Tuesday, January 31, 2006

Grand Rounds is Up!

Grand Rounds is being hosted this week by Barbados Butterfly --- and while she's not actually in Barbados, she does live on a (rather large) island with a fair amount of beautiful scenery. It's always worth the trip, so head down under to see this week's sampling of the medical blogosphere.

Saturday, January 28, 2006

Surgical Narcissism, Part II

I recently wrote a bit about the way surgeons may behave, or at least may be perceived, as fairly narcissistic. But, gee, I'm not really that way, am I? Well, a new survey suggests otherwise -- Perceptions of Teamwork in the OR Differ Sharply (go to page 19). It seems that, my own feelings aside, surgeons are not viewed as very good team players -- by the very team members they depend upon.

Dr. Makary surveyed 2,135 surgical team members, including surgeons, anesthesiologists, certified registered nurse anesthetists, scrub nurses, and technicians, about the social dynamics in the operating room that have been proven to affect surgical outcomes.....He found that surgeons rated the quality of their colleagues' collaboration and communications skills in the OR much higher than their colleagues rated them. On a 100 point scale, surgeons rated fellow surgeons at 85, anesthesiologists at 84, and nurses at 87.

Nurses rated surgeons at 48, and anesthesiologists rated surgeons at 70.....Surgeons generally felt all was well, while other team members disagreed.
Well, alrighty then! Give me just a moment to collect the pieces of my shattered ego and put the bloodied shards into the "sharps" container. While Dr. Freud might have a few interesting things to say about why, that kind of makes me feel a bit like the goofy kid nobody wants to play with!

Why is this a big deal? Because if everyone in the operating room does not work as a team, the patient can suffer. According to Dr. Makary:
"This is a topic that speaks to the issue of a nurse in the OR knowing that a sponge is retained in the abdomen but not saying anything because of the hierarchy that we have espoused....not saying anything because the last time she did she was criticized."
I agree that there are many of us, including myself at times, who are controlling and even imperious SOBs. And I agree that in most situations, that is not only bad manners, it creates an atmosphere where mistakes can be made. Communication between all members of the OR team needs to be clear and free from criticism.

However (you just knew I had to throw in one "but-monkey"), there are times when pretenses need to be put aside and decisions are made by one and only one person -- the person with the ultimate responsibility for the patient's care. In a critical situation, the surgeon is the "captain of the ship" and must make sure that the patient's best interests are looked after; he or she is frequently the only team member to know all of the facts regarding the patient's history and preoperative care. There's a bit of finality involved with some decisions made in the OR -- sort of crossing the Rubicon -- and the process at arriving at those decisions has to be respected. The patient bleeding from a major liver laceration may need to be packed, and it does not help to have the scrub or circulating nurse complain loudly that it's "against AORN guidelines" to leave packs in the abdomen --- yeah, I know that, but this is what the patient needs, right now, please don't argue with me!

Now that I got that out of my system, it's pretty obvious that communication between team members is critical. I feel the best ways for a surgeon to facilitate this in the emergent situation is to:
  1. Make the OR a fun place to work -- play music, tell jokes, and above all be nice -- in the non-emergent situation; the staff is more comfortable with the surgeon who is interested in them, rather than in themselves
  2. Educate the staff -- they are almost uniformly interested in learning more
  3. If the staff is educated, they are much more likely to understand what you are trying to achieve in the emergent setting
  4. There is almost always time to explain what you are planning to do or are doing at the time, and why, which once again is helpful in keeping appropriate communication going
  5. Say "thanks," especially if a team member catches a potential hazard (wrong sponge count, etc.), but always say "thanks" when you leave the OR --- and yes, that means you should thank the anesthesiologist too!
One of my personal heroes is Ronald Reagan. Putting politics aside, one thing nearly all of those who knew him recognize is that he was very willing to surround himself with capable, intelligent men and women -- not "yes-men" -- and was not afraid to hear their opinions before making his own final decisions. Surgeons could do far worse than emulating this example.One of my partners is known to ask student nurses in the OR, "who is the most important person in this room?" It's a great lesson for the often timid student to hear this man, who has been practicing surgery for over 30 years, "no, it's not the surgeon -- it's the patient."

Thursday, January 26, 2006

Take a Bite Outta Pork!

