Wednesday, June 29, 2005

Thoughts on Evidence and Medical Practice

My OB colleague to the north had an interesting insight while reading the much-discussed New Yorker article The Bell Curve (emphasis mine):

So, we can follow best practices, evidence based guidelines, the results of randomized clinical trials, etc., and apply them to our practice of medicine and surgery. But that alone will not enable us to achieve the results of a Dr. Warwick. What will then? I think the answer is time. Re-read the above. Imagine how much time that encounter with the patient took. Imagine if Dr. Warwick hadn't taken the time to discover why she wasn't taking her treatments? He gave her the greatest gift of all. His time. And compassion. Ultimately, that just may be the method.
I agree. It is one thing to follow the results of studies and try to practice in a truly "evidence based medicine" style. It is yet another to utilize the patience, time and thought needed to actually care for living, breathing, thinking human beings. Despite all the new buzzwords, the "con-fusion" of the two is what medicine has always been about. Kudos to the Red State Moron for pointing that out.

Tuesday, June 28, 2005

Turnabout is Fair Play

If I may be so bold as to borrow a phrase from Glenn Reynolds, heh.

Passing Information, Instead of Passing the Buck

To those not in the medical arena, it seems unthinkable that Hospital "A" would not tell Hospital "B" that a particular physician on "A's" staff was less than stellar when he applies for privileges at "B." There are very strict guidelines regarding the peer review process, and it is difficult from a legal standpoint to say much in these situations. A new legal precedent, however, may make it a whole lot easier for hospitals to divulge this type of information.

A federal court in Louisiana recently held that a Louisiana hospital had a duty to disclose information about their medical staff members to a hospital in Washington in order to protect future patients.
Certain types of physician problems, such as loss of privileges, must generally be reported to state medical boards, but "concerns" that have never resulted in outright revocation of privileges generally are not. In many cases, there is a careful legally negotiated resignation from a hospital; this is not reportable to the state board, and therefore not public knowledge. This decision will (hopefully) allow and encourage hospitals to pass along this kind of information without the threat of legal recrimination. And that's a great thing, IMHO.

Hat tip to the MSSP Nexus Blog, with an assist in finding this site from the Health Business Blog!

We need to do a better job in cancer education

It looks like those of us in the health care arena need to do a better job of educating the public about cancer care. A new study published in Cancer demonstrates that certain myths about cancer are widely believed in the US adult population; the shorter press release is here. The five misconception statements include:

  1. Pain medications are not effective in reducing the amount of pain people have from cancer
  2. All you need to beat cancer is a positive attitude, not treatment.
  3. Treating cancer with surgery can cause it to spread throughout the body.
  4. There is currently a cure for cancer but the medical industry won't tell the public about it because they make too much money treating cancer patients.
  5. Cancer is something that cannot be effectively treated.
As a surgeon, it is surprising to me how often patients cling to belief #2 --- in fact, that was the most commonly held misconception, believed by a whopping 41% of the survey population. That seems a bit high compared to my own experience, but does reflect a clear lack of understanding of cancer and cancer care in the general population.

Hopefully, this type of information will encourage physicians to educate our patients appropriately, even when patients may not express their misconceptions openly. Our educational system also needs encouragement to educate students regarding this type of mistaken belief --- something that requires a good science foundation, IMHO.

Grand Rounds XL

Grand Rounds is being hosted this week at the Health Business Blog. Check out what the best of the medical bloggers and commentators have to say this week!

Monday, June 27, 2005

Take the MIT Weblog Survey
Click the logo above to take the survey --- this is being conducted an MIT PhD candidate who is also the creator of Blogdex.

Photos from Hawaii

I just noticed that Blogger has a new photo uploading feature, so I thought I'd try it out. Looks like it will work a bit more easily for me than Picasa/Hello.

The above photo has graced my computer screen since my family and I returned from Hawaii --- a whimsical fence made of surfboards that is just as iconic as the Cadillacs in the sand outside of Amarillo. We had a great time there (first trip), and SWIMBO & I hope to go back sans the surglings some time -- maybe to Molokai.

The can of worms is open......

I know I'm getting ready to step into a big pile of stinky fecal matter, but the whole idea of spending public dollars earmarked for health care on chiropractic services is something that has always bothered me. As I noted in my previous post, a new report from the Office of the Inspector General at the Dept of HHS reveals that there have been significant Medicare overpayments to chiropractors due to fraudulent billing. All physicians understand how difficult it is to bill Medicare within ever-changing guidelines; indeed, there is a whole industry built around helping physicians and hospitals appropriately bill Medicare. However, the report is fairly straightforward, and did not look at minor billing discrepancies. Nearly all of the overpayments were due to "maintenance" therapy, something specifically excluded from payment by federal law.

