie ought to address his morbid obesity prior to entertaining thoughts of running for the Presidency in 2016. 

“It’s almost like a time bomb waiting to happen unless he addresses those issues before he runs for office,” Mariano told CNN, saying she's concerned Christie could suffer a heart attack or stroke.
 

The short-fused Christie unloaded on the good doctor in typically fiery fashion:

“People who have a medical license, who have the privilege of having a medical license, should in my view conduct themselves more responsibly than that.  If she wants to get on a plane and come here to New Jersey and ask me if she wants to examine me and review my medical history, I’ll have a conversation with her about that. Until that time, she should shut up." 

Well then. 

Dash 22

The consult came in around 3:30 on a Friday.  The surgeon wasn't on call but his partner was tied up and he, the surgeon, felt obligated to see the new patient before it got too late.  To do otherwise is known as a "dick move" in the world of small private surgical practice.  The computer record outlined the picture of a man in his late seventies with an unremarkable medical history.  He only took something for gout and various other over the counter vitamins.  He took something called Life-X 3000.  The consult request was "evaluate for gallbladder disease".  The patient had been admitted three days prior.  That was interesting.  The admitting diagnosis was "diarrhea".  The surgeon perused the completed  blood work and imaging.  Mildly elevated liver function tests.  White blood count (WBC) over 20,000.  The CT report had the surgeon logging out of the terminal and brisk walking to the other side of the hospital--- severe cholecystitis, possible malignancy vs liver abscess. 

I want to ask them

What's it like to be old and afraid like this (if you are in fact afraid I apologize if I am leaping to conclusions because you look like it, you have this terrified look on your face, a face with a caved in gash where a mouth should be and black horrifying eyes, like they are trying to leap out of your head, to escape somewhere) in a mechanized complexly caterpillared hospital bed and are you worried that everything you thought was true until now you are starting to doubt and maybe it's not true it's all a comforting lie or delusion and you worry you dont have the energy or zest or whatever you call it life force to find something else, lunge forward, seek, seeking, think of something else, latch onto something else there's always time, like the way you used to think when you were younger and full of spirit and confidence and limitless possibilities, or are you just tired and you don't care anymore and that's what happens (physiologically, evolutionarily as a solution to existential angst) when you start to actually d.i.e. and oh my god what if that's what really happens you just get tired and burn out stop grinding stop burning for answers and reasons, you just stop.  Are you sad.  Are you angry, disillusioned?   Are you cranky lying there alone and half nude because you are dwelling internally on the possibility that this is the end and it's like I'm not even here you're not even really there disembodied sort of like floating above and everything irrelevant and distracting.   Dont be afraid I would say if you asked.  But I dont really know, do I?  What am I, some sort of Christ doppelganger?   I have nothing to offer anymore.  You know better.  You look at me like I am a robin pecking the grass in spring.  A waterfall.  Tree branches soughing in a June breeze.  Inanimate.  If you want to talk about it now. Talk to me. I am here going through the motions of listening to your heart and mindlessly ripping off gauze and cloth tape and performing and I am a doctor it is important, from an identity perspective, that I play this role while you lie here and I have done all I can and the numbers look bad and I do not know a rale from a rhonchi, definitionally, but whatever it is that I hear is no good and the nurses have stopped paying attention to you I want to say I am sorry and when I try to hold your hand it is like dry leaves and limp and I have lost you.  If only you would say one thing.  Talk to me one last time.   

Roger Goodell: A Modern RJ Reynolds Spokesman

Roger Goodell's interview last Sunday with Bob Schieffer about the link between football-related head trauma and long term cognitive impairment (CTE) was a a sickening display of arrogant obfuscation and denial.  This line, when asked if he would ever allow his own son to play football, is especially revealing:

  “Absolutely,” the NFL commissioner insisted. “I have twin daughters just like the president, and I’m concerned when they play any sport. The second-highest incidents of concussions is actually girls soccer. So what you have to do is to make sure the game is as safe as possible. In the NFL, we’re changing the rules, we’re making sure the equipment is the best possible equipment, we’re investing in research to make sure we can address concussions, not just to make football safer at the NFL level, but all levels in other sports.”
 