Oh, baby, do I love this idea:

To rein in wasteful spending, Dr. Coburn intends to offer an amendment on every pork project stuffed into appropriations bills this year. There were at least 13,998 earmarked projects contained in last yearÂ’s appropriations bills. By way of comparison, the Senate had only 366 roll call votes last year. Needless to say we are beefing up our appropriations staff for this challenge and we have requested that we be given at least 72 hours to review appropriations bills before they are considered.
Comments from Mary Katharine Ham:

Sen. McCain has also signed onto the effort, and the two have shot off a "Dear Colleagues" letter that must have Senate aides clasping to their little appropriating chests the plans for the Central Idaho Celebration of Railroad Conductors Museum. Appropriators think they can leverage enough pressure to make the Coburn threat an empty one, but I think it's a mistake to underestimate Tom Coburn's desire to shake things up in the Senate. It's equally dangerous to overestimate his desire to make buddies in the Senate.

And the coup de grace from Andrew Roth at the Club for Growth:
Memo to Ted Steven'’s office: Bring a defibrillator with you to the Senate floor from now on.
Maybe the good folks behind the porkbusters idea should generate a new, Senator Coburn-specific logo. They could stick with the "pork" motif, but add a bit of oomph:

But I prefer a less subtle approach.
Whatever it takes, it's time to hold our representatives accountable for where they spend our money. If that requires Sen. Coburn to adopt a pit bull's persona, so be it.

Tuesday, January 24, 2006

My Kind of IV

Now that's what I want for my preop sedation next time! (from Close to Home by John McPherson)

A Way Out of the Finger Trap

The health care policy debate in this country tends to be emotion-driven at times with a push towards more government involvement, rather than by a careful review of facts with implementation of economic policies based upon those facts. These vastly different methods tend to intersect like autobahns at right angles; the public struggle between the two may alternately be seen as a child struggling with a Chinese finger trap. It will come as no surprise to the two or three of you who read this blog that I favor the latter approach to getting us "out of the trap." An opinion piece published in the Wall Street Journal on Jan. 13th, entitled Keep Government Out (reproduced at the American Enterprise Institute web site), espouses just the kind of cold, hard look at the economics of health care policy and makes an excellent case for less, rather than more, government intervention in health care delivery. It is authored by R. Glenn Hubbard, visiting scholar at the American Enterprise Institute and dean of Columbia Business School, also former chairman of the Council of Economic Advisers; John F. Cogan, the Leonard and Shirley Ely Senior Fellow at the Hoover Institution, and also former deputy director of the Office of Management and Budget; and Daniel P. Kessler, a professor at Stanford Business School and a senior fellow at the Hoover Institution. They are the authors of Healthy, Wealthy, and Wise: Five Steps to a Better Health Care System. A few excerpts:

Should health-care reform increase our reliance on markets, or on direct government involvement? The debate is often cast as a struggle between employers or insurance companies on one side and workers on the other, with workers getting the short end of the free-market stick. This view results from a fundamental misunderstanding of basic economics. A handful of policy changes that harness the power of markets for health services have the potential to give patients and their physicians more control over health-care choices, create more health-insurance options, lower health costs, reduce the number of uninsured persons--and give workers a pay increase to boot.

Last year, on these pages, we argued that health-care policy should limit, not expand, government intervention. Greater reliance on individual choice and free markets are the solutions to what ails our health-care system. As a starter, we recommended three main proposals to correct the harmful effects of current government policy:

  • Make all out-of-pocket health-care expenses deductible against income taxes for everyone who has at least catastrophic insurance--whether or not they itemize their deductions;
  • Allow qualified insurance companies to sell insurance nationwide, free from politically motivated state mandates and other costly state-imposed regulatory practices; and
  • Set reasonable caps on damages for pain and suffering in medical malpractice cases.

...If out-of-pocket health-care expenses are made tax deductible, workers would demand that employers provide health plans with lower health-insurance premiums and higher co-payments. The premium savings will accrue to workers in the form of higher money wages. In the past, workers have borne the higher cost of health-insurance premiums by receiving smaller wage increases.