Looking at the report itself, a few things stand out:

  1. The Medicare Carriers Manual states that "ongoing maintenance therapy is not considered to be medically necessary under the Medicare program." I think that is a pretty simple-to-understand statement.
  2. Medicare outlays for chiropractic care have increased from $255 million in 1994 to $683 million in 2004.
  3. This review was done by performing a random sample of 400 Medicare services submitted by chiropractors and allowed by Medicare in 2001; the reviewers were practicing chiropractors.
  4. Nearly 94% of chiropractic services reviewed lacked at least one of the supporting documentation elements listed in the Carriers Manual; this included many that were completely undocumented.
  5. Upcoding resulted in $15 million in overpayment.
One of the major criticisms of chiropractic care is the idea that patients need "maintenance" therapy. This leads to overbilling and what Medicare says is unnecessary treatment:
As chiropractic care extends beyond 12 treatments a year, it becomes increasingly likely that individual services are medically unnecessary. The likelihood of a service being medically unnecessary increases even more significantly after 24 treatments.
OK, so what? As the report itself states, chiropractic services accounted for only 0.26% of Medicare fee-for-service claims in 2001 ($500 million out of $191 billion paid to hospitals, physicians, outpatient care delivery services, etc.) For me, the "so what" part of things comes down to the way that CMS has decreased payment for medically necessary treatments, sometimes drastically, while continuing to pay for care that has no scientific basis. We are in an era that is demanding ever more scrutiny on outcomes, compliance with "evidence-based medicine," grading hospitals on meeting certain care delivery guidelines, etc. Why are those standards not being applied to chiropractic care?

What is more concerning to me at a time that health care expenditures are going ever higher is the fact that most of us with health insurance are required to pay for coverage for this type of unsubstantiated care. While Medicare has very strict guidelines for what they will pay for, other insurers are often required by state insurance commissioners to cover all sorts of chiropractic services. Our new plan includes coverage for "spinal manipulations, adjustments modalities; limited to 20 visits per calendar year." Hell, this is a plan without dental coverage! I suspect that if each person that reads this reviews his or her own insurance coverage in detail, they would find medically necessary and scientifically validated therapies that are not covered as those services are too expensive --- transplants, aggressive chemotherapy regimens, etc. We are slowly heading towards an era of care rationing (how do you think they keep costs lower in England), and need to look at where each dollar is spent.

In our community, there are some chiropractors who see their role as basically providing good massage treatment and instruction on muscle strengthening, posture, etc. I think that's great, and arguably something to pay for; there may be a good role for this type of therapy for acute low back pain. Unfortunately, there are many more who have taken too big a swig of the chiropractic Kool Aid and advertise that they provide "wellness care," "family practice," naturopathic endocrinology," natural health care," "pediatric care," and even "pregnancy care." All of these are direct quotes from Yellow Pages ads in my community.

What the......? Pregnancy care? Endocrinology? Wellness? Where does this kind of stuff come from? It all stems from the fact that chiropractic care was invented out of whole cloth, with ridiculously unsubstantiated claims that most health problems stem from spinal problems --- in particular, "subluxation". This is a standard medical term which has been adopted and completely bastardized by the chiropractic community, and one which chiropractors cannot even adequately define:
Chiropractors also disagree on whether their "subluxations" are visible on x-ray films. "Straight" chiropractors tend to believe that they cause nerve interference, are readily visible, and that virtually everyone gets them. Most other chiropractors (commonly referred to as "mixers") define subluxations loosely and see them when it suits their convenience. Chiropractors who reject subluxation theory consider them invisible but have been forced to acknowledge them to get paid by Medicare.
If one peruses one of the multitude of chiropractic web sites, you will discover repeatedly that "subluxations are epidemic in our society."


Why, it seems that even children are in need of regular "correction" of their subluxations, as they are not immune to this terrible epidemic. And what about the littlest members of our subluxation-prone community, newborns? Sure enough, they need adjustment because of "traumatic birth syndrome" (Google it yourself):
All children should be examined by a Chiropractor immediately after birth. Take this critical step to ensure that your children are as healthy as they are designed to be.
With this subluxation problem of epidemic proportions, how does one know what's wrong with oneself in the chiropractic view of things? Rather than link to any particular web site, this chart produced by a designer of chiropractor web sites gives one an idea of the kind of things chiropractors preach: all of the organ systems of the body are directly affected by the spine. Detailed descriptions are found on many web sites; this exact quote can be found on a total of 145 web sites in a Google search (emphasis is mine):
The internal organs supplied by nerves from the thoracic spine include much of the body parts supplied by the sympathetic nervous system. This portion of the nervous system innervates many of the organs in the chest and abdomen including, the heart, lungs, bronchial tubes, gallbladder, liver, stomach, pancreas, spleen, adrenal glands, kidneys, and small intestines. Subluxations affecting these organs can lead to a large list of functional and systemic problems including, asthma, certain heart problems, bronchitis, blood pressure problems, ulcers, allergies, kidney trouble, and digestive problems, to name only a few. Most subluxations affecting these areas go undetected for a long time before a health problem is ever noticed.
And that's just the thoracic spine!

