Sunday, December 24, 2006

Publication Frustration

If I were my 13-year-old son, I think my response to this article would be "well, duh!" As it is, my response is hardly suitable for a family publication like this. From the conclusions in the abstract (all that's available without a subscription):

The mortality rate for class C cirrhotic patients posttrauma continues to be higher than that predicted by TRISS (trauma injury severity score), although patients with less severe hepatic dysfunction do not appear to have significantly lower than predicted survival. The degree of hepatic dysfunction remains an independent predictor of mortality and CTP (Child-Turcotte-Pugh) C criteria must be considered when determining outcomes for patients posttrauma.
OK, let me review:
Cirrhosis? Bad. Cirrhosis + Trauma? Real Bad.

Did we really need yet another publication to get that simple point across? It's as if the authors of this retrospective review of their trauma patients seem to think that us hick surgeons in the sticks don't understand basic medicine. Oh, and although they offer ab-so-lute-ly no evidence in support of this statement, the last sentence in the article contains this gem:
These patients should be considered high-risk patients and should be cared for at a Level I trauma center.
OK. I get it. These are sick patients. In fact, this review of statistics at the authors' own Level I trauma center demonstrated a 64% mortality rate (9 out of 14) for trauma patients with Child's Class C cirrhotic patients --- so what exactly do they feel that a Level I center can provide that a Level II center cannot for these patients when they have demonstrated such a dramatic mortality rate? Well, the article holds no such answers.

Of course, when faced with a drunk driver who has just driven his VW Microbus into a telephone pole and is covered with blood and vomit, the first thing I do is calculate his Child's classification. What rubbish!! Our job is to care for the patient, and it would not be readily apparent that a patient had significant cirrhosis upon presentation --- when his most critical care will be delivered. I guess we should have a crystal ball available so that we can simply whisk the Child's C patients (but not the As or Bs!) off to the Miracle CenterTM with the Level I designation provided from on high.

What most of these number crunchers fail to realize is that trauma severity scores, Childs classifications, and a whole host of other "scoring" systems that have been developed to statistically analyze patients have absolutely no -- none, nada, zilch, the big goose egg, zippo -- clinical utility when we are actually caring for a patient. Clinicians do not calculate patients' "scores" while caring for them to make decisions; the final score tallies are often not done for days (if not ultimately at discharge). As a result, they are helpful in retrospective reviews of treatment, but by their very nature cannot be utilized to make prospective care decisions. Until these authors, or anybody else, can come up with some treatment strategies that differ from our current mode of therapy based upon CTP classification in trauma patients, I would suggest they report the facts and not make sweeping suggestions that "all such patients should be treated at your local Miracle CenterTM."

Sorry for the rant --- since I had to work on Christmas Eve, I thought I would catch up on my journal reading. Big mistake! Have a Merry Christmas!

The Train, The Train

Being sort of obtuse, I often find it useful to try to explain things to patients and their families using metaphors that make sense to the two Betz cells desperately clinging together for survival in my skull. I guess that is also the reason I pepper these random blog posts with pictures --- it seems I never graduated from the Dr. Seuss phase of my life.

In any event, I am not infrequently faced with presenting options regarding chemotherapy. I am not a medical oncologist, but it is certainly common (and, I think, normal) for patients to ask the opinion of the guy they let open their body cavities when they are weighing the pros and cons of chemotherapy. Given my innate inability to think creatively, I of course turned in my search for a suitable metaphor to that great guiding light of my misspent youth -- TV. Being a mere youngster at age 44, that means that glorious period in TV history dominated by the master of schlock, Aaron Spelling --- big hair, big b**bs, small plots. All in all, probably very bad juju for a teenage boy.

But which of these great shows would be best as a starting point? Starsky & Hutch, The Love Boat, Dynasty, TJ Hooker, Vega$? No, I had to look to the epitome of Western civilization in the 1970s -- Fantasy Island! Who could forget Tattoo shouting "Boss! Da plane! Da plane!" Ah, memories --- what, you haven't watched these over and over yet?

Da plane! That was it! And so, for a while I thought that taking a plane ride would be a reasonable way to explain chemotherapy --- you pay (a high) price for a ticket to reach a certain destination, and you cannot reach that destination easily in any other way. But I found as I thought about it that a plane ride really doesn't explain easily the potentials that a course of chemotherapy, or radiotherapy for that matter, can present. Fortunately, I didn't blow a fuse coming up with another, similar yet hopefully more helpful metaphor. And I can still pretend I'm Tattoo ---- Da Train! Da Train!

I think I can best explain what chemotherapy means to (most) patients is by describing that it is sort of like taking a train ride. One can get on a train in, say Denver, and plan to travel to Chicago. But there are two important things to remember about that train:

  1. There is no way to play "catch-up." In other words, if you plan on making it to Chicago --- if you plan to achieve the maximum benefit from a proposed course of therapy --- you have to get on in Denver, as there is no way to run the train down in Omaha and get on there without a whole lotta cost to your potential outcome.
  2. The train makes stops. If you get on the train with full intentions of making it to Chicago, but for one reason or another --- if you are simply flat done in by the therapy --- there is no train conductor that will force you to continue all the way to your destination. You can get off in Omaha or Des Moines, or anywhere else you feel like.
Of course, some train rides are considerably longer --- and more exhausting. Some trips require the traveler to get off and reboard a different train, or even change courses entirely. And some patients require series of different "rides" on different trains in order to reach their ultimate destination.

Some patients, presenting with disease that is beyond our current therapies, can never reach the destination they desire more than any other --- a cure. This is the most difficult scenario for me to approach of all, as it feels as if I am walking a tightrope between offering a pessimistic outlook and one that is overly optimistic. However, if we appropriately counsel these patients that a reasonable degree of palliation while trying to preserve a reasonable quality of life is a worthy goal, then they can "board the train" with realistic expectations ---- and when it is plain that staying on the "train" has limited or no potential for further "travel," it is easier for the patient and their family to get off the ride and stop the treatment.

And then, at the risk of stretching this metaphor to a breaking point, neither we nor they will "Train in Vain."

Saturday, December 09, 2006

Saturday morning surprise, surprise, surprise

I have to admit, I was surprised. After this year's election results, and all of the speculation and posturing that ensued, I seriously doubted that the outgoing Congress would make any serious attempts at legislation during the "lame duck" session. So, it was without warning that coffee spewed from my nose while I took in this morning's paper --- buried in an article (I can't find the original one from my paper online) about a last minute massive bill was this little tidbit:

Also driving the massive bill was an effort to prevent a 5 percent cut in Medicare payments to doctors scheduled to take effect Jan. 1 under a complicated government funding formula.
I will freely admit that this was a surprise, and one of no small magnitude. I don't anticipate that it will last forever, as the cold hard realities of Medicare funding will at some time catch up with us, but it's welcome just the same. At least 37% of my patients are Medicare recipients (with a much higher percentage if we look only at inpatient consults), so a 5% or greater reduction in payment gets my attention --- not to mention that all of our contracts are based upon RBRVS formulas, so we would absorb that reduction for insured patients as well.

Now, if I could just get the coffee grinds out of my nostrils....

Sunday, November 26, 2006

Fly me away to the OR

In my last post, I brought up the issue of the current push to ensure that docs and hospitals should meet a whole series of quality improvement measures. Many in the business world (such as the Leapfrog Group) look upon medicine as a rag tag bunch of people who are trying to do the right thing, but need better management to reign in complications (really with an eye to reigning in costs). They, correctly, point to the success the airline industry has had in establishing an excellent safety record; we could learn a lot from these folks, IMHO (actually, there is a good review of airline safety applicability in the July, 2005 issue of the Journal of the ACS -- "The Aviation Paradigm and Surgical Education"; McGreevy JM, pages 110-117). But I do think it's a bit over simplistic to compare health care delivery to the delivery of people and goods via aircraft. Here's the best way I can describe the differences.