...We estimate that, in response to making out-of-pocket expenses tax deductible, the typical worker will shift from a health plan with a 25% coinsurance rate to one with a 35% coinsurance rate. Coupled with our other reforms, this shift will reduce the premiums of the average employer-provided family health plan by around $2,300 per year. The economics of competitive labor markets ensures that this amount will accrue to the worker in the form of higher wages. To be sure, higher out-of-pocket expenses will offset part of this increase--$1,000 of it. But this still leaves the worker, on net, $1,300 ahead.

This is a well written, well reasoned article, worth the few minutes it takes to read. This approach is IMHO an excellent first step towards a better, more flexible health care policy that will provide better coverage for Americans than our current system.

UPDATE: It looks like the President is going to promote at least a portion of this plan -- see this article.

Grand Rouds, Vol. 2, No. 18

Kevin, M.D., is hosting this week's Grand Rounds -- and boy, is it a doozy. There are enough posts collected this week to keep even the best speed reader occupied for a few hours. Lots of great medical writing for your perusal -- check it out!

Monday, January 23, 2006

RFID in the Hospital

This article describes a proposed system in for patient tracking in the OR -- basically, ensuring accurate time information for when patients enter and leave the operating room. This is important in the world of hospital CFOs, who need accurate billing information (most ORs base charges on the amount of time a patient spends in surgery). The system tracks patients with an RFID tag, which is attached to the bed.

Holbert Systems installed a Wavetrend RFID reader in each theatre and a data buffer per theatre complex. A record of the patient's identity, along with the precise time spent in surgery, could be transmitted to a software interface capable of communicating with the hospital's own information system.

By confirming the accuracy of time-keeping, Medi-Clinic say the system has dramatically improved payment terms with insurance companies. Initial figures show that this benefit, along with the greater operational efficiency within the pilot hospitals, means the system will have a pay-back of less than 12 months.

Manager of Patient Administration at Medi-Clinic Deon van Blommestein says the system provides benefits to both the patients and the funders, since the theatre times produced are accurate and thus indisputable.
I think this type of technology could be used throughput the hospital, allowing accurate tracking of patients in the ED, to and from Radiology, in the OR, even during registration. That allows the hospital to identify common bottlenecks in patient care --- such as OR turnover (the time between patients in the OR is just as important to the bottom line as the time patients spend there), patient transport problems, etc. It may be, as I suspect, that hospitals will find that adding a few extra transport personnel and radiology techs ends up making them more money in the long run. We could also "tag" items such as surgical trays or other equipment to monitor their usage and movement through the system (such as when they go for cleaning and sterilization). In the US, Medicare does not pay hospitals for the time a patient spends in the OR, as payment is based on DRG information. However, if enough data can be obtained across many facilities that indicates that the payment is inadequate compared to the time most patients spend in the OR, payment could theoretically be changed.

Now, if we could just find a way to place an RFID tag on physicians who are on call, we might just get somewhere!

ADDENDUM -- A few more thoughts about FRID from a non-physician perspective can be found at Medical Connectivity Consulting.

Friday, January 20, 2006

My Favorite Sport --- Humor at Teddy's Expense

In response to the news that Teddy "The Swimmer" Kennedy has released a children's book (featuring his Portuguese Water Dog, named Splash --- no irony there) the good folks at FARK have collected a series of other titles the Senator may want to publish in the future. This is my favorite, but there are about 30 other hilarious submissions. It's worth a look for a good laugh this morning.

Tuesday, January 17, 2006

Marcus Welby Narcissus, M.D.

I have a good friend with whom I share many books; he is always lending me one book or another that he thinks I might enjoy, and I try to reciprocate. Recently, I lent him my copy of Under the Banner of Heaven --- a fascinating, disturbing, and very well-written look at the violent world of American polygamists by Jon Krakauer. When he gave it back to me, he had two copies of a page in the book, one for me and one for him to keep --- it lists the personality traits of narcissistic personality disorder:

  1. An exaggerated sense of self-importance
  2. Preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love
  3. Believes that he or she is "special" and can only be understood by, or should associate with, other special or high-status people
  4. Requires excessive admiration
  5. Has a sense of entitlement
  6. Selfishly takes advantage of others to achieve his or her own ends
  7. Lacks empathy
  8. Is often envious of others or believes that others are envious of him or her
  9. Shows arrogant, haughty, patronizing, or contemptuous behaviors or attitudes
The DSM IV states that this diagnosis can be made in a person who exhibits 5 or more of these traits; the lifetime prevalence rate of NPD is approximately 0.5-1 percent; almost 75 percent of individuals diagnosed with NPD are male.