So, if I get this right, almost every health problem imaginable is caused by spinal problems, specifically subluxations; all of us, including newborns and children, need regular "adjustments;" and we should be increasingly utilizing chiropractic care because " Chiropractic restores health, relieves pain and restores life with drugless, knifeless, natural, holistic methods" (from Parker College of Chiropractic). If you think chiropractic care is appropriate for your medical needs, we are fortunate enough to live in a society that allows you to seek out that care. It is worrisome to me, however, that we are being forced to pay for this type of unsubstantiated care through our tax dollars --- even now with the knowledge that much of those funds are being disbursed due to fraudulent billing. Our health care resources are limited, and are now being stretched to their limit; if we need to look hard at evidence-based medicine and have report cards for hospitals in order to ensure appropriate use of those funds, we need to critically look at expenditure of those limited resources on chiropractic care.

There are many more eloquent evaluations of chiropractic care to be found on the internet, and I'd encourage anyone with curiosity to check them out.

Improper Claims on Chiropractic College Web Sites at Chirobase


Nat'l. Council Against Health Care Fraud - Position Paper on Chiropractic

What are the warning signs of a bad chiropractor?

Chiropractic's Elusive Subluxation


Thursday, June 23, 2005

I know I'm opening a can of worms....

Billing Medicare for services rendered can be a difficult process --- there are unending rules, difficult to meet or understand documentation requirements, conflicting regulations, and a coding system that does not cover all conceivable situation. So, when the news media reports that one entity or another has been audited and accused of Medicare fraud, I am often skeptical.

However, this article caught my attention because, in all honesty, I am biased.

The questionable payments in 2001 amount to $2 out of every $3 that Medicare spent on chiropractic services that year. The payments were improper because they reimbursed providers for treatments that failed to meet the government's criteria for medical necessity, or because providers lacked the proper documentation to prove the services were needed, the report said.
For some time, I have tried to get a handle on exactly how much money is being spent by Medicare and Medicaid on chiropractic services. I have downloaded the 39 page report this article is based upon, and hope to come up with a reasonable answer. What may be harder to discover is how much money is spent on chiropractic care by private insurers --- for example, we recently switched health insurance coverage for our physicians and staff. The state requires that health insurance cover chiropractic care, and we were therefore unable to purchase "chiropracticless" coverage; this type of rule drives up costs for all of us.

I'm sure I'll have more to say after I've read the whole thing.

Tuesday, June 21, 2005

New Blog Showcase

One of the interesting things I have found about the blogging world ("blogosphere" just seems to pretentious to me) is how nice most of the other bloggers out there are. I stumbled across the "New Blog Showcase" at My Vast Right Wing Conspiracy, so I submitted a link. Caltechgirl at Not Exactly Rocket Science is this week's host, and she was nice enough to link to me. It's worth taking the time to check out the Showcase every week to see what's new out there. One of the blogs feature this week is Ray's Coffee Break, who writes about one of GruntDoc's recent gripes -- the problems with Formula 1 racing in the US (actually, I have an aversion to that sort of stuff). It's a nice diversion for me to browse through new blogs, and nice to know that people take the time to browse through mine!

OK, so I'm not a computer whiz

Lost all my trackback and comment info ... I apologize to those who were kind enough to comment on what I have written. Comments and trackbacks are back up and running.

Grand Rouds XXXIX

Grand Rounds XXXIX is being hosted by my fellow surgeon-blogger Dr. Bard Parker. Head on over to see the best of the med-bloggers this week.

Monday, June 20, 2005

Vinyl Heaven

Ok, no more bitchin'. I made it home, and SWIMBO & the surglings are out doing all sorts of things....leaving me to make a martini, catch up on paperwork, and start putting that new turntable to good use! Right now, it's the classic early Chicago VI; I love the intro to "What's this World Comin' To?" --- somebody in the background starts out with "we can cut it in any key." I know I sound like my father, but they just don't make music like that any more!

Next up,we'll spin an album that I've never been able to find in any form since it came out --- the Bee's Knees "Pure Honey." Any long-time (as in old like me) observer of the Dallas music scene will know that The Bees Knees was one of the early groups that Anson Funderburgh -- now of Anson and the Rockets -- played in.

Maybe later we'll put on a little Bugs Henderson, and then relax with Dark Side of the Moon. This has got to be the best present the surglings have ever given me!

Screwed -- and Just Bitchin' About It

There are times when I think that my dislike of the legal profession is not just an idle passion. After returning from vacation, I found in the mail both a jury summons and a subpoena to testify in a trauma case. My office had dutifully blocked out the morning requested for my testimony, and I had to block off a whole (operating) day for jury duty. Of course, the assistant DA never bothered to contact me about the trial. Surprise, surprise, surprise.