Surely the Rog knows that CTE has little to do with concussions, right ?  Surely he knows that current scientific research indicates that  CTE is a neurological degenerative process that evolves over time, as a result of a lifetime of accumulated sub-concussive blows?  So why bring up the thing about girls soccer?  It's a distracting non-sequitor. 

And then this line:

Bush Redux: The Obama Assassination Memos

Michael Isikoff from NBC News was granted  had leaked to him a 16 page "white paper" last night, carefully prepared by the Obama Department of Justice (DOJ).  This paper was a summation of the arguments made in an official Office of Legal Council (OLC) memo (which itself inexplicably remains a top-secret document) used to justify the due process-free, unilaterally-determined assassination of American citizens by Presidential decree.

Libertarians like Glenn Greenwald, Marcy Wheeler, Connor Friedersdorf and Adam Serwer have elegantly deconstructed the absurdity of it all (with special emphases on the redefinition of "imminent threats", the idea that "Al Qaeda-affiliated" is so broad a phrase as to include, potentially, anyone who may harbor sentiments or thoughts that could be construed as "anti-American", and the frightening implications of a permanent Global Battlefield)  with far more expertise and eloquence than I could ever muster.  Please read them all. 

But the bottom line is this:

Suicide Docs

From the Economist in October 2012 was an article on physician assisted suicide.  In the United States, terminally ill patients can apply for permission to end their lives with the guidance of a doctor in Oregon and Washington state.  Several safeguards are in place to prevent this from becoming the default death pathway (only 0.2% of total Oregonian deaths).  Also, I had no idea that Holland, Switzerland, and Belgium allow assisted suicide even in non-terminally ill citizens.  So you can be suffering from, say, severe acne vulgaris, in the Netherlands and be within your rights to seek immediate death from a certified death-administering professional.  Revelatory, indeed.  And heartwarming to read about on a Sunday. 

My main interest is in the doctors who are contracted to carry out these ghoulish deeds.  By physician assisted, I think what everyone has in mind is some sort of benign, humane, minimally invasive practitioner of life sapping.  You lie on a table.  Calming eastern mystic yoga music plays softly in the background.  The room smells of lilac and aloe.  A soothing voice whispers in your ear, "it's going to be alright, peace and love await you".  And then a white robed man with a Francis of Assisian face of compassion slowly injects painless sedatives until you pass out and then the final killing agent is administered while you are in a state of blanked nothingness. 

Single Port Appy?

First off, I am rather dubious of this whole "single port" business as a new tool in the laparoscopic armamentarium.  Several reasons. 

One, given the two dimensional aspect to today's instrumentation, there is a high premium on the concept of "triangulation" of your ports.  In other words, being able to approach a target from angled positions on the abdominal wall augments the efficiency and usefulness of right and left handed instrument control.  Approaching a target with instruments originating from a zero degree position is awkward at best, and hemorrhagic stroke inducing at worst.  Ultimately, in perhaps the most stinging rebuke, it lacks elegance.  Any surgeon worth a darn, from a technical perspective, will always seek the Way of Elegance when performing an operation.  (As an aside, relative absence of elegance is directly correlated with overall OR mood and surgeon/ancillary staff relationships.)   Until the instrumentation improves (i.e. articulating capabilities, curved shafts, ect) then any and all attempts at zero degree single port laparoscopy will be efforts in frustration. 

Contingent Healthcare: Birth Control

The Obama Administration announced yesterday a compromise plan to appease opposition from religious organizations (i.e the Catholic church) regarding the coverage of birth control under the auspices of Obamacare.  Under the compromise, employees of churches and non-profit religious organizations will receive free oral contraceptives through a separate healthcare plan, to be paid for by health insurance companies. 

The litigants are not satisfied.

But Kyle Duncan, the general counsel of the Becket Fund for Religious Liberty in Washington, which is representing employers in eight lawsuits, said the litigation would continue. “Today’s proposed rule does nothing to protect the religious freedom of millions of Americans,” Mr. Duncan said.

 

Religious groups dissatisfied with the new proposal want a broader, more explicit exemption for religious organizations and protection for secular businesses owned by people with religious objections to contraceptive coverage.

Layers of Nonsense

Wrong site surgery is never acceptable.  A surgeon ought never to find himself in a situation where he has to inform the family that he just operated on the wrong body part.  It is embarrassing, unprofessional, and an egregious violation of the patient/physician covenant. 