You buy a ticket to go from Dallas to Chicago. You check in, board the plane, and are flown with a surprising degree of ease to your destination by a pilot who will then shepherd the same plane on to Boston, and maybe points beyond. After a certain period of time, he will fly a similar plane on a similar set of routes. Cool. You don't think twice about all of the little things that go into a successful flight --- the mechanics, the safety checks, the fuel, weather issues, etc.

Now let's compare the pilot to, oh, I don't know, a general surgeon (what I lack in imagination is made up by a complete deficiency of imagination), and that surgeon will do four operations today. The first is a laparoscopic cholecystectomy on a healthy 50 year old; the second is an incisional hernia repair on an obese, diabetic, hypertensive 70 year old; the third is a colectomy for cancer on a reasonably healthy 65 year old, who had an MI last year; and the fourth is an urgent laparoscopic cholecystectomy --- but that patient is put at the end of the day, because she is on Coumadin and needs to have her anticoagulation reversed, carefully though because of her CHF. Please don't laugh --- I have these types of days not infrequently.

That, to my way of thinking, is sort of having the pilot above start out flying on a nice sunny day in a 737, switching to an aging 747 that's not in the best of shape for the next flight, flying as carefully and straight in a thunderstorm for the third flight, and then trying to safely land a Sopwith Camel with one wheel missing at the end of the fourth flight.

I'm not trying to say that what I do is in any way more stressful or difficult than what others do for a living; this comparison is itself overly simplistic. I am just trying to make the case that each doctor-patient interaction is not the same, and some are vastly more challenging than others --- and that coming up with an absolute set of parameters that must be met in each and every instance is difficult, if not impossible, and will not be applicable in a large number of cases.

Medical Staff Credentialing --- c'est finis

I'd like to try to wrap this series of posts up by discussing what happens beyond the realm of the training program. If our hypothetical "marginal" resident makes his way into the real world, and if he then does not receive appropriate mentorship, he may fall into bad habits and poor practice patterns, eventually encountering complications. What is to be done?

In an ideal world, he would be given the opportunity to be taken in by a group of more experienced physicians, who would be responsible for monitoring his progress and thought processes, with an eye to ensuring that he could re-emerge from this "apprenticeship" as a more functional doctor.

Let's be honest. That ain't never gonna happen.

Why? Well, there's too much at stake on many levels. First of all, the physicians in his community are (a) not a part of a teaching program; (b) his competitors; and (c) liable for his actions if he is under their wing. Secondly, community hospitals are not set up for this kind of ongoing training, and could similarly be held liable. Finally, there are practical issues that come up --- somebody has to take call with him, see all of his patients, look at his notes, etc., and that takes a lot of time, and generates a lot of expense.

An alternative would be to return this surgeon to his residency program, requesting further training (6 months? a year?) with reevaluation upon completion of such training. Actually, these types of arrangements are (extremely rarely) constructed, but I do not have any information about how successful they are. But, when you think about it, the training program may say "Hey, we just gave you 5 years to get this stuff down pat. What makes you think more time with us would make any difference at all? Sorry, you've gone past the point of no return." And they would probably be right.

And so, it often comes to pass that before this type of surgeon has real troubles, he makes his way to another hospital system, sometimes another state, and may or may not have similar issues in the future (I'd bet a few bucks on the former). And because it is damn near impossible for hospitals or state agencies to communicate even egregious problems, he will likely have no difficulty getting staff privileges.

Right about now the non-medical type who has been patiently reading this just had coffee spew out of his nose --- do you mean to say that a physician can even completely lose his hospital privileges and easily obtain them elsewhere? Even have state medical board problems and get a license to practice in another state? The short answer is --- you bet your booty. The long answer is that state medical boards are all autonomous, and there is no uniformity in how they license physicians, how they report problems, etc. And hospitals are a big fat legal target if they pass along details of a physician's history without careful attorney oversight. And that, in most cases, is a damned shame.

Except, of course, when it's not. Remember that Lady Justice carries something other than her scales -- she packs some old-fashioned heat! There are countless cases of physicians who have had their careers ruined in one facility/town/state by overzealous peer review, false reporting of complications, etc. And that is where a good lawyer can be (OH GOD, I CAN'T BELIEVE I'M GOING TO TYPE THIS) a physician's best friend.

So really, in the end, I don't have a perfect solution for this particular problem. I do believe that there are occasional graduating residents who might be better served with further training, but how that can be accomplished is hard to see. As far as hospitals, state medical boards, and ultimately the public being able to separate the wheat from the chaff, here are a few significant hurdles that need to be overcome, along with some "if I were king" suggestions:
  1. There is a total lack of uniformity for physician licensing among state medical boards. Gee, doesn't it seem that we could establish a pretty solid minimum set of standards?
  2. There is inadequate reporting between state boards when physicians have their licenses restricted. Hey, guys, it's the internet age. Electronic communication of these basic, fairly infrequent issues should be as easy as setting up a blog.
  3. At least in my state, hospitals are required to report to the state medical board when a physician loses his privileges or has them restricted; however, that information is not always readily available to other hospitals in the same state. Once again, if we are in the business of trying to deliver high quality care and protect patients, all hospitals in a given state should be able to at least be informed when this type of restriction arises --- with, of course, notification if and when these restrictions are lifted.
  4. What about physicians who have no hospital privileges? In this era of hospitalists, the numbers of docs who practice in a purely outpatient setting is growing by leaps and bounds. I'm afraid that I have absolutely no idea of what to do here; we have to rely totally on the state boards for these folks.
  5. What responsibility do insurance companies have? Ooh, boy, talk about adding a 64 oz cup of coffee and a pound of salt to my blood pressure. It seems totally incongruous to me that an insurance company would choose to keep a physician on their panel who had lost their privileges at a hospital they do business with --- without doing due diligence at least. They are caught, however, in a legal trap, damned if they do....
  6. What about the current push to ensure hospitals and docs meet a whole raft of quality measurements? This could be the subject for a textbook, much less another post, but the bottom line is that measurement of a whole series of individually complex doctor-patient interactions is a bit harder than it seems.
  7. Shouldn't the peer review process be enough to make sure that "problem" doctors are weeded out? Actually, yes, but the reality is much more difficult. Peer review is a careful process, designed to ensure that the physician being reviewed is not unfairly reprimanded; as a result, it can take some time to remove "problem" physicians from a hospital staff. And that can cause further legal issues -- in fact, some attorneys are working hard to make peer review processes discoverable, which would ensure that no sentient being would ever again serve on a peer review committee.
  8. Who should be in charge of making these changes? That's easy. Me -- we just need to negotiate a bit about my fees.
I apologize to anyone who has taken the time to wade through this morass and feels it was wasted. Medicine is a complex field, with little uniformity in just about every area you look into, but we all understand the need to ensure that quality care is delivered. The definition of quality is, however, hard to put one's finger on --- and in all honesty, it is often defined as Supreme Court justice Potter Stewart defined pornography --- I know it when I see it. It would be prudent for anyone interested in trying to make (needed) changes to work one step at a time, rather than trying to throw a Hail Mary pass.

Friday, November 24, 2006

Medical Staff Credentialing -- II

Now that I've had time to digest a little turkey, it's time to dive back into the medical staff credentialing issue introduced in my last post. If you were reading, I ended with a few questions about a hypothetical surgeon who is having "problems" in practice:

Why would this be his biggest mistake?
Why in the H-E-Double-Hockey-Sticks did "they" let this guy out of residency?
Why does this really matter?
Why can't we "fix" this problem?
One among many difficulties in training a physician is how to appropriately mentor him or her --- and identifying those physicians that need more than your average dose of mentoring. Actually, I don't really care for the word "mentoring," as I think it implies a greater responsibility for the trainer, rather than putting the onus on the trainee where it more properly lies. I prefer to think more in terms of apprenticeship, which residency more closely approximates.