So, at 4 PM the day prior to my scheduled testimony, my office manager received a call from the asst. DA's secretary to tell her to switch the time of my testimony to the afternoon --- meaning, she had to move about 15 patients to the morning, given an hour's notice. Still, no contact with me; while I had the defendant's name, I did not even know the name of the person I was to testify about!

At 10 AM the next morning yet another call: it's off, to be rescheduled. And sure enough, it's rescheduled for the morning after my jury duty date. And today is my jury duty date (wonder why I've had a few posts?) So, my entire day today is blocked --- I was instructed to call after 5 PM on Friday, and was told "we don't need you, yet; call after 11:30 AM Monday." Stuck in neutral all morning, and I'm eventually told at 11:30 "don't come." I was hoping to get picked to be on the jury I would be testifying in front of ---- as I still had not heard from the asst. DA!

It's now 3:30 PM; my subpoena is for tomorrow at 9 AM. My office manager just informed me that I now have a free morning tomorrow!!!! Because my testimony has been moved, again, to Thursday morning!

I want to help. I want to help put bad people behind bars. But I can't help if I'm really, really ticked off and don't even know what they want me to testify about! Oh, well, it's time for a martini.

UPDATE: at noon today I received a call from the DA's office and actually got to speak to the asst. DA in charge of the case......who (drumroll please) informed me that the judge had put this trial off for another 3 weeks. (sigh) (bigger sigh) (martini craving is setting in, but I'm on call). Oh well, it sure is a lot of hubub for what I suspect will be a grand total of 10 minutes of testimony.

The Open Abdomen -- An Anachronism?

An interesting editorial was published in the Journal of the American College of Surgeons this month (subscription required) entitled "Enough But Not Too Much: Or, Are We The Dinosaurs?" (by H. David Reines, M.D. and Russell P. Seneca, M.D.). It is actually another expression of a concern that many academic, as well as non-academic, surgeons have been mulling over the past few years: are current surgery residents getting enough exposure to "open" surgery in this era of minimally invasive surgery?

As laparoscopic techniques have advanced over the past 10-15 years, they have achieved wide acceptance. Initially, with laparoscopic cholecystectomy, there was considerable concern that surgeons well out of their training would not receive appropriate instruction and preceptorship to perform these operations well. I was fortunate to spend a year during the middle of my residency learning and teaching courses on these (then new) techniques, and this was a concern expressed often by the organizers of those courses. As a result, guidelines were developed to ensure that adequate training was available to surgeons out in practice, allowing patients access to physicians well-versed in this rapidly expanding field. Now, procedures such as laparoscopic splenectomy, colectomy, fundoplication, appendectomy, and bariatric surgery are done commonly in both the academic and private practice arena.

Now, any surgery resident worth his or her salt is going to try to get as much minimally invasive surgery experience as possible. But does that leave them with enough "open" surgery experience? For example, does the average surgery resident finish training with many common duct explorations? Open Nissens? Open cholecystectomies? This is not a moot point, as the "easy" cases will always be done laparoscopically --- when we convert to an open procedure, you can bet that it is because the operation is much more difficult, due to anatomy, bleeding, etc.

So, now we have come full circle. Some in teaching programs are now wrestling with how to ensure their residents get adequate training in open procedures (from the editorial):

We propose that the RRC (Residency Review Committee) and the American Board of Surgery look at their requirements for essential cases and revise them to reflect the rapid rise in minimally invasive techniques. We can find no data on the number of open procedures necessary to make a competent surgeon, only total numbers. The RRC doesn'’t even require “advanced” laparoscopic cases. We need to talk to the young surgeons and the experts who perform primarily laparoscopic procedures, and ask what is necessary to train the general surgeon of the future. If general surgery is to survive, minimally invasive bariatric procedures, splenectomy, Nissen fundoplication, and colectomy need to be taught in residencies. We still need to teach surgeons how to do a hand-sewn anastomosis, close an incisional hernia, and take out a gallbladder through an incision, just in case there is a reason to abandon a scope and do it the old fashioned way. Oh yes, and do this in 80hours a week.
In the best of all possible worlds, newly minted surgeons would take jobs with older, more established surgeons that provide expertise and help ("mentoring," to use the current buzz word) -- here, again, I was and continue to be extremely fortunate in this regard. That is probably not attainable for many graduating residents. It is hard to conceive a situation where the RRC would mandate a certain percentage of cases to be done "open," either: can you imagine the consent form for patients at teaching facilities then ---- "if we determine that the resident helping with this operation has insufficient experience with the open technique, you'll get a bigger incision." That would be about as popular as Howard Dean at a NASCAR event.