That being said, we have allowed this issue to be defined entirely in terms of "systems management".  And hence the rise of the Time-out and the Checklist.  The ultimate responsibility for identifying the proper surgical site has been diluted.  No longer is it at the sole discretion of the operating surgeon.  Now we have a Team-Based approach involving nurses, anesthesia personnel, mid level providers, and surgeons.   Performance of a group time out (of which I am actually a strong proponent) has quickly become the standard of care at most American hospitals prior to initial incision.

CTE continued

Two quickie links:

• A harrowing interview with former Browns running back Leroy Hoard exploring his post-football struggles with memory loss, depression and severe headaches--- “My legs are both numb. I can’t feel my toes. I can’t feel this arm, and I’m getting a headache from these damn lights. Other than that, I feel great."
• Ta-Nehisi Coates, from the Atlantic, has a great timeline detailing the NFL's culpability in downplaying the long term effects of repeated head trauma sustained over time

I also need to address the argument that "these men know exactly what they are getting into, they are grown men, mature adults, they are well compensated for assuming a certain element of known risk, etc etc".

Safety Net Hospitals Squeezed

The weakest aspect to Obamacare is in its cost control strategies, or lack thereof.  The predicted savings from converting to Electronic Medical Records (EMR) have failed to materialize.  And the Rube Goldberg-esque plan to save money by penalizing hospitals and doctors for having poor HCAHP scores has reaped its own set of unforeseen complications.  HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) is the Press-Ganey survey tool that Medicare has decided to use as its sole objective instrument in determing relative hospital/physician "quality" rankings.   A low HCAHPS score puts a hospital system at risk of forfeiting up to 1% of its Medicare reimbursements.  High scoring systems can actually receive bonus payments.  Further penalties are accrued by hospitals for having high readmission rates after coronary events or pneumonia.
 

"Justice"----Post Modern American style

The Aaron Swartz suicide is one of those momentous events that will be covered ad nauseum by a certain tiny subset of living humans who give an actual shit about things like democracy, openness, liberalism (in the John Locke, Rousseau sense), transparency in government, and blinded justice---and very little by the mainstream media.  Niche fiefdoms of the Interwebs will express outrage via a series of finely articulated blog posts and columns denouncing the bullying by the American government and the disproportionality of punishment meant to be dealt out to this talented, intelligent young man who believed in the free exchange of knowledge, a young man who seemed to have abided by a set of principles-- so unusual in this post modern era-- a young man who believed that the internet existed precisely for the purpose of potentiating the unfettered flow of ideas, facts, research, anything that could potentially advance the state of the human condition.  It was imperative to him that information not be controlled by any one entity, that anything potentially advantageous to human beings collectively, be put in the public domain.   

Abraxane and Pancreatic CA

The new drug from Celgene for metastatic pancreatic cancer, Abraxane, has been shown to add a little less than 8 weeks of life to patients with the terminal disease. 

Celgene’s drug Abraxane prolonged the lives of patients with advanced pancreatic cancer by almost two months in a clinical trial, researchers reported Tuesday, signifying an advance in treating a notoriously difficult disease but not as big a leap as some doctors and investors had hoped.  

“It was not the breakthrough we were anticipating,” said Dr. Andrea Wang-Gillam, an assistant professor and pancreatic cancer specialist at Washington University in St. Louis, who was not involved in the trial.
 

The cost for this amazing advance in futile care?  $6000-8000 per month.  And there is already a drug on the market, folfirinox, that has demonstrated longer survival expectations that Abraxane.  I'm sure signing off on Big Pharm profiteering FDA approval is right around the corner. 

CTE Diagnosed in the Living?

From what I have read and heard, the NFL playoffs have been quite the little Entertainment this year, what with the high scoring and down to the wire finishes.  And now some sort of sibling rivalry theme awaits in the Super Bowl, apparently.  Since my very public declaration a few weeks ago that I was quitting football cold turkey, I have not watched a single game.  So far, it hasn't been too terribly challenging.  The true test of my principles will come next year when Urban Meyer is BCS-eligible and Chud has the Browns steaming toward an AFC North title.....