So, as he handed this list to me, he winked and loudly asked (in the surgeons' lounge), "Look familiar? Recognize anyone?" And he's right. To one degree or another, most surgeons could be accused of harboring a few of these personality traits, particularly while in the OR; many might say that the phrase "narcissistic surgeon" is redundant. In many instances, that's a good thing --- you don't want a surgeon who is indecisive or unsure of him/herself. In others, that's a bad thing --- empathy is an important quality, for example, as long as it does not keep the surgeon from doing the right thing.

But what about the truly narcissistic surgeon? The kind of guy who thinks that the electric company generates power just so that he can operate? Everyone has read fictional (and occasionally non-fictional) accounts of this type of surgeon --- with cardiac surgeons being the prototypical narcissistic physicians. Do they really exist today, or are they an anachronism as out of place today as the ether mask?

The short answer is "yes," in my experience. However, I have a sense that there are far fewer narcissistic surgeons around today than, say, 30 years ago; that's a good thing, as they can make life miserable for the people with whom they work (and even more miserable for the folks that have to discipline problem physicians in hospitals and medical boards). Perhaps mine is a regional perspective -- in the west, we tend to attract a certain type of physician personality, and it could be that things may be somewhat different in New York City (I'm not trying to pick on anyone) or in L.A.

SWIMBO would probably say that all of us are narcissistic, with me at the top of the heap, but I wonder if those non-surgeons out there would say the same. Are we surgeons still viewed this way, or have times changed?

A Texas-Sized Grand Rounds

GruntDoc is hosting Grand Rounds this week from the wonderful confines of Fort Worth. There are a whole host of submissions this week, all worth a gander. Check it out!

Monday, January 16, 2006

The Straight Poop on Anal Fissure Therapy

Ever had an anal fissure? Speaking as someone who has treated many folks with them, and who developed one in medical school, I can assure you that they are a wee bit painful. To go along with a baseline of rectal discomfort, they make the normal bodily function of having a bowel movement into an exercise in self torture. Sort of like passing shards of glass. When they are acute, they can be painful beyond your wildest expectations; when chronic, well, they are a real pain in the.....you get my drift. Treatment for chronic anal fissures has remained somewhat controversial, as the "gold standard" surgical therapy (lateral internal sphincterotomy) is associated with a small, but clear, risk of incontinence of stool or gas.

A study from USC, presented at the SSAT meeting in May and published in the December issue of the Journal of Gastrointestinal Surgery, produces what I think is one of the best algorithms for the treatment of chronic anal fissure (CAF). Entitled "Cost-Saving Effect of Treatment Algorithm for Chronic Anal Fissure: A Prospective Analysis," the study evaluated a step-wise, escalating treatment protocol for 67 patients with CAF:

All patients were offered a treatment algorithm with stepwise escalation, starting with (1) topical NTG (0.2% Nitroglycerin ointment), (2) injection of BTX (Botox) into the internal anal sphincter, and (3) lateral internal sphincterotomy. Patients were followed at least every 4 weeks to assess the effectiveness of the treatment with regard to pain, bleeding, and healing of the fissure. Lack of either a partial or a complete resolution noted on follow-up or prohibitive side effects from the treatment were considered a failure of that level, and the next level of the algorithm was recommended to the patient. At any moment, patients had the option to shortcut the algorithm and advance to the next level or to proceed with surgery from the beginning.
What was not made clear in the paper, but was subsequently addressed in the discussion at the meeting, is that all patients were requested to initiate stool bulking agent therapy as well (i.e., Metamucil/fiber therapy). This is because anal fissures are direct result of constipation; despite most patients' protestations that they are "never" constipated, all benefit from daily fiber therapy to bulk up, and soften, their stools. I have this conversation with one or more patients every day in the office, and it amazes me how many patients don't follow through with this simple recommended therapy.