In the long run, this type of concern in the era of the mandated 80 hour work week may lead to a push to lengthen an already long residency (see Bard Parker). My proposal would be to try to shift some of the operative experience away from those residents travelling down a different training pathway (i.e., towards plastic surgery, urology, etc.). While that might provide some limited help, it certainly would wreak havoc with those trying to juggle schedule to ensure they don't go over that 80 hour limit.

Mark Steyn on Canadian Health Care

Mark Steyn, as usual, writes with insight and wit about the troubles brewing in the Canadian health care system (if the link does not take you directly there, try the NRO Online page to get there). My favorite bit is this:

I confess to being something of an agnostic on health care. I'm no fan of "insurance" that bears no relationship to the cost of treatment or your likelihood of getting any particular ailment, or of the defensiveness of a medical system that has to keep one eye on John Edwards prowling the wards for clients.

On the other hand, to spot the drawbacks in your medical treatment, you first have to be getting some.
As I said a few days ago, the dike is leaking and about to burst. The problem is that many in our country do not want to learn from our neighbors' mistakes.

Old Dad's Day

I had an absolutely wonderful Father's Day with the surglings yesterday. It was a day to remind me, and them, exactly how old I am getting! The sun was shining and there wasn't a cloud in the sky, so we went on a long bike ride....and I was the slowest. After that, they took me to a local audio store and bought me something I've wanted for several years -- a new turntable. After I got it set up, I treated them to the best albums of my college years (Jimmy Buffet, Pink Floyd, Buffalo Springfield, The Band, Jean-Luc Ponty, etc.) The thing that was the most fun was to watch my son stare at the spinning platter and finally understand that these things aren't just "big CDs." To cap off an evening for the old guy, we rented and watched one of my favorite old movies -- Charade. When I was growing up, I wanted to be just like Cary Grant (for some reason, I couldn't carry it off). It's nice to watch a movie that takes its time setting things up; today, it seems that all movies are expected to move along at a "Star Wars" pace.

Thanks to SWIMBO and the surglings for giving me a great day!.

Friday, June 17, 2005

Orac is the MAN!

Orac at Respectful Insolence has an absolutely wonderful post today about a very poorly researched and one-sided piece of medical "journalism" put out by Salon. The post is long, but well worth your time -- he has gone to great lengths to expose the very biased nature of the Salon piece, which has the potential to do real harm by influencing parents to avoid vaccination for their children. This is a very important issue; unfortunately, as Kevin points out, some in the chiropractic community are on the anti-vaccination bandwagon as well.

Wednesday, June 15, 2005

Underreported Study of the Uninsured

This study garnered two 3-sentence paragraphs in the Business section of my local paper. It is a study by the Employee Benefit Research Institute entitled "The Impact of Immigration on Health Insurance Coverage in the United States," briefly reviewed at Medical News Today. Their "take home points" from the study based on census data from between 1994 and 2003 include:

  1. Immigrants accounted for 26% - or 11,600,000 people - of the USA's uninsured in 2003, a 70% increase from 1994.
  2. Noncitizens were more than twice as likely to be uninsured as naturalized citizens;
  3. Immigrants who arrived in the United States after 2000 were twice as likely to be uninsured as those who arrived before 1970.
  4. 60% of uninsured immigrants lived in four states -- California (27%), Texas (15%), New York (10%) and Florida (9%) (Lipman, Atlanta Journal-Constitution, 6/14).
  5. Immigrants represented 86% of the growth in the number of uninsured between 1998 and 2003.
While Medical News today correctly states that the study did not distinguish between "undocumented" and "documented" immigrants, the graph on page 3 of the study clearly illustrates that 9.4 million, or 21% of the total, uninsured individuals are characterized as "Foreign born, not a citizen." In other parlance, these are illegal aliens; I suspect that number is a significant underestimate. While these folks are uninsured, they are not denied care when they arrive at your friendly local ED. The study basically blames Congress for this rise in "uninsured immigrant" population, as in 1996 it passed the Personal Responsibility and Work Opportunity Act, which restricted benefits under public assistance programs for five years after they enter the US.

A lot of much smarter people than me can debate circles around me fast enough to make my head spin as if Angelina Jolie gave me one of those delicious, "I'm a homewrecker" sneer-smiles. But if we are going to talk about these complex issues, I would ask that some simple, understandable terminology to be used:

  • An illegal alien is an illegal alien. As in "illegal." As in "not entitled to taxpayers' money." "Undocumented" is an intentionally misleading description.
  • A legal immigrant is "legal," having gone to the trouble of actually becoming a citizen of this country, with all the good and bad that entails.
  • "Uninsured" is not synonymous with "unable to get emergency medical care." Each and every medical blogger can explain that when people show up at our door, we take care of them. Period. It is charity care, but people should not be so naive as to believe that the costs of delivering that care are not passed on to the insured population.
Stating that we have a problem with illegal immigration is not racist, xenophobic, greedy, or any of a number of other nasty things. It is simply stating a fact. How we deal with that fact, and its economic ramifications on the healthcare system (and the educational system, taxes, etc.) is what needs to be debated ....... and in order to have that debate, we need studies such as the one above to be clear in their definitions. It does none of us, or our policy leaders, any good to work with numbers that are skewed because of political considerations. For example, 70% of the uninsured in this study are described as native Americans. How many are working? How many are children under 18? Children under 10? Single parent households? Between jobs? Elderly? Have been uninsured their entire adult lives? Have lost employment due to illness? Make enough money to purchase insurance, but choose not to? Have a job that offers insurance, but do not purchase coverage for their children (something I see not infrequently)?