Speed Bumps

Modern science, as they say, advances at warp speed.  This article from the British Journal of Medicine is emblematic of the phenomenon.  Researchers in the UK, using sophisticated surveys, were able to identify a heretofore unacknowledged clinical indicator of acute appendicitis:  the Speed Bump Sign. 

RESULTS:

The analysis included 64 participants who had travelled over speed bumps on their journey to hospital. Of these, 34 had a confirmed histological diagnosis of appendicitis, 33 of whom reported increased pain over speed bumps. The sensitivity was 97% (95% confidence interval 85% to 100%), and the specificity was 30% (15% to 49%). The positive predictive value was 61% (47% to 74%), and the negative predictive value was 90% (56% to 100%). The likelihood ratios were 1.4 (1.1 to 1.8) for a positive test result and 0.1 (0.0 to 0.7) for a negative result. Speed bumps had a better sensitivity and negative likelihood ratio than did other clinical features assessed, including migration of pain and rebound tenderness.

CONCLUSIONS:

Presence of pain while travelling over speed bumps was associated with an increased likelihood of acute appendicitis. As a diagnostic variable, it compared favourably with other features commonly used in clinical assessment. Asking about speed bumps may contribute to clinical assessment and could be useful in telephone assessment of patients.

Interview: Phillip Hornbostle,MD Bariatric Surgeon

This is the first in a series of  interviews I plan on publishing.  Dr Phillip M. Hornbostel, M.D., FACS, FASMBS is an accomplished bariatric surgeon in Missouri who has performed thousands of weight loss procedures over the years.  He is also the resident dean of the commentariat at the physician-only social media website Sermo.  The following represents a series of email exchanges he and I had over the holidays:

Whoopsies

The family of an elderly German man named Dirk Schroeder is suing a hospital in Hanover because, allegedly, the surgeon who did his prostatectomy in 2009 left 16 foreign bodies inside him. 

When surgeons operated on Schroeder again, they were stunned to find 16 pieces of medical equipment in the man's body. This included "a needle, a six-inch roll of bandage, a six-inch long compress, several swabs and a fragment of surgical mask," writes the Daily Mail.

Words fail.  I mean I've left 8 or 9 items inside a patient before, but 16?  Just kidding.  I don't do that sort of thing.  The best was the hospital's official response:

 The facility claims that the instruments may have found their way into Schroeder's body "post-operation," according to German publication Osnabrücker Zeitung.

Very similar to OJ Simpson's claims that Nicole's exsanguinating throat wounds must have occured "post-visit" after a lovely afternoon of scones and green tea and pleasant conversation about the kids and the coming Mostly Mozart Festival at the LA Symphony.

Post Call Operating

A new paper from JACS reviews outcomes of elective procedures performed by surgeons operating the night after being on trauma call.

Conclusions

Performance of general surgery operations the day after an overnight in-hospital trauma shift did not affect complication rates or readmission rates. At this time, there is no compelling evidence to mandate work-hour restrictions for attending general surgeons.
 

This is right up my alley.  I am a general surgeon in a practice of two who takes call every other night, every other weekend.  I also cover the trauma pager 7-8 times a month.  Most of my post call days involve attending to electively scheduled cases.  All I can say is that I agree with the above findings.  I do not need naps post call.  I do not feel compromised by interrupted sleep.  This is my life.  I am a general surgeon.  This is what I bought into all those years ago.  Perhaps the paradigm and the expectations are changing.  Perhaps the millennial generation of surgeons will see me as some sort of strange anachronistic oddity-- what the hell is he doing trying to operate this morning?  I heard he only slept 4 hours last night???

Unfortunately the effects of such papers are doomed to fall on deaf ears.  The wheels of change are grinding.  Work hour reform is already entrenched at the residency level.  Papers such as this have an ever diminishing audience.  A generation of super-specialized, fellowship-heavy, shift work ingrained surgeons cannot comprehend what a paper like this even means.  It's inexplicable, a relic from an expired era.  The loss of an old ethic, a noble professionalism goes unacknowledged. 

Everyone gets tired.  The call comes in.  The alarm goes off.  It's time to rise again.  You say to yourself: That patient needs me.  Somebody loves him.  This is what you are meant to do.  Rise.  Run the cold water across your face.  Somebody loves her.  It's time to work again.  With all your heart and all your mind.  Do your job.  There is a transcendent joy for you too, if you just hang in there.....

