Tuesday, February 28, 2006

Grand Rounds -- Mardi Gras Edition

My surgical colleague to the east is hosting Grand Rounds this week -- and what an extensive collection he has! Click on over to see Bard Parker's Mardi Gras edition of Grand Rounds!

Sunday, February 26, 2006


The AMA does not speak for me. In fact, it does not speak for the majority of physicians in this country, with only about 28% of actively practicing US doctors counted in their membership rolls. It is an organization that has repeatedly shown that it is far out of touch with the average physician and patient. It was midwife and mother to the current RBRVS system that has distorted our reimbursement system into something only the IRS could love.

With the kind of "success" that the RBRVS system has achieved, only arrogance can explain the AMA's most recent decision to develop yet another Rube Goldberg apparatus with the government. This week it was announced that the AMA has contracted with the government to develop "Measures of Quality of Medical Care".

The American Medical Association has signed a pact with Congress promising to develop more than 100 standard measures of performance, which doctors will report to the federal government in an effort to improve the quality of care.
Oh joy! Wait, there's more!
"We are concerned that the push to measure quality will become just a smoke screen to cut costs and to reduce the resources devoted to health care," said Dr. Frederick C. Blum, president of the American College of Emergency Physicians. But leaders of the American Medical Association said they had agreed to help develop uniform measures of the quality of care because otherwise doctors would have dozens of disparate measures foisted on them by insurance companies, health plans and government programs.

Under the accord between leaders of Congress and the A.M.A., doctors groups are to develop "a total of approximately 140 physician performance measures covering 34 clinical areas" by the end of this year. In 2007, the agreement says, doctors will voluntarily report to the federal government "on at least three to five quality measures per physician." The agreement says doctors "should receive" some additional payment to offset the costs of collecting and reporting the data.
I get it -- the AMA believes that instead of letting the free market sort this out, with the input of a variety of specialty societies, only they are smart enough to get the job done. Of course, who do you think would be better at, say, coming up with a basic set of standards for preventing DVT in the postop total hip patient -- the AMA, or the American Academy of Orthopaedic Surgeons working in concert with hematologists, internists, etc. And of course the reporting will be voluntary, and whoever reports the right data, in the right form, will get a few extra bucks. And there is a pot of gold at the end of the rainbow, too! The "pay for performance" train is already rolling, as I have previously noted, and there is nothing that will stop it at this point. But should the AMA really be the sole arbiter of what clinical measurements are to be rewarded?

Well, forget what I'm quibbling about; with such a gee whiz, super duper plan, everybody must be on board, right? Uh, not really.
Medical specialists, including emergency doctors, orthopedic surgeons, neurosurgeons and gynecologists, said they wanted to improve the quality of care and were already developing performance measures. But they objected to the confidential pact, titled a "joint House-Senate working agreement with the A.M.A.," and its ambitious timetable for assessing doctors' performance. In a letter this month to Dr. Cady, the presidents of seven medical specialty groups said they had not been consulted or informed. "The A.M.A. acknowledged the existence of this agreement only after we uncovered it," it said, adding, "The A.M.A. agreed to the imposition of a pay-for-performance system" without getting an assurance that doctors would be adequately paid for treating Medicare patients.

In a separate letter to Congressional leaders, 10 national doctor groups representing a wide range of specialties said: "We are dismayed that an agreement was reached on issues that are critical to the future of our specialties and our patients without our participation or knowledge. The American Medical Association cannot be the sole representative for the groups who are paramount to the development and implementation of quality measures."
This sort of behind-closed-doors deal is just the right kind of inanity that keeps AMA membership plummeting --- and it will ensure that the "quality" measures they come up with are [1] likely to be ignored, [2] well out of date by the time they are published, and [3] unable to meet any objective measurement of success. Why? Because we deal in a world of trial and error, with real consequences. As Dr. Stuart L. Weinstein, a University of Iowa professor and president of the American Academy of Orthopaedic Surgeons, said "Performance measures need to be developed by specialty societies, then tested and validated, to confirm that they really affect patient care in a positive way."

What a great idea! Make sure that the quality performance measurements actually have some degree of validity before inflicting them on the public! Why didn't the AMA think of that? What we should be asking is why the AMA is so intent on pressing its version of quality measurements that it resorted to a confidential pact with a few members of Congress to seal the deal. It doesn't sound as if they are really out for the patients' best interests.

Medical Algebra -- "New Math" for Physicians

Let's go through everybody's favorite high school exercise, the algebraic word problem:

Somewhere in the US is a busy, and by all accounts, good and caring cardiothoracic surgeon. Let's call him Surgeon A. He is a member of a group of well respected cardiac surgeons; let's call them Surgery Group X. Surgeon A and Surgery Group X receive patients in consultation from a variety of sources, but many come from a particular group of cardiologists --- Cardiology Group Y.

Believing they can increase their revenue, the cardiologists in Cardiology Group Y approach Surgery Group X with an offer: join us as our employees, and you will get a good salary and see all of our patients! They are mathematically stating:

(Cardiology Group Y) + (Surgery Group X) = good things for all

As it turns out, the dollars and cents part of that equation was somewhat lacking for Surgery Group X, so that they felt:

(Cardiology Group Y) + (Surgery Group X) = good things for all ....of Cardiology Group Y

Since no mutually agreeable method of joining could be found, Y + X never occurred. But, as spurned physicians are wont to do, Cardiology Group Y found and brought in Hired Gun Cardiac Surgeon Z, so:

(Cardiology Group Y) + (Hired Gun Z) = a change in referral patterns!

Let your imagination run wild, and I think you will agree that things might have been just a little testy in this alphabet soup. However, there's nothing inherently illegal in this arrangement, and such situations are present all over the country; any multispecialty group is based upon this type of setup. It can, however, appear somewhat undignified to one day stop referring patients to a specialist, who up until this time was perfectly capable of caring for your patients, all because of a financial arrangement.

Enter Patient C, who is in need of heart surgery as determined by a cardiologist in Cardiology Group Y....and who has been operated on by Surgeon A.....and who, upon being informed of the need for more surgery, specifically requests Surgeon A, whom he likes and trusts. His formula is therefore:
(Patient C) + (Surgeon A) = hopefully good results

But there is a problem -- Cardiology Group Y tells Patient C, "we're sorry but Surgeon A is not available, but we have Hired Gun Z right here and ready to take care of you this instant." Patient C acquiesces, Hired Gun Z operates, and.....there are complications requiring more procedures --- cardiac reoperations are nothing if not difficult, hazardous, and not a lot of fun for patient or surgeon.

(Patient C) + (Hired Gun Z) = oh, shit

Patient C subsequently finds out that Surgeon A was available all along, and that the financial arrangements of Cardiology Group Y, rather than his own requests for surgical care, were the sole reason he was sent into the operating room with Hired Gun Z. And, boy, was he pissed --- not about the complications, as he understood his risks, but about the fact that his physicians lied to him and camouflaged their financial shenanigans as appropriate delivery of care. The ultimate equation, in his estimation, is:

Cardiology Group Y's $$ >> Patient C's desires (which approach the value of "zero")

(cue the music) Enter Slick Attorney G, who sues Cardiology Group Y and Hired Gun Z for fraud and battery on behalf of Patient C. And who wins -- big. To the tune of $2.25 million in compensatory damages, and $2.75 million in punitive damages, finding the two physicians and their group guilty of fraud, and Hired Gun Z guilty of battery -- for having operated on Patient C