Health care in this country is severely affected by illegal immigration, but it is a minor part of the entire problem. We need to get out of the politically correct arena and have a real debate, with real data, in order to decide what is best for the country.

The Train Wreck that is TennCare

Dr. Rangel gives a blow-by-blow account of the TennCare fiasco, laying out in painful detail how this disaster unfolded (as was predictable). It should be required reading for all members of the US Congress, and any other fool who thinks that a single payer, universal access system is good for America.

It is interesting how so many in this country see the problems we have with health care, which have blossomed with the fertilizer provided by government regulations, and ask for yet more fertilizer!

Hat tip to GruntDoc!

UPDATE: See Dr. Tony's thoughts -- he actually has to work in the TennCare system.

Convertible Envy

I'm not sure what primeval instinct drives the modern man to desire certain types of cars. While I've never given in to car lust, I certainly suffer from it. So, at age 43, with more gray in my hair than I'd like to admit, I periodically want to throw myself at one car or another --- almost always a convertible. So, when my ED colleague (an unmarried lady) told me the other night she dumped her Saab convertible for one of my dream cars, I started getting convertible envy. She bought this beautiful Beemer:

Ok, it's not practical, and at a base price of $76,900, not cheap either. So, adding insult to my injured pride, while I was having a beer to soothe my feelings the next night, my neighbor drives up in one of these (you could hear it about a block away; what a sweet sound). It was apparently a real, honest-to-God Shelby, not a knockoff; the whiplash I got can testify to it's horsepower. I didn't ask about the cost (he's a dealer). I did ask if it was a reasonable substitute for Viagra.

As a result, my desire for a convertible starts to soar -- especially with spring and early summer giving us great weather. So, I start to drop hints to SWIMBO: "Wouldn't it be nice to go out to dinner in one of these?"

I have always wanted a TT, with those great leather seats that look and feel like the catcher's mitt I had in 8th grade:

"But what about the surglings?" SWIMBO asks. "We need something that our eldest surgling can drive next year when she's 16, and learn on in the meantime." Wailing and gnashing of teeth ensue, and all of my dreams go up in a puff of money -- used to purchase a safe Toyota. Oh, well. Maybe in about 7 years, when the littlest surgling heads off to college, I can get my Porsche. Then again, maybe not!

Tuesday, June 14, 2005

Grand Rounds is in session at Red State Moron. Git your coffee mug and git some learnin' done!

Monday, June 13, 2005

Pay for ED Call

Just another bit of information to mull over in regards to the difficulty community hospitals are having providing specialty coverage for their emergency departments. There is a brief article in this month's ACS Surgery News (page 3), which is certainly thought provoking.

  • About 64% of physician executives surveyed reported having a problem getting specialists to take call at their hospitals. Many of them -- about 47% -- report that their hospitals are coping with this problem by paying specialists to take call.
  • Emergency physicians have a different take on the issue, however. It's often the hospitals with the highest number of uninsured patients that face shortages in specialist care........but those are also the hospitals that are least able to provide stipends to physicians. [I'd say that is certainly understandable; if one takes call at a hospital with a large uninsured population, there is a lot of work required for little compensation. A.D.]
  • Paying stipends to physicians to take emergency department call is taking away from other services and the funding for uncompensated care. [There are provisions in some areas for the government to partially pay for the care of the uninsured --- to the hospitals, but not to the physicians. A.D.]
I don't have any great ideas as far as this is concerned. Once again, as long as reimbursement keeps getting ratcheted down (another 4.6% decrease in Medicare payments are expected next year, for example), folks are going to have to look at getting paid for things that have previously been provided for free as "community service." The same set of problems that is driving this is driving the creation of specialty hospitals. For the record, I am compensated for providing trauma call for the hospital (Level II trauma center), as we are required to stay in the hospital round the clock, etc; I am not paid for taking general surgery ED call.