Transplant Morality

In our aging society, older Americans are increasingly receiving organ transplants.

 The number of kidney transplants performed annually on adults over 65 tripled between 1998 and last year, according to data from the Scientific Registry of Transplant Recipients. In 2001, 7.4 percent of liver transplant recipients were over 65; last year, that rose to 13 percent.
 

The allocation of certain organs in this country is determined by need and severity of underlying illness.  It's not like at the deli where you draw a number and simply wait your turn.  Length of time spent on the wait list has nothing to do with your likelihood of getting the next available liver or lung.  Each potential recipient is assigned a score (MELD, Lung Allocation Score) based on clinical factors, bloodwork, functional capacity, etc etc.  (Kidney allocation still relies heavily on wait times, length of time on dialysis, etc). 

Who Decides on Surgery?

The American Journal of Surgery had a nice little (38 patient cohort) study from the VA database that tried to determine the process by which patients make informed decisions on elective surgery.  The results were rather surprising, at first glance.   

Sixty-nine percent of patients decided to have surgery before meeting their surgeon, and 47% stated that the surgeon did not influence their decision. Although the surgeon was an important source of information for most patients (81%), patients frequently described using information gathered before meeting the surgeon, such as other health care providers (81%) or family members (58%).

How Nurses Save Lives (and make surgeons look better)

I had seen the lady in the ED at around noon.  She presented with a 1 day history of non specific crampy abdominal pain and nausea/vomiting.  The CT demonstrated a garden variety small bowel obstruction (SBO), likely related to adhesions from a hysterectomy from years ago.  Her labs were all normal and her belly exam was not especially impressive.  Nonetheless, I placed an NG tube and admitted her to the hospital for close monitoring.

In over 70% of cases, an SBO will resolve on its own just with nasogastric decompression, bowel rest, and appropriate hydration.  Typically we will initiate a trial of conservative therapy in these cases.  Lack of progress or outright worsening over the next 24-72 hours then warrants operative exploration. 

Goodbye to All That

Junior Seau had CTE, chronic traumatic encephalopathy, the degenerative brain disease known to afflict individuals who have sustained repeated head injuries over time.

Junior Seau played football his whole life and was never officially diagnosed with a concussion.  Last May he sat down one day and shot himself in the heart.  Dave Duerson, the former Bears safety, did this too, as a way to preserve his cadaveric brain for post-mortem study.  The official report from the NIH confirmed a diagnosis that surprises exactly no one.  A lifetime of small, seemingly minor, but accumulative traumatic head blows sustained playing the sport he loved lead to a degenerative brain disease associated with depression, despair, and cognitive deterioration.

EMR Savings Fall Short

Well, well, well.  This is entirely unsurprising.  The NY Times this morning reports on a new assessment from the RAND Corp regarding implementation of electronic health records:

The conversion to electronic health records has failed so far to produce the hoped-for savings in health care costs and has had mixed results, at best, in improving efficiency and patient care, according to a new analysis by the influential RAND Corporation.
 

This is the same RAND Corp whose analysis back in 2005 predicting $81 billion in health care savings triggered the mad rush by practices and hospitals to adopt EMR.  That report was sponsored by the very same corporate conglomerates who stood to benefit the most from mass implementation (GE, Cerner, AllScripts, etc).  So this is not some fringe Luddite organization drumming up data to support an anti-EMR creed.

Processed

I saw a patient recently who described a four day history of severe RUQ abdominal pain that started shortly after consuming a slice of extra cheese meat lovers pizza.  The pain was piercing, like a through and through spear wound.  She had been vomiting and febrile and she looked quite a bit like absolute hell.  Her CT done by the ER showed an ugly distended gallbladder.  Her labs demonstrated an elevated WBC (over 20k) and mild early acute renal failure (creatinine 1.9, up from baseline).  On exam, in addition to peritoneal signs in the upper abdomen, she had some sort of complex pressure dressing on her right groin. 

-It's the same pain I told them on the other day, she said
-Told who?  You went to an urgent care?
-No, I was here.  They sent me home.  I told them I was still hurting.
-What's that bandage on your groin?
-They did a heart scan, made sure I wasn't having a heart attack
-I see, I said.  I'm not going to be sending you home.  You don't have a heart problem.  You need an operation.