In any event, we have over the years established fairly rigid time frames for producing practicing doctors --- in the case of general surgeons, almost all training programs are 5 years in length. It is anticipated that upon completion of 5 years of training that all of the general surgeons who graduate are reasonably similarly educated, and can be assumed to have a similar skill level in caring for patients. But ask any parent of a college-aged child and they will regale you with stories of kids who take 4, 5, 6, etc. years to get a degree ---- not always out of laziness. So it may be reasonable to assume that for some training physicians, the "standard" residency term is not long enough (I shudder at the thought of longer residencies!).

If we make that assumption, then training programs are charged with deciding who either needs more time in residency or who should be forced to find an alternate career path --- and that, as the saying goes, is easier said than done. Just try telling a 3rd year surgical resident that he is not cut out for the job --- and then call your lawyer as soon as that discussion is over. Long gone are the days that allowed program directors great latitude in these matters --- and extending residency training time involves not only legal issues, but monetary ones, as CMS only funds a certain amount of training. And this is how in the H-E-Double-Hockey-Sticks "they" let this guy out of residency.

With these difficulties, it is then easy to see that the occasional (and I emphasize occasional) less qualified resident makes his way into the real world. The best possible place for him to land, then, would be in a group practice surrounded by physicians who have several years of practice under their belt ---- from whom he could continue to learn. There is no question that I learned a tremendous amount from my senior partners over the years, and that has allowed me the self-assurance to ask for help when needed. If the less-than-fully-qualified resident lands in another situation, he very well may flounder, and end up digging a rather deep hole completely unintentionally.

So, this hypothetical surgeon gets what by all objective measurements is good training, but not quite enough for him. He then takes a position that does not provide him with what he needs most, the steady hand of one or many experienced mentors. And then he has what every other surgeon who has ever picked up a scalpel has ---- complications. Because we all have complications, unless they are so grievous and unusual as to generate scrutiny quickly, it takes a while before they reach a "critical mass" that causes a group of his peers to point out that, hey, there's a problem here, and initiate a closer look at his practice.

Is this now someone who should continue to practice? If not, is he a candidate for "salvage?" This is (part of) what Rita had to say:
I've met the somewhat bumbling average resident you describe - more than once. And you're absolutely correct - many average Joes can become stellar performers with a bit of mentoring and guidance. Unfortunately, established physicians who do not work with formal programs in teaching hospitals are often afraid to put their own practices at potential legal risk in order to mentor the new kid. I suspect that this is a case of "fear making the wolf bigger than he is," but the "wolf" of potential litigation does indeed prowl just outside the door.
I do believe that there are some potential areas that we could improve to ensure that we protect patients and ensure appropriate training, but they would not be easy. So, if I were king, here are a few things I would enact:
  1. Allow residency program directors more latitude in deciding who should [a] continue their chosen specialty training and/or [b] who needs more training. Perhaps the various Residency Review Committees could establish guidelines for making those decisions at certain times during training; unfortunately, they have a tendency to focus a bit too much on testing data (such as the), and I would prefer allowing program directors to make these decisions based purely on clinical performance.
  2. Establish formal cooperative arrangements between training programs, so that the resident who needs longer training has the opportunity to get at least a part of that training in an alternate, unbiased arena.
  3. Establish a uniform appeals process, so that residents who are asked to leave a training program or undergo further training cannot run to the nearest sympathetic lawyer and make the whole thing into a circus.
  4. Encourage graduating residents to look primarily for established practices to join --- perhaps the ultimate impossible dream (and I am the prime example, given my original practice).
These suggestions are, of course, as impossible to enact as they are impractical in many respects. However, they represent an acknowledgement that there are areas for improvement.

Now, what do we do with our hypothetical surgeon, who has not been able to train under the rules of my kingdom? On to the next post, a look at credentialing for hospitals and insurance companies, as well as peer review.

Tuesday, November 21, 2006

Medical Staff Credentialing - Part the First

There is an interesting, brief post at Rita's place about medical credentialing that has piqued my interest. Actually, given the difficulty I have had with sleeping/thinking/etc. that I described below, it has been a pleasant diversion to think about this topic --- which, by the way, is near and dear to my cold, rock-hard heart. Here it is, in its entirety:

I was recently introduced to a Chief Medical Officer who opened our conversation with, "As far as I'm concerned the medical credentialing system in this country is broken."

My response? "You'll get no argument out of me."

In this age of global communication and technology why must we gather, validate, and store the same information on the same individuals repeatedly, (and often simultaneously to one or more of our colleagues)? Law, interpretive guidelines, and accreditation standards mandate some of the redundancy, but as the healthcare system's credentialing experts, do we allow habit and fear to block our minds to the exploration and development of new concepts?

Something to consider.

Something to consider, indeed. So, without a single moment's pause, I dashed off my typical comment --- rash, unconsidered, and usually including some (well-deserved) attorney bashing:

I agree -- the current system is not one that provides for the best possible care to be delivered at each institution. However, despite the original intent of the privileging process, it has never been one that would be up to that task. Our current system is designed to prevent hospitals, hospital boards, and physicians on peer review committees from being sued (see what happened at Presbyterian Hospital in Dallas recently).

And that, while sad/ridiculous/disingenuous/etc., is a reflection of the tort system we live in.

{While searching for links to the Presbyterian Hospital saga, and the huge award it will have to pay, I discovered that one of my close high school friends is an attorney in the firm representing the plaintiff. Dear God, help me figure out how a Jesuit education produced that!}

Anyways, back to the topic at hand. For argument's sake, let's create the perfect "problem child" physician. He (let's forget sexist issues for the moment) is an average student, who graduates from the average medical school (not in Lake Wobegon) and is accepted to an average residency. Because I have some experience with this arena, let's say he is a resident in general surgery.

Soon, issues arise. He's late for rounds. He doesn't always answer his pager. He's not the prototypical "stellar" resident, and fumbles enough for answers while being pimped by senior residents and faculty that everyone suspects he's just not quite cut out for life as a surgeon. But, at other times, he shines like a 16-year-old boy's first car.

The years roll on, and he is promoted; he may be shuffled off into a lab year, just so the folks in charge of his education can watch him a bit more closely. Upon returning to clinical rotations, he starts to have a series of blunders --- operative, at times, but mostly errors in judgement. By this time, however, he's a senior resident and the errors really aren't felt to be that bad, and it's really, really hard to not graduate someone from residency......so off he goes, to the real world.

The real world, mind you, is unsuspecting. Just as we expect that a new car will always perform up to its advertising, we expect that a newly minted and trained physician will be a widget that we can plug into a system and expect him to function --- flawlessly. Depending upon his situation, it must be made clear that the new-to-practice surgeon I described above may eventually become a very capable practitioner, a dependable and clinically proficient surgeon ---- Depending. Upon. The. Situation. Not every surgeon is fortunate enough to land in a position that provides him with the support and mentoring necessary to ensure his eventual success. The surgeon described above may opt for a position that will allow his shortcomings to blossom like a field of tulips in Holland, and multiply like the weeds in my lawn ---- he may choose, out of an inner sense of inadequacy, to practice at a "small" hospital, out of the way, where the likelihood of really sick patients, and really difficult surgery, is minimized.

That becomes his biggest mistake, and eventually initiates a chain of events that leads, ultimately, back to the beginning --- leaving folks like Rita wondering why in the H-E-Double-Hockey-Sticks did "they" let this guy out of residency?

OK, so now you may be wondering why --- on many levels:
Why would this be his biggest mistake?
Why in the H-E-Double-Hockey-Sticks did "they" let this guy out of residency?
Why does this really matter?
Why can't we "fix" this problem?
If I can solve the housing issues I described in my last post --- let's just say I've sold my damn house but don't have one to move into yet! --- I'll go on to the next phase of this problem in my next post!

Diagnosis --- Arrgghh!

Time for a little quiz. This patient presents today complaining of the following symptoms:

Lack of sleep
Stiff neck
Short temper and the disposition of a pit bull
Queasiness that doesn't improve with eating, no better with an empty stomach
Dull ringing in the ears
Headache with all the bells and whistles -- throbbing, pounding, relentless

Diagnosis? He's been plucked cleanly from the pleasant reverie of daily humdrum, and thrown headlong into the medieval torture known as real estate! That's right. No Comfy Chair --- it's the Iron Maiden for him!

OK, so maybe it's not that bad --- but I can tell you from living with these symptoms that this lovely game of selling and buying houses, full of disclosure forms, paperwork, bickering and dickering, and outright BS is enough to drive me to live in a '72 VW Microbus! And there's one sure thing I've discovered --- the headaches that I have gotten over the past three weeks have been real monsters, the kind that look at a 1,000 pill bottle of Tylenol or Motrin and laugh uncontrollably. Hell, they scoff at a liter of Vodka!

Perhaps it will be settled soon (please, SWIMBO!), and I can look towards a holiday season of packing, moving, and unpacking! Thank goodness the Surglings are old enough to help; maybe I can just say that I got called back to work.....

Thursday, November 16, 2006

Raspe Syndrome

I belong to this quirky group of docs that gets together once a month --- we have a few adult beverages and a nice dinner, and then each evening two of us give a talk. The talks have to be 10 minutes long, with no notes or visual aids (I said it was quirky). My turn comes around every two years or so --- I posted one of the talks I gave a while back here. Anyway, a lot of my time the past few weeks has been spent trying to put together something that I thought would be entertaining for a group of us stuffed shirt physicians --- and then editing and re-editing and re-editing.....and finally memorizing the thing. Anyways, here was last night's talk (I'll try to add some hyperlinks when I catch up with sleep):

It’s the election season, so I thought tonight it would be appropriate to tell a story about a liar --- a liar who’s sheer talent for misrepresentation is matched only by his total obscurity today. But this is a story that also provides the background for a clinical scenario well known to us in practice today. This is the story of a man named Rudolf Erich Raspe.

Raspe was born in Hanover in 1737, the son of a Prussian Lady of the Junker family and a respectable accountant. He grew up in the orbit of minor nobilities, influenced by the prestige of the English court --- King George II, as you may remember, was a dual monarch for both England and Germany.

At 18, Raspe entered the University at Göttingen, what is felt to be the “cradle of German Romanticism.” It had been founded in the year of his birth by the former Hanoverian minister in London, giving him another taste of English culture. Intelligent and eager to make his mark on the academic world, he had a particular aptitude for science and a gifted way with words and languages.

Clever though he was, the young Rudolf soon discovered that keeping pace with the lesser nobles crowding the university scene was more than his meager allowance would cover, and he quickly accumulated what he termed “debts contracted out of zeal for learning and youthful frivolity.” This was a problem that was to be revisited upon young Mr. Raspe with the frequency, certainty and pain of menstrual cramps throughout his adult life. To deal with these troubles, Raspe just as quickly learned the art of stretching the truth much farther than he could stretch his nearly empty wallet.

Raspe was not, however, without talents, with interests ranging from science to mathematics to antiquities and art. To his good fortune, he was able to impress the renowned mathematician and philosopher Gottfried Leibniz enough to be a contributor to one of Leibniz’s last great publications in 1762. The following year brought acclaim for his own publication of an ambitious work on volcanic geology, and, if it wasn’t for his later activities, Raspe may well have been remembered favorably for this substantial production, which became a standard text for the next half-century.

Raspe had already mastered several languages, and not being content to focus his attentions on science, he published a dissertation on a series of Gaelic poems. His versatility and cleverness was certainly noted, and he was dubbed the “Puer Septum Artium,” or the boy enveloped by the arts, by his colleagues. Such was their esteem that Raspe was given the heady responsibility of editing and publishing Leibniz’s posthumous papers --- quite a feather in his cap, as Leibniz was universally felt to be the most distinguished German of the previous generation. With such acclaim, Raspe began to wallow in the attention of his learned friends so much that he developed an appetite for that attention for the remainder of his life.

Soon he was named the Secretary of the State Library of Hanover. His star was rising, but not fast enough to keep up with his expenses, or with his arrogance. Raspe made the rounds of balls, parties, and operas --- and in so doing squandered his inconsequential income. And so he lied to protect his reputation – he lied to friends, he lied to acquaintances, and he certainly lied to his many creditors, somehow concocting stories that were believable enough to avoid public discovery of the fact that he nearly always teetered on bankruptcy. Not content to simply fib a little about his finances, he also publicly dated his cousin’s wife, whom he described as “beautiful” and – to put it delicately, “most agreeable.” The majority of his time, however, was spent in dogged pursuit of his main goal of establishing an estimable international scientific reputation --- above all, he desired recognition and attention.

It wasn't long before he was given another choice position, being appointed Councillor, Professor of Antiquity, and “Keeper of the Collections” of Frederick II, the Count of Hesse-Cassel. Frederick possessed such a vast collection of antiquities and art that it had never been catalogued, and was therefore relatively useless. The university to which Raspe had been appointed was also more ornamental than it was useful, having more professors than pupils, and therefore generating little income.

Such a modest position meant only a modest salary increase --- it was certainly welcome, but by this time not in the same stratosphere as the money he owed. And so, he spun yarns with the skill of a politician, playing one creditor off another, borrowing from Peter to pay Paul. Attempting to ignore his financial woes, Raspe tore into the task of cataloguing the vast and quite valuable collection at hand --- and as a result was able to squeeze the count for a cash advance upon its completion. Once again, the money was not enough, as by this point he owed about three years of his salary to various moneylenders.

Despite, or perhaps because of, his money troubles, Raspe was hardly lazy --- but much of his energy was spent ensuring the continued attention that he desperately coveted. Unfortunately, this was costing him not only time but also money, as sending correspondence to colleagues in order to maintain his European reputation was costing him more than a tenth of his salary in postage alone. But he was able to cultivate such a small army of learned acquaintances in doing so that he was elected to the Royal Society of London in 1769. For Raspe, this was the ultimate triumph, and should have ensured his standing in the social and scientific communities for years to come.

But. But. But by now the wheels were coming off. The accolades he had been handed did not fill his wallet or soothe the appetite of his creditors, and so Raspe turned to that most ancient form of income generation --- marriage. Artfully avoiding his cash-strapped situation, he wed the 18 year old daughter of a wealthy Berlin physician. However, the hefty dowry that came with the lovely young thing took up residence only temporarily in his pockets, being quickly doled out to those creditors who hounded him now on a nearly daily basis.

Over the next few years, his debts grew exponetially, and his creditors became more numerous and more dangerous, to the point where they threatened him with a bankruptcy that was sure to destroy his carefully guarded reputation. Even further loans from his now suspicious father-in-law were not enough. But Raspe was crafty enough to weave carefully misleading stories, prevaricate like an orthopedic surgeon on a History and Physical, exaggerate like a Texan, and bald-face lie his way out of trouble like a United HealthCare CEO. But the hole he had dug only grew deeper.

Desperate for a way out of this mess, Raspe grasped the opportunity to get out of Germany, taking a position in Venice. To do so, he lied yet again. He planted his unknowing wife in Berlin and raced out of town, praying his creditors would not follow him. But there was one simple problem --- what was he to do with the keys to Frederick’s valuable collection, which he himself had painstakingly catalogued, and from which he had been steadily embezzling for several years? His own meticulous accounting of Frederick’s vast treasure trove was the noose that would be used to hang him.

Caught red-handed, he confessed, but mercy was not at hand --- and so he fled to England to save his hide. Surely, he thought, there he would still be welcomed as an esteemed member of the Royal Society. However, as soon as word of his character made its way across the Channel, he was unceremoniously ejected, a dishonor handed out only a handful of times in the history of the Royal Society.

Rudolf Raspe was, according to his arrest warrant, a middle-aged, dumpy, balding, deceitful flop of a man, now far removed from his aspirations of scientific acclaim, shunned from polite society, soon to be divorced --- and he was absolutely flat busted broke. A less resourceful man may have slunk away and never be heard from again, but let’s give the man some credit.

Over the next few years, he was able to cobble together a living, particularly by applying his aptitude for science in the Scottish mining industry. His gift for languages served him well in translating scientific articles from the continent, and he wrote several of his own ---- always with an eye to regaining some modest degree of respectability. Never to be trusted, however, Raspe was involved in an embezzlement scheme a few years before his barely acknowledged death in 1794 of Scarlet fever. He died as a 56 year old man who started life full of cleverness, wit and promise, ending obscurely as a social pariah who had taken dishonesty to levels unheard of until Bill Clinton uttered his wedding vows.

So what? Why should I bother talking about a liar, an embezzler, an unscrupulous prevaricator of no small proportion? Because there is something that Mr. Raspe produced in 1785 that survives to this day, a collection of stories that he published --- anonymously --- trying to make a little money during those cash-strapped years in Britain. Compared to the likes of Robinson Crusoe and Gulliver’s Travels, this little book of outlandish tales full of sheer hyperbole took first England, and then Europe, by storm. Intended as a political barb aimed at his many German detractors, they gained a wide audience as a well-read set of tall tales.

These stories, like America’s Paul Bunyan tales, described the outlandish and impossible exploits of one Karl Friedrich Hieronymus who, unlike Paul Bunyan, was a real man and very much alive at the time. Karl Friedrich had been a distinguished soldier, and was a warm host to his guests at his estate upon retirement. He was well-known for entertaining his guests with straight-faced recitations of impossible to believe exploits. But Raspe’s stories went much further, describing such things as flights to the moon in a hot air balloon, daring military feats while riding a two-legged horse, and riding cannonballs shot across a battlefield. Perhaps the years of practice at weaving tall tales of his own came in handy as Raspe wrote this collection.

The book of stories was soon translated into German, and numerous successive editions were produced by a variety of authors and publishing houses all across Europe. They were most famously illustrated by the French artist Gustave Doré, who compared them favorably with the challenge of his most famous illustrations, such as Dante’s Divine Comedy, Don Quixote, and Edgar Allen Poe’s The Raven.

But with the wide enjoyment of these entertaining stories, why did Raspe remain anonymous? Why did he not publicly stake his claim as their author? Why, to come back to the overriding theme of his life, did he lie? Quite simply, he still clung to the belief that somehow, some way, he could be welcomed back into the arms of the learned scientific community from which he had been so thoroughly ousted. And so, this man, who had built his life upon a series of falsehoods and deceits, would not, in fact could not, admit that he had written the most entertaining and fantastic series of lies ever published --- because in the final analysis, he craved the attention of the learned men of the Academy.

And what of Karl Freidrich? The poor man was still living when the book was published, and he made clear his displeasure at being singled out as the world’s greatest liar by everyone in Europe. It is said that he never again entertained his guests with the type of tall tales with which his name had so suddenly become synonymous.

Karl Freidrich Hieronymus, Baron von Münchhausen, died in 1797, a sad and bitter man, but his name lives on to this day --- because in 1951 a British psychiatrist named Richard Asher reached back to an old set of tall tales for a catchy name to apply to patients who fabricate elaborate stories of symptoms to gain medical attention. Given the origin of these stories and the attention so desperately sought by their author, I would say he could just as well have called it “Raspe Syndrome.”

Tuesday, November 07, 2006

Health Courts Webcast

OK, I'm a slug. The kind folks at Common Good have been quietly sending me e-mails to remind me that they have organized a conference about health courts tomorrow November 8th --- and I have continually forgotten to put a note about it on this blog. Well, let me make amends, because they have informed me that there will be a webcast of this event:

Common Good and the Harvard School of Public Health will be webcasting their upcoming event, Health Courts and Administrative Compensation: Opportunities for Safety Enhancement.

Speakers at the event include: Harvard School of Public Health Professors David Studdert and Michelle Mello, Dr. Dennis O'Leary, President of the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), and Massachusetts State Senator Robert O'Leary. These speakers and others will discuss how an administrative approach to injury compensation could enhance safety and quality, as well as legal and policy issues likely to be raised by proposed demonstration projects. The webcast will begin at 1 p.m. EST on Wednesday, November 8th. Access the webcast and more information here .

P.S. – For anyone in the DC area, there is still space available to attend the event in person.
Needless to say, given today's medicolegal climate, I believe that health courts may turn out to be the best possible way to climb out of our current malpractice sinkhole. I think that anyone who is interested in this option would be well served to look into this webcast, which will be available at the same link for a month following the conference.

Grand Rounds is Up!

It's not just election day --- it's Grand Rounds Day! Head on over to Rita's Place and catch up on what the medical bloggers are saying today. Trust me, it's way better than listening to election day coverage!

Saturday, November 04, 2006

I spy ..... an IV!

Every surgeon on the planet has heard some version of these phrases at least a few zillion times:

We can't get an IV; can you come put a central line in this patient (who has been poked like we were playing "Pin the tail on the donkey" with a bunch of 2 year olds)?

This patient's IV has blown for the fourth time today and we can't get another one in! Can you please put in a central line for Dr. X's patient (even though it's 2:36 AM and Dr. X's last patient referral to you was -- surprise! -- a call for a central line in the middle of the night)?

This patient is too large for us to find a peripheral IV site; we need a central line!
And so on. And you know what? These are almost always legitimate calls. In today's world of modern medicine, we are so reliant on IV access that it has become almost an afterthought for most non-medical folks. IV fluids, kill-everything-IV-antibiotics, IV chemotherapy, transfusions, etc. -- all require reliable IV access.

The problem is, some people just flat run out of easy-to-find veins, and then we're stuck (sorry for the pun) with performing a more invasive procedure to provide adequate IV access. And please remember, when a surgeon says "invasive," there is also the implication of "higher risk for complications" that comes along for the ride. There is a middle ground alternative, called a PICC line, which is a peripherally inserted catheter that is passed into the central venous circulation, but in my experience, I tend to get called to place a central line because the PICC nurse has just spent two hours exhausting her options in a patient who has really no visible veins.

For me, the most vexing problem is the patient who does not really "need" central venous access at all --- they don't need longer term IV access, they are not receiving TPN or chemotherapy, etc. --- but they need some form of IV access to get through their hospitalization. And they just don't have any visible place for the nurses to stick them.

Who can solve this problem? Einstein is dead, Stephen Hawking is using his considerable intellectual prowess looking into the origins of the universe, and Aggravated DocSurg (you were wondering how I would get my name in the same sentence as those two, just to throw off Google searches, weren't you) is just too dense to think of anything other than "OK, I'll put in another central line."

Well, let me introduce you to IRIS. In Greek mythology, Iris is the personification of the rainbow, linking the gods to the earth as the gods' messenger. She is said to travel with the speed of the wind, even into the depths of the sea and the underworld. Cool. Kind of like, oh, I don't know, infrared light, maybe?

IRIS also happens to be the acronym for InfraRed Imaging Systems, which makes a neat device for finding subcutaneous vascular structures called the IRIS Vascular Viewer. The portable and apparently easy to use system employs a high intensity infrared LED which penetrates the tissues, is picked up by a detector (an adhesive bandage on the skin), and is converted to a real time image on a monitor. The company's web site has a few good videos showing how the thing works, and this article explains it very well.

This little gizmo apparently costs about $15,000, and each one-time use sensor pad probably costs a few bucks as well --- so it certainly isn't financially a good thing to use for each and every IV. However, as any nurse can tell you, there is never a shortage of patients who are "problem children" when it comes to IV access --- can't find a good vein, or the vein that is cannulated turns out to be a bust, etc., so that by the time the third nurse comes in the room with a handful of needles, the patient runs screaming down the hallway like a teenager in a slasher movie. I suspect that is the situation that would be perfect for IRIS to ride to the rescue -- and save a few bucks in the process. And one of its best features is that, unlike ultrasound, it is very easy to learn how to use -- and its potential is just being explored (see the article). Coming full circle, it could turn out to be a useful tool in central line placement as an alternative to ultrasound.

Of course, since I am an aficionado of Animal House, I also have to say that IRIS, with her swivel-anywhere wheels, looks like a wonderful dancing partner. Now, if I could just get our hospital administrator to liberate a few kilodollars to pay for one of these, I'm sure it would pay off --- in the ED, on the patient floors, in the GI lab and radiology suite, and in the call room, where I can get a bit more sleep.

Tuesday, October 24, 2006

I Agree --- In Spades

For those general surgeons out there who receive General Surgery News, I hope you took the time to read this article by Dr. David Cossman --- he redefines the term "rant," and in the process pokes a stick in the eye of the of those who push "quality improvement" initiatives upon us that have no proven quality nor any hope for improvement. Here are a few excerpts:

This time, the blood on my hands was my own. And it was from a self-inflicted wound. Unintentional, not wholly unexpected, but surprisingly painless for a cut down to bone from a 10 blade through a latex glove. For those of you who have watched me operate lately and suspect a demyelinating disease as the root cause of this vicious digital attack, you’ll have to wait a little longer before I hang up the needle holder. I’m neurologically intact, but apparently incapable of operating the new “safety sleeves” on our scalpels without what must have appeared to have been an earnest attempt at autoamputation.

After the tetanus shot, six stitches, Ancef and washing off the “yes” in magic marker on the bleeding finger, I did what every red-blooded injured American would do—I called the manufacturer of this stupid thing and threatened to sue.

Silly me; I missed the point again. It seems that this protective device had been added for everyone’s protection except the one using it. .... The safety sheath was not there to protect me or my patients. It was there to protect the manufacturer, the distributor and the hospital that handed me the knife against lawsuits charging malfeasance, negligence and disregard for the user’s safety. There it was, a bloodstained inch-and-a-half piece of half-penny plastic, the symbolic refinement of modern day risk management at its best.

.....Sound familiar? Is it still a surprise when laws, policies and programs not only don’t work but too often are 180 degrees off target? No, it’s not surprising, because too often these instruments of public policy are little more than an opportunity to articulate a point of view instead of well-thought-out solutions to problems. It’s not surprising that policies and laws that are nothing more than ornamental expressions of political correctness not only fail to achieve a stated goal but may, paradoxically, almost comically, produce exactly the wrong results. Part of the problem is that they frequently address problems that don’t exist or might not exist.

.....failed social policies long on good intentions but short on results enjoy near-immortality because to criticize them exposes one to a veritable thesaurus of epithets. It seems that society saves rigorous outcome analysis and expectations of perfection only for projects where profits are involved. If you’re spending money instead of making it, you get a free pass if the cause is right. That’s why the drug companies take such a beating, even though there isn’t a single reader of this column whose life won’t be prolonged because of their products.

.......The moral equivalent of the carpool lane hit our profession big time with the brilliant introduction of the 80-hour workweek. I have to chuckle each time I read a “study” that attempts to quantify the effect the 80-hour workweek has had on patients, residents and surgical outcomes, as if anything would convince the perpetrators of this foolishness to retract the policy if it wasn’t working.

....Of all that has been written about the 80-hour workweek there is only one irrefutable fact: It is here to stay but not because it contributes even an imaginary sliver to patient safety. It is here to stay because it is the public’s warning shot fired across the bow of the medical profession to warn us that we’re in the crosshairs of public scrutiny. It really is hard to imagine that the policy could serve any other purpose. After all, you have to admit it’s a stretch to believe that a “postcall” resident asleep on the end of a retractor somewhere in the right upper quadrant is a danger to anyone. Oh I forgot, they’re going to go home, get some rest, and then read, read, read Schwartz’s Textbook of Surgery so they’re going to be better and smarter doctors in the future. Or better yet, they’re going to read Proust and Voltaire so they’ll be better, more cultured and more humane doctors so they won’t wind up jaded and cynical and write columns like this.

...On the other hand, the purpose isn’t really to solve the problem, is it? No, what we’re witnessing here is as primitive (and futile) as an ancient animal sacrifice, hoping that the gods (media, lawyers, politicians and patient advocacy groups) will sate themselves with the scent of the entrails laid at their feet.

....Remember the law of unintended consequences. Even if you could squeeze surgical education into a shorter workweek, even if you could prove to the Resident Review Committee that your residents are actually doing as many cases as they used to, even if you can make up numbers to show that no one has died in a hospital since the enactment of this absurd offering to the gods, we would still have the unintended consequence of what punching a clock has done and will do to a surgical culture molded by a century’s obsession with tireless adherence to dedication, detail and discipline. To defend that culture against the ululations of the compliance jackals and the medical error junkies is to get tarred as the anachronistic defender of an outdated order.

....In the final analysis, I’m not far from lying in my hospital bed looking up at my surgeon who is fixing to rummage around in my chest, brain or abdomen. I don’t want to look up and see a time clock puncher in my hour of need. I don’t want someone who went weeping to the program director because some attending looked at him or her cross-eyed. I don’t want someone who was given six chances to pass the boards. I don’t want someone who had the time to wait 30 minutes in the Starbucks line to get a double decaf vente latte. I want someone whose training has steeled him or her to handle whatever it is he or she is about to find inside. I’ll take such a person, even when she’s tired. I know he or she will wake up and do the right thing when the time comes.

One day, I'll find a way to match the voices of frustration whispering inbetween my ears with the words I write the way Dr. Cossman does. And, I'd like to add, there is not one single word in this column I could even remotely disagree with.

Sunday, October 22, 2006

Cultural Competence? Incompetent

So, there I was, awake and alert with a Glasgow Coma Score of 15, freshly infused with a huge cup of coffee as black as murder, and ready to gain the insight of the finest minds in all of surgicaldom. I picked up my registration materials and program and began to plan out the first morning of the American College of Surgeons meeting. I was pleased to quickly spot a few lectures given the group heading of "Evidence-Based Perioperative Risk Reduction." Productive, for sure, and a worthwhile update for dealing with the elderly, sick patient population in my tertiary care center. As outlined below, it was a good use of my time.

But then I made a mistake. The kind of mistake that caused that aromatic coffee to scald my nasopharynx as it was forcibly transported out of my nose. The kind of mistake that made my arms twitch and twist so uncontrollably that I looked like I was auditioning for the remake of Dr. Strangelove. The kind of mistake that gave me heartburn --- no, not heartburn. Angina!

What did I do? I simply perused the other offerings on the slate for Monday's Clinical Congress. Let's see --

  1. Laparoscopic Colectomy: Beyond the Basics (been there, done that)
  2. Breast Cancer Update: What Every Surgeon Needs to Know (not much new news this year for anyone that keeps up)
  3. New Prevention and Treatment Strategies for Male Sexual Dysfunction (why do we let urologists come to these meetings?!)
  4. Open vs. Endovascular Approaches for Vascular Disease: What Are the Outcomes? (interesting, but I don't do vascular surgery)
  5. Postoperative Pneumonia: Strategies for Prevention, Diagnosis, and Treatment (I'd like to hear some of this, but can't be in two places)
  6. Pancreatic Pseudocysts and Chronic Pancreatitis: Evidence-Bases Management (difficult patients, but the treatment is really not that difficult)
  7. Inguinal Hernia Repair: An Evidence-Based Approach (old controversy, but the data to be presented is somewhat new --- and has been touted in every surgical journal for about 2 years)
  8. Information Systems: How the Information Explosion Will Change How We Educate Surgeons and Treat Patients (I've heard variations on this theme for years)
  9. Update on Blood Transfusion (boooooooring)
  10. Cultural Competency: Does It FacilitateBetter Delivery of Health Care (WTF?!?!?)
(Deep breath. Must. Get. Nitroglycerin!)

I hardly know where to begin. Well, yes I do. This kind of absurdity, this rubbish, this preposterous lunacy, this AB-SO-LUTE SOCIAL ENGINEERING BULLSHIT should be presented in front of surgeons only to initiate a program to COMBAT IT!

Was it too much to ask that surgeons, for Pete's sake, the last group of physicians that one would expect to go for politically correct pablum, would try to bring some semblance of sanity to this arena. Yes --- it was too much to ask. The Clinical Congress News, the official "press" of the meeting, had a fawning page one article explaining to us insensitive rednecks that cultural competency is simply a "no-brainer." But just what is this thing called cultural competence? Here is one definition, and a Google search brings up a paltry 9,650,000 sites listing the term; however, as pointed out by this essay, it mutates depending upon the prevailing wind being blown by those windbags who espouse multiculturalism as the cure for all of our ills. New Jersey politicians have already passed a law mandating that physicians undergo "cultural competency training as a condition of obtaining or renewing their licenses to practice medicine." And you won't be able to get this type of indoctrination training like traditional CME, according to one of this law's proponents:
Like believes cultural competency training can succeed, but will not be attained through a "cookbook approach to care. We have to see this as different from other types of CME courses," he says. "It has to be a process of how we continue to learn about the diverse populations we're caring for as well as our own personal and professional biases, values, beliefs, and behaviors—I don't think taking a one- or two-hour course is going to be effective." He also argues that cultural competency training should extend to all health care workers, including nurses, dentists, physical therapists, pharmacists, psychologists, social workers, and other allied health professionals.**
**Yes --- that means you, too will get to share in this wonderful, mandated politically correct groupthink experience.

Other physician bloggers have had a few things to say about this, and it's unlikely that I'll add anything substantive in this post. But let me just blow off a little steam, so that the next time I'm faced with this crap I can try to be a bit more articulate --- if this comes up for debate in my state legislature, I'll have to carry a scalpel and not a Howitzer.

I am a surgeon. A white, male surgeon, to be "culturally identified." I was raised in Texas, but have no more "Texan" in me than an unladen African swallow. I lived in France for a few years, and --- horror of horrors --- learned the language and tried to "fit in." I have been fortunate to have visited Mexico, New Zealand, Australia, Germany, Italy, England, Belgium, The Netherlands, Switzerland, Luxembourg, Canada and the foreign country of Louisiana. But while those experiences certainly have enriched my life I am, and always will be, an American. And I intend to continue to treat patients in the best manner I know how ---- and dammit, it's just too bad that I can't speak Bantu or understand the complex courtship dances of every Pilipino tribe. I can, and do, learn about many things that are of interest to me, but don't expect me to be so "culturally aware" that I will perfectly mesh with every person who comes through my office door. And who is to say what cultures I should be appraised of? The answer would hardly be the same if I was practicing in New York City or in Bay City, Texas. And what about the diversity that is seen within our own country? Are we to be indoctrinated soaked in the social customs of the midwestern corn farmer, the southern oil magnate, the southern "belle," etc.? I kindafuckindoubtit.

The bottom line is that I cannot be everything to everybody. If I am perceived by a patient as not communicating well with them, for whatever reason, because I'm culturally insensitive or because I'm just not nice enough, they have the opportunity to seek care elsewhere. If I find that a whole lot of patients are doing just that, I will have to find a way to change my behavior or go out of business. That is the American way. I don't need a Cultural Competency Czar making me sit in seminars and sing Kumbaya in Norwegian to understand that basic priniciple of life.

I guess what really stuck in my craw was the way that this is being passed off as a self-evident, overwhelmingly important movement in surgery, without a shred of evidence that it holds any intrinsic value whatsoever. Buried at the end of the article puff piece is the indicator of the way that this "discussion" is to be held in the future:
During the question/answer session that followed, the panelists agreed that although there are no concrete data to support the claim that cultural competence is an important element of effective health care delivery, it is a given and that the need for such cultural competence in health care must be addressed.
Uh-huh. It is a given. I would say that it is a given that the more of these feel good, do-nothing policies that get forced upon busy physicians, the fewer there will be available to care for the urgently ill --- because they'll just say "screw it." It amazes me that on the one hand the ACS has finally awakened to the problems we have just covering emergency rooms, and on the other hand is wasting its time on drivel such as this.

Tuesday, October 10, 2006

ACS Chicago --- III

Spent most of the day in a post-graduate course --- one focusing on a procedure that I spend a considerable amount of time doing (laparoscopic colectomy; perhaps something I should write a few words about some time). Certainly there was not a lot of new information presented for those who keep up with literature and techniques, but it is nice to have one's own biases and ideas confirmed by folks in academia who focus almost solely on that one topic.

The late afternoon sessions included a nice review of dealing with medical comorbidities in the trauma patient. Given the trauma population that most often hits my ED, who are primarily the recipients of blunt trauma (auto accidents and the like), it was a nice review. Unfortunately, nobody seems to have anything to say about how to deal with the patient on Plavix except to shrug their shoulders and say "try anything you think that may work."

The ACS is a bit behind the times as far as the internet is concerned --- thier web site, for example, is not the most user-friendly place on the web. However, they have introduced this week something that I think will be helpful for many general surgeons who don't have the time or resources to put together their own practice web site with patient instructions and information. "Patients as Partners in Surgical Care" is the new patient education web site that the ACS has put together, and it looks fairly promising. It certainly duplicates some of the things my practice has made available to patients on our site, and is a nice complement in other respects.

Now, as for the aggravating part of the meeting....I am not sure I'm fully prepared to rant in a coherent fashion jsut yet, but let me give you the title of one of the first sessions of the entire meeting: "Cultural Competency: Does it Facilitate Better Delivery of Health Care?" I'll have plenty to say about this later, but it amazes me to know that the presenters' opinions were basically that yeah, we don't have one iota of data that this is meaningful, but we're gonna mandate it anyways. Arrggghhhh!

Monday, October 09, 2006

ACS Chicago - part deux

A few interesting tidbits from today's overwhelming plethora of lectures. In actual fact, I arrived not really expecting to get a whole lot of new information, but was pleasantly surprised tohave a pair of lectures, delivered back-to-back, that actually were timely, informative, and very clinically useful. The first of these was a great review of the ways in which surgeons can reduce the risk of venous thromboembolism, and its sequelae, with appropriate prophylaxis. This was hammered ito me during my training, and in some ways did not come off as "new," but this field of study is dynamic and evolving. What was particularly helpful was that the speaker has put together a great web site --- www.venousdisease.com --- with all of the information (and more) presented, along with risk stratification profiles, prophylaxis stategies, etc., all available gratis.

The second lecture carried a similar profile --- things we surgeons can do to reduce the risk of perioperative cardiac complications. Basically, he was a one-man band playing the (undersung) tune of beta blocker use to prevent cardiac complications in the patient at risk for the same. Bottom line --- beta blockers good, no beta blockers bad. And for those who can't take them, there's some good data to support using Clonidine instead. And, just as helpful as the first presenter, he has a web site to help the physician or hospital that needs to get a cardiac prophylaxis program underway --- www.betablockerprotocol.com.

Don't worry -- there were plenty of things for me to get good and Aggravated about; I'll just save those for later! Hint ---- they involve a little bit of "PC-thinking," something that I don't think fits in with surgery, not in the least!

Sunday, October 08, 2006

ACS Chicago -- 1

Well, I guess that I'll steal a page from Professor Reynolds and try something new (for me). I'm here at the McCormick Center in Chicago, which is rapidly being transformed into a surgical showcase for the 92nd Clinical Congress of the American College of Surgeons. They have set up a nice "Internet Cafe" in the exhibit hall, and hopefully I can give anyone that's interested an idea of what's happening day-to-day.

I have to admit, however, that I often find the activity behind the scenes to be at least as interesting as what actually happens in the meetings. It is fascinating to see how quickly an enormous, empty room can become filled with state-of-the art exhibits. Behind me a small army of people are erecting temporary walls, laying carpet, wiring huge video screens, etc. -- all of which are designed to catch the eye of the general surgeon who is roaming the hall in a stupor after listening to a few hours of (sometimes monotonous) lectures.

We'll see what tomorrow brings in terms of the "new and exciting." For now, it's time for me to find some famous Chicago pizza....

Tuesday, October 03, 2006

Just Plain Wrong, or at least Wrong-Sided

So it appears that LA Lakers coach Phil Jackson is scheduled to undergo surgery today --- a total hip arthroplasty, or hip replacement, is on today's game plan instead of opening day of training camp. He seems like a nice enough guy, though a bit too "Zen masterish" for me, and I hope all goes well and he recovers nicely.

But. But. But......what if everything doesn't go well? What if he becomes one of the (fortunately reasonably rare) cases of wrong-sided surgery? What, then, will pundits say (OMINOUS TONE) went wrong?

There is a study that has been published in the September issue of Archives of Surgery that, like many that have preceded it, tries to address that very question. Entitled "Wrong-Side/Wrong-Site, Wrong-Procedure, and Wrong-Patient Adverse Events: Are They Preventable?," it is authored by a pediatrician at the University of Chicago Comer Children's Hospital and an anesthesiologist at the University of Miami School of Medicine. One of the obvious difficulties they encountered is a lack of consistent data; they tried to collect as much data as possible from sources such as

(1) the National Practitioner Data Bank (NPDB), (2) the Florida Code 15 mandatory reporting system, (3) the American Society of Anesthesiologists (ASA) Closed Claims Project database, and (4) a novel Web-based system for collecting WSPE cases (http://www.wrong-side.org).
I guess I should not be surprised by two things about this report that jump out and grab me. First of all, there is a very difficult to substantiate OMINOUS CLAIM (from the abstract; full text requires subscription):
Based on these findings, we estimate that there are 1300 to 2700 WSPEs annually in the United States. Despite a significant number of cases, reporting of WSPEs is virtually nonexistent, with reports in the lay press far more common than reports in the medical literature.
That's a pretty big number, particularly when the National Practitioner Data Bank has evidence for only 5,940 such incidences --- in 13 years. Now, I will grant the authors some latitude, as there is no consistent, mandated method for reporting such incidents. But to throw out these kinds of unsubstantiated WAG numbers is irresponsible.....why, I haven't seen such irresponsibility since, let's see, oh yeah! The Institute of Medicine's report on deaths attributable to hospital errors!

Sorry. That bit of statistical voodoo still sticks in my craw.

Now comes the second thing that may not seem so obvious but is clearly linked with the OMINOUS FINDINGS of the report. The authors of this study, Samuel Seiden, M.D., and Paul Barach, M.D., MPH, just so happen to be the guys in charge of (guessed it yet?) www.wrong-side.org! Well, isn't that special! Kind of like publishing a study that "finds" that carpet dirt can cause acne while at the same peddling a "new" vacuum cleaner.

OK. Please do not misread my aggravation. I do not think wrong-site/wrong-side surgery is over-reported, and it certainly deserves a much clearer, probably mandated, reporting system. But this type of "academic study" appears, at least to me, an attempt to get funding for one proposed solution --- the one being proposed by the study's authors ---- rather than a clear look at the problem.

For me, there are some fundamental issues that are at the heart of the wrong-side/wrong-site surgery problem, and they differ to some degree from the non-surgical wrong-treatment/wrong-procedure problem. First and foremost is the importance of a good old-fashioned doctor-patient relationship. This means in my practice not seeing the patient and scheduling them for surgery some weeks away without a preop appointment soon before the operation is to take place. That allows at least two occasions for the patient and I to interact, and the visit within a few days of surgery keeps me well aware of what I am doing to that particular patient. I think I lose a "feel" for the patient, their history, and their surgical problem if I don't see them a day or so ahead of time.

On the day of surgery, I always see the patient before they are carted off to the OR. I just have always felt that was common courtesy, at a minimum, and it gives me a chance to make sure there are no unanswered questions from the patient or their family. Because it is mandated by JCAHO, that also gives me the opportunity to mark the patient when I am doing surgery on one side or the other (such as a hernia repair). I'm also a stickler for making sure the patient is not prepped until I am in the room, so that I don't arrive with the wrong side already prepped, draped and begging for an incision.

It's not all left up to me, however. There are guidelines that have been established to ensure a multiple-step process to try to prevent the wrong procedure from being done. Everyone involved with the procedure is involved, from the preop nurses to the anesthesiologist to the scrub techs. Essentially every specialty society has policy statements about how to prevent wrong-side/site surgery --- the American College of Surgeons, the American Academy of Orthopedic Surgeons, the American Academy of Ophthalmology, etc. --- all following the basic outline of the JCAHO protocol. For example, here are the ACS guidelines:

The American College of Surgeons (ACS) recognizes patient safety as being an item of the highest priority and strongly urges individual hospitals and health organizations to develop guidelines to ensure correct patient, correct site, and correct procedure surgery. The ACS offers the following guidelines to eliminate wrong site surgery:
  1. Verify that the correct patient is being taken to the operating room. This verification can be made with the patient or the patient's designated representative if the patient is under age or unable to answer for him/herself.
  2. Verify that the correct procedure is on the operating room schedule.
  3. Verify with the patient or the patient's designated representative the procedure that is expected to be performed, as well as the location of the operation.
  4. Confirm the consent form with the patient or the patient's designated representative.
  5. In the case of a bilateral organ, limb, or anatomic site (for example, hernia), the surgeon and patient should agree and the operating surgeon should mark the site prior to giving the patient narcotics, sedation, or anesthesia.
  6. If the patient is scheduled for multiple procedures that will be performed by multiple surgeons, all the items on the checklist must be verified for each procedure that is planned to be performed.
  7. Conduct a final verification process with members of the surgical team to confirm the correct patient, procedure, and surgical site.
  8. Ensure that all relevant records and imaging studies are in the operating room.
  9. If any verification process fails to identify the correct site, all activities should be halted until verification is accurate.
  10. In the event of a life- or limb-threatening situation, not all of these steps may be followed.
Call me old fashioned. Call me a curmudgeon. Call me an arrogant bastard. Just don't call me Shirley. The problem with this type of policy is that it leaves sufficient wiggle room for laziness. Most hospitals have policies that allow a physician extender to take the place of the surgeon in the steps above --- so it's the orthopedic PA that says "hi" to the patient and marks them preop (and the orthopedic PA that dictates the preop history and physical, and obtains the surgical consent,...I pick on orthopods because [1] they are responsible for most of these incidents, as they do "sided" surgery all the time; [2] they all seem to have a PA attached to their hip; and [3] because I can, and it's fun).

In fact, JCAHO guidelines even state the operating surgeon "should," rather than "must," mark the patient, and even the OR nurse --- who has never even met the patient --- is considered an adequate substitute for the surgeon in marking the patient. That's just plain wrong.

Look, I'm not full of sour milk here -- I agree with the study authors that wrong-side/site surgery is likely underreported, and I agree that we need a better system to report and monitor such events. As much as I might hate to admit it, I think that JCAHO is on the right track in trying to ensure a system-based approach to prevention of this 100% preventable problem. But I also believe that the "best defense is a good offense," and in this case, the best offense is good communication between patient and surgeon.