Sunday, June 12, 2005

CT Colography

Although it's not from a typical medical journal, this article on CT "Virtual Colonoscopy" is an interesting read. The procedure has a few pros and cons to consider (emphasis mine):

While CT colography has numerous advantages in comparison to other leading screening tests, such as high patient acceptance, safety, lack of sedation, and extracolonic review during polyp screening, it also has several limitations, including inability to perform simultaneous detection and removal of polyps, exposure to ionizing radiation, and requirement of colonic cleansing with cathartics.
I think the biggest issue with virtual colonoscopy from a medical perspective is the inability to remove or biopsy polyps that are the patient then has to undergo a second, "non-virtual" colonoscopy, preceded by a second bowel prep. I find that patients complain the most about the mechanical bowel prep, rather than the procedure itself; presently, a mechanical prep is still required for CT colography, but "fecal tagging" (see article) may reduce or eliminate that requirement.

Overall, I suspect that patient demand will continue to push this procedure along. A multicenter trial is underway to try to determine if "virtual" colonoscopy is as accurate as "real" colonoscopy -- patients are being sought here.

The Dike is Leaking

Lots of folks have had plenty to say about the recent Canadian Supreme Court ruling which struck down a law banning private health care insurance --- see DB, Dr. Andy, and Kevin, M.D. for thoughts and comments. Perhaps the reasoning behind the decision can be summed up by this quote from the ruling itself (emphasis mine):

"The evidence in this case shows that delays in the public health care system are widespread, and that, in some serious cases, patients die as a result of waiting lists for public health care," the Supreme Court ruled. "In sum, the prohibition on obtaining private health insurance is not constitutional where the public system fails to deliver reasonable services."
I won't belabor the many ills of the Canadian system --- most physicians in the US have a ready source for that kind of information in the form of colleagues who are Canadian expatriates. And, I won't belabor the purported benefit of the system -- universal coverage -- in comparison to the US. What I think can be said, however, is that the cracks in the Canadian system would have shown up much sooner, and be much deeper, if many Canadians had not had ready access to care in the US (at their own expense).

While this decision may be a way for the Canadians to start moving away from total government control of their health care, I am afraid that we in the US are firmly headed in that direction. What would our system look like if all were covered by Medicare and Medicaid? Would we end up with lines, waiting lists, and worse care? I believe so, but in the current climate of "sound bite" politics, it is easier to propose "universal coverage" than it is to design a system that works.

UPDATE: Monday June 13th -- The Wall Street Journal has a good editorial on this today. As usual, their ability to write far outstrips my meager efforts. To me, the pithy part of the editorial states:
The larger lesson here is that health care isn't immune from the laws of economics. Politicians can't wave a wand and provide equal coverage for all merely by declaring medical care to be a "right," in the word that is currently popular on the American left.

There are only two ways to allocate any good or service: through prices, as is done in a market economy, or lines dictated by government, as in Canada's system. The socialist claim is that a single-payer system is more equal than one based on prices, but last week's court decision reveals that as an illusion. Or, to put it another way, Canadian health care is equal only in its shared scarcity.
It's worth taking the time to read. I suspect you already know that I would not recommend reading Paul Krugman's take on things (I wouldn't even spend the time to link to it.)

Saturday, June 11, 2005

Altered States/Altered Anatomy

All physicians are acquainted with normal anatomy. What can be hard, however, is to know what happens when folks like me alter that anatomy.

A 25 year old young lady presents to the ED with a 12 hour history of vague mid abdominal pain. The pain is across the mid abdomen, radiating through to the back. She denies nausea and vomiting initially, but subsequently admits to some "queasiness." Normal bowel function. No fevers. The pain has been persistent, and by the way, has occurred to a lesser degree on three other occasions since she underwent laparoscopic RYGB (gastric bypass) a few years ago. This pain prompted laparoscopic cholecystectomy several months after the bypass.

She has a completely normal lab evaluation, with a white cell count of 5K and a normal differential. Plain abdominal films are normal. Her exam is very benign, but she complains of discomfort in the right and left mid-abdomen. Next stop: the CT scanner. Score one for the ED -- gotta give due credit to the ED physician (as much as it pains me, GruntDoc and Dr. Tony) for ordering it, with no real abnormal findings and a very unremarkable exam. When going through the images, there is a very obvious abnormality occupying the middle of the abdomen (circled):

There is a large, sausage-shaped soft tissue density in what appears to be the small bowel mesentery; on the larger view, vessels can be seen, and the mass has the density of essentially water. A second view from a few cuts lower:

Once again, the majority of the mass is significantly lower in density than the normal fat of the mesentery. There is no dilated bowel anywhere in the abdomen (arrows denote normal caliber small bowel):

The radiologist's differential diagnosis includes lymphoma, sarcoma, inflammatory change, and hemorrhage. The key, however, lies in the area just above the fluid density mass:

There is a "swirl" in the root of the small bowel mesentery (circled), indicating a likely volvulus. This is certainly a soft call, but given the known history of altered anatomy with a Roux-en-Y, there is the possibility of an internal hernia. An internal hernia is something I've encountered before, but the mass seen on this CT is certainly not typical.