I checked the medical record on the computer to confirm what I already knew.  She came in three days prior with a diagnosis of "chest pain".  Now, to be fair, many gallbladder attacks present with upper abdominal/lower chest pain.  However, rather than a complete work up to determine the source of her discomfort, she went directly from the ER to the cath lab where angiography was performed in order to prove she had completely normal coronary arteries.  She was discharged home 6 hours later.  She had been seen and examined (allegedly) by an internist and cardiologist.  The electronic medical record appeared pristine.  Discharge summary airtight.  The home medications had been reconciled.  Explicit post-procedure instructions provided.  Follow up care had been documented.  She had been processed, on paper, perfectly. 

I called the OR to book the case.  It was 11pm on a weekday. 

McChrystal on Drones/Guns

No one would ever mistake General Stanley McChrystal for some sort of bleeding heart pacifist.  His take on the escalating Drone Wars of the Obama Administration:

"What scares me about drone strikes is how they are perceived around the world," he said in an interview. "The resentment created by American use of unmanned strikes ... is much greater than the average American appreciates. They are hated on a visceral level, even by people who've never seen one or seen the effects of one."
 

Of course, this is the same man who wanted to increase the number of troops in Afghanistan, indefinitely (kind of a Perma-Surge).  So maybe he just finds drones distasteful because they allow for reduction in troop levels.  But still.  The former top commander in Afghanistan thinks maybe we are over-doing it with unmanned terror sorties from the sky.  Perhaps that is a viewpoint worth considering.....

In addition he also has an interesting take on assault rifles:

“I spent a career carrying typically either an M16 or an M4 Carbine. An M4 Carbine fires a .223 caliber round which is 5.56 mm at about 3000 feet per second. When it hits a human body, the effects are devastating. It’s designed for that,” McChrystal explained. “That’s what our soldiers ought to carry. I personally don’t think there’s any need for that kind of weaponry on the streets and particularly around the schools in America.”

Only an effete, Ivy League elitist liberal would ever claim such a thing, right?  An actual soldier who served in combat couldn't possibly believe that we would be safer without free access to military ordinance.  This is not possible.  GUNS DONT KILL PEOPLE, PEOPLE KILL PEOPLE, la la la la.

Cardiology Greed

This is embarrassing.  A hospital in Eyria, Ohio just settled a federal lawsuit for almost $4 million in response to allegations of hospital cardiologists performing unnecessary coronary angioplasties and stent procedures.

The high rate of heart procedures at the hospital was the subject of a front-page article in The New York Times in August 2006. Medicare patients in Elyria, Ohio, where the hospital is located, were receiving angioplasties at a rate nearly four times the national average, a figure that prompted questions from insurers and raised concerns about overtreatment.

The concerns included whether many patients in Ohio and elsewhere were receiving expensive and inappropriate medical treatments because of the high fees the procedures generated.

Over Transfused

A new paper from NEJM indicates that perhaps we need to re-calibrate our blood transfusion strategies in patients with severe upper gastrointestinal bleeds.  Patients were randomly assigned to liberal (transfuse for HgB under 9) vs restrictive (transfuse only for HgB under 7) transfusion treatment protocols and outcomes were measured (survival, bleeding, portal venous gradients, etc). 

The probability of survival was slightly higher with the restrictive strategy than with the liberal strategy in the subgroup of patients who had bleeding associated with a peptic ulcer (hazard ratio, 0.70; 95% CI, 0.26 to 1.25) and was significantly higher in the subgroup of patients with cirrhosis and Child–Pugh class A or B disease (hazard ratio, 0.30; 95% CI, 0.11 to 0.85), but not in those with cirrhosis and Child–Pugh class C disease (hazard ratio, 1.04; 95% CI, 0.45 to 2.37).

Soldier Suicides

Last year, more active duty soldiers died from suicide than in the field of combat.  There were 177 documented suicides in 2012, up 54% from 2007.  And even these appalling statistics underestimate the true suicide epidemic when you factor in discharged or retired soldiers.

You will hear calls for increased military spending on mental health resources.  Greater funding will be sought for Defense Department anti-suicide initiatives.   Although certainly warranted, do not think for a moment that simply hiring more psychiatrists and mental health professionals is the solution. 