OK, some of you may be wondering "Nitroglycerin? Botox?!! On my derriere?" The idea behind these treatments is to relax, or even partially paralyze, the internal sphincter so that stool can pass more easily and prevent the continual re-injury to the fissure, allowing it to heal. The softer the stool, and the more relaxed the internal sphincter, the better the chance that the fissure will heal. Believe me, when you have an anal fissure, you don't want to be "uptight" in any way. But the bottom line (pardon the pun) is, do these non-operative therapies work?
NTG alone was successful in fissure healing in 31 of 67 patients (46.2%). Two developed a recurrent fissure and then received BTX as part of the protocol. Of the 36 patients who failed NTG trial, 3 requested surgery; the others were treated with BTX, which was successful in 84.8%. Five patients (15.2%) failed BTX and subsequently required surgery. The overall surgery rate in the whole study group was 11.9%, whereas CAF healed in 88.1% of our patients with medical treatment alone. Cost for NTG is $10; for 100 units BTX, $528; and for outpatient surgery, $1119.
I think that's a pretty strong argument for adopting an aggressive, non-operative approach for patients initially. Some patients have difficulties with nitroglycerin therapy, developing headaches and mild hypotension, but it is generally well-tolerated. As far as Botox is concerned, the treatment involves two injections of 20 units each; as each vial contains 100 units, that means 60 units must be discarded --- but some patients ask for injections elsewhere (they paid for it, why not?). This approach leaves surgery as an option for those patients who have the most potential benefit, and who have therefore the best understanding of the potential risks. Believe me, if it's my bum, I'd want to exhaust all of my options before having an operation that can (rarely) result in fecal incontinence. And that's the straight poop.

Monday, January 09, 2006

Small Bowel Diaphragm Disease

Last month's Archives of Surgery contained the first article I have seen about a specific type of NSAID-induced small bowel injury with more than one case. The article, entitled Small-Bowel Diaphragm Disease: Seven Surgical Cases, basically is a case report of seven patients who presented with symptoms of chronic, incomplete bowel obstruction or GI bleeding. All were heavy users of NSAIDs (a variety of them), and all were diagnostic challenges. The diagnosis of "small bowel diaphragm disease" was eventually made at video capsule endoscopy or laparotomy, and diaphragms were randomly distributed in the jejunum and ileum; treatment was resection.

I have seen one case of this recently, in a patient who has been using NSAIDs for years for a variety of long distance running-induced chronic injuries. His symptoms were of vague abdominal discomfort and bloating, with normal upper and lower endoscopic studies. His gastroenterologist, however, had read a case report about small bowel diaphragm disease and appropriately ordered an enteroclysis.....which showed a series of what appeared to be strictures. At laparotomy, and upon pathologic evaluation of the specimens, the lesions were not typical cicatricial strictures; rather, they were a series of very rubbery webs. We were fortunate that a capsule endoscopy had not been done, as a few of these had openings far too small to allow passage of the capsule (see a related situation here); that problem was seen in the current report as well.

NSAIDs are great medications, widely used with a good degree of safety. Most patients who develop GI symptoms from their use get gastritis or ulcers. The patients who get small bowel injuries similarly will more often present with bleeding from very proximal small bowel NSAID-induced ulcers. This new category of problems may stem from patients doing all the right things -- i.e., taking their NSAIDs with food to prevent stomach injuries; the damage of their heavy NSAID use is therefore seen farther downstream. Given the huge numbers of patients on chronic NSAIDs, we may need to be a bit more aggressive about looking for this problem when they present with fairly vague GI symptoms.

Wednesday, January 04, 2006

The Medical Weblog Polls Are Open

Medgadget is handling the polling duties for the 2005 Medical Weblog Awards --- including the categories:

  • Best Medical Weblog
  • Best New Medical Weblog
  • Best Literary Medical Weblog
  • Best Clinical Weblog
  • Best Health Policies/Ethics Weblog
  • Best Medical Technology/Informatics Weblog
If nothing else, it's a great starting place for those interested in perusing what other medical bloggers have to say.

Tuesday, January 03, 2006

A Big Fat Red Raider Flop

That was ugly! Congrats to 'Bama.

London Calling

Grand Rounds is being held at Random Acts of Reality this morning; take an imaginary trip on the Concorde and read the best of the medical blogs this week.