With persistent pain, abnormal CT, and potential for an internal hernia, we needed to spend a little time under the bright lights of the OR. Upon opening the abdomen, we were greeted with a modest amount of chylous ascites (milky white fluid resulting from obstructed lymphatic drainage). The fluid-density mass seen on CT was a large portion of the small bowel mesentery which was acutely and chronically edematous due to a large volvulus accompanying an internal hernia. The base of the mesentery was quite thick with edema, and its periphery (along with the mesenteric aspect of the small bowel -- the entire ileum and half the jejunum) was bright white with chyle in obstructed lymphatics. Interestingly, unlike a more typical presentation, there was absolutely no bowel obstruction. Here is a series of films of a more classical presentation of internal hernia (click the arrows for all of the pictures). This abstract lists the 7 most common CT findings of bowel obstruction in post-RYGB patients.

It is easy to overlook that often the difficulty in caring for gastric bypass patients is not the actual surgery -- it is being aware of the potential complications of that operation, both acutely and long term. Without an ED physician aware that these patients can do "funny things," she would not have had a CT. Without the knowledge of her altered anatomy, it would be easy to take a "wait and see" approach before operating; this can lead to ischemic bowel and a much worse outcome. For these patients, if there is any doubt, the OR is a very good place to be.

Thursday, June 09, 2005

Great Medical Blogging

Where to start? I missed some great medical posts while I was toiling away at the beach (hey, it's hard to track that bartender down sometimes!).

The ever interesting Orac got appropriately incensed by comments made in a post at Pharyngula:

Surgeons and other medical staff are the equivalent of technicians, engineers, plumbers or carpenters. They are not scientists. They are not studying the details of the relevant science. They don't have to understand it - just carry out procedures by rote. Though the ones who do have a clue will be a lot better at adapting to new circumstances because they'll make more correct guesses based on their understanding than the clueless ones will.
Gee, all along I thought that college and medical school diplomas on my wall, and the six years of training that followed it, represented a little more than what one might expect to get from ITT Tech. Fortunately, we have comments like this that amply illustrate the need to improve our educational system -- starting with elementary school, which seems about as far as this commenter got. See Orac. Read his post, and you'll understand that evisceration is too nice a word to use to describe how he goes after this guy. Believe me, evisceration is best left to us technicians.

Bard Parker has two insightful posts that concern what I would term "trendy" medicine. The first analyzes an article in Annals of Surgery which is one of the few studies that critically evaluates whether the mandated 80 hour work restriction has actually produced its intended effects: are errors being reduced? The answer is, as I have long suspected, not really. In fact, as Dr. Parker shows, decreasing resident experience may be leading to more problems ..... and that will be magnified when these residents eventually make their way into private practice. Dr. Tony throws in his two cents here.

The other post I would point readers to is a good review of this WSJ editorial concerning the British Health Service. Kitty was kind enough to point me in this direction as well.... but I was too far away from a computer to get to it in time. Dr. Parker's post is worth reading, as is the original article. I don't think that anyone aside from a few on the far left really believes that the British system would be a good replacement for our own, but too many people in the US get sucked in by the "universal care" mantra without looking critically at what goes on in their hospitals (more problems exist in Canada).

Finally, Kevin had a great post today about practicing defensive medicine. Who does it? Virtually all of us. Why? I think the term "defensive" should be self-explanatory. He's asking for e-mails from those who have clear-cut cases where they have had to do more, rather than what is actually necessary, to provide "CYA Insurance." I'll be sending mine, and encourage others to do so as well.

That's it for now. It's 2 PM where I was a few days ago, 6 PM here, and my body feels like it's 3 AM.

Burning up on Reentry

So my alarm clock goes off at the usual 5:30 AM today, and my head starts to wail like a David Gilmour solo, thumping like I'm waking up from a three day tequila bender (gee, sort of like college). Yep, vacation's over, and reality is starting to sink in. I have always felt like returning from vacation is like returning from space, only without those nifty heat-resistant tiles. On arrival to the office, one peek at my desk tells me that my worst fears have arrived in the form of an inbox so full of paperwork that it looks on the verge of collapse. Phone calls to return, lab and x-ray reports to review, a jury summons(!), a subpoena to testify in a trauma case(!!), 6 journals, and pathology results that need to be conveyed to patients fill my next few hours. Then a full office follows --- and I am so discombobulated by travel through time zones that it feels like August, 1975.

On the bright side, I find that the unbelievably sick patient I left in the ICU is alive and slowly improving. For this I give thanks to the Holy Trinity of the private practice surgeon: Good Partners, Good Colleagues, and Good Nurses. I am blessed to work in a place with all three; while away, I certainly worried about the patient, but never about the ability of those caring for her.

What I found interesting was a new experience on this vacation. I felt guilty about not blogging, and not reading the interesting thoughts of other bloggers. My site gets a paltry few hits, so my guilt is really directed inward, I suppose. Hopefully later I'll have a chance to see what's been going on out there later in the day.