The solution is to turn away, finally, from Endless War and the permanent occupation of lands and people who resent our presence. 

It's time to bring everyone home from Afghanistan and wherever else young Americans are needlessly placed in harms way. 

Radiology Stress?

One Dr Matthew Rifkin had a post up on KevinMD the other day expressing the fearful notion that radiologists are facing unprecedented challenges.  And by "challenges", what he means is that his specialty is starting to experience some push back from private insurers and Medicare on their heretofore rather generous reimbursements. 

He writes:  "The nice 9-to-5 lifestyle and never being on call started to fade away, making the stress associated with radiologists lives become more apparent"

Horror of horrors!  Next thing you know, someone will demand that radiologists wear pagers. Or actually talk to each patient after a study is performed.  Or take less than 6 weeks of vacation per year.  Pajamas/slipper ensembles could be banned from darkened viewing rooms.  It's like something out of Germinal.  You can only push a man so far until rebellion erupts from his heart. 

Of course this silly rant is all in the context of radiology inexplicably  being one of the most lucrative specialties one could choose.  From Medscape:

 In 2011, radiologists were the highest-compensated of all specialties surveyed, tied with Orthopedists. Respondents earned a mean income of $315,000 – about 10% less than in Medscape's 2011 survey. Fully one third of radiologists earned $400,000 or more, although this proportion was down from the 2011 survey. Almost one half (48%) earned from $300,000 to about $500,000.

Residency Blues

Last month, JACS published results from a national web-based survey completed by general surgery residents.  The findings paint a bleak picture of overall morale:

Results

A total of 464 completed surveys were analyzed. Overall, 75% of residents expressed dissatisfaction with the new duty hour limitation. PGY II to V residents reported a higher level of dissatisfaction compared with PGY I residents (87% vs 54%, p < 0.01). Eighty-nine percent of PGY II to V residents responded that there has been a shift of responsibilities from the PGY I class to PGY II to V residents, with 73% reporting increased fatigue as a result. Seventy-five percent of PGY I and 94% of PGY II to V residents expressed concerns about the adverse impact of the restrictions on the education of PGY I residents (p < 0.01). Residents at all PGY training levels reported encountering problems due to inadequate sign-outs (PGY I, 59%; PGY II to V, 85%; p < 0.01). Sixty-two percent of PGY I residents and 54% of PGY II to V residents believed that the new 16-hour duty restriction contributes to inadequate sign-outs (p = NS). Most PGY II to V residents (86%) believe there is a decreased level of patient ownership due to the work hour restrictions.
(emphases added by me)
 

The first thing to point out is that surgical interns are not allowed to work more than 16 consecutive hours.  Because they might get sleepy.  And those bedhead hairdos on morning rounds were just too distracting for well coiffed Attendings.  Or something.

So we have unsurprising findings that residents being sent home from apprenticeship based on arbitrary time limits are concerned about both their own education (less time in hospital/OR equals decrease in comfort level with complex surgical issues) and patient safety (compromised patient-info sign outs).  That's fantastic.  I can't wait when I'm old and broken down  and these folks will be taking care of me at 3AM.     

Poo-Poo Platter

This article was, for some odd reason, the front page story in today's Plain Dealer.  (Slow post-holiday news day?)  Two gastroenterologists from New England are working on a randomized controlled trial comparing the efficacy of fecal transplantation vs placebo in cases of refractory, recurrent clostridium difficile (c. diff) colitis.  What exactly is "fecal transplantation" you ask? 

Just what you what might expect, alas:

Transplants can be performed in a number of ways. Most often, doctors use a colonoscopy-like procedure, sedating a patient and depositing liquified, donated stool through a tube in the rectum. But sometimes they use a nasogastric tube, that goes through the nose, down the throat and into the gut. Other times, the stool is administered as an enema.

Surgeons as Employees

AMA Physician Masterfile data was examined to determine the shifting paradigm in surgical practices.  The results are unsurprising:

Results The number of surgeons who reported having their own self-employed practice decreased from 48% to 33% between 2001 and 2009, and this decrease corresponded with an increase in the number of employed surgeons. Sixty-eight percent of surgeons in the United States now self-identify their practice environment as employed. Between 2006 and 2011, there was a 32% increase in the number of surgeon in a full-time hospital employment arrangement. Younger surgeons and female surgeons increasingly favor employment in large group practices. Employment trends were similar for both urban and rural practices.
 

Interesting that younger surgeons are gravitating toward an employed model.  I suspect that onerous educational debt loads contributes to the decision to opt for a "safer" earnings environment.  When you are forking out $1500 a month to Wells Fargo, it's nice to know you have bi-monthly checks coming in regularly.

Also, don't forget that the majority of graduating general surgery residents are pursuing fellowship training in various subspecialties.  A general surgeon can hang his shingle pretty much anywhere in the USA.  A trauma surgeon?  Cardiothoracic?  Vascular?  Hand specialist?  You pretty much need to link up with the giant tertiary care centers (as an employee) to guarantee a steady, sufficient referral base. 

Secrecy Triumphs Once Again

An attempt by the NY Times to obtain memos from the Justice Department that provided the legal rationale for the due process-free assassinations of Anwar Al Alaki and his son (American citizens, both) has been summarily shut down by a federal court.  Once again, the US government has successfully made the argument that anything deemed a "state secret" cannot and will not be made available to the American people.  Nothing to see here.  Move right along.  Most Transparent Administration Ever, indeed. 

Again, this was not an attempt by the Times/ACLU to publish Top Secret intelligence data.  They simply wished to make public the mere legal rationale that our Noble President uses when determining which American citizens he can execute. 

Just trust us, they say with a wink.  It's only a brown-skinned terrorist with an unpronounceable, strange-sounding name.  They would never think of exercising such unprecedented state powers on Caucasian dissidents with names like Smith and Jones.  Right?

High Cost of Robots

I'll have more on the Da Vinci robotic surgery phenomenon in the near future.  But a good taste of what's to come is nicely elucidated by this article in Archives, describing the ungodly costs of taking a perfectly good operation (in this case open thyroidectomy) and foisting the robotic technique on it:

Results The relative costs calculated were $2668 for ST vs $5795 for RT. This represents a 217% increased cost of RT compared with ST. The mean operative times were 113 minutes for ST vs 137 minutes for RT.

Nothing like doubling the cost of a medical procedure in this era of cost containment.  Sounds like a winner.    

Universal Care???

Yet another example that complex, poorly understood Obamacare is anything but a template for universal healthcare:

Employers asked for guidance, and the Obama administration provided it, saying that a dependent is an employee’s child under the age of 26.  

“Dependent does not include the spouse of an employee,” the proposed rules say. 

Thus, employers must offer coverage to children of an employee, but do not have to make it affordable. And they do not have to offer coverage at all to the spouse of an employee.

 

We can stop with the self-congratulatory "healthcare for everyone" claim from Obamacare advocates anytime now.  Is it an improvement over the status quo?  Inarguably.  But we are long ways from a just society.....

Accelerated Degrees

Amen to this:

But now one of the nation’s premier medical schools, New York University, and a few others around the United States are challenging that equation by offering a small percentage of students the chance to finish early, in three years instead of the traditional four. Administrators at N.Y.U. say they can make the change without compromising quality, by eliminating redundancies in their science curriculum, getting students into clinical training more quickly and adding some extra class time in the summer.

Not only, they say, will those doctors be able to hang out their shingles to practice earlier, but they will save a quarter of the cost of medical school — $49,560 a year in tuition and fees at N.Y.U., and even more when room, board, books, supplies and other expenses are added in.

 

It is a well-known fact amongst physicians that the fourth year of medical school is, for the most part, a tremendous waste of time.  Granted, you have to bust your ass in July/August of fourth year in order to secure the necessary GLOWING RECOMMENDATIONS from faculty members in your chosen specialty, but once the leaves start to turn, it's slacker time.  I vaguely seem to recall numerous days where my clinical responsibilities were over by noonish and I was lacing up my shoes for a four hour session of pickup basketball at the gym. 

Certainly, one could choose to work a lot harder, i.e. by voluntarily signing up for demanding fourth year clinical subspecialty rotations in fields like pulmonology, cardiac surgery, etc.  But if you're planning on being an radiologist or an endocrinologist, why, other than pure intellectual curiosity, would you want to do that?  Is it worth an extra 50 grand of debt?

At least put the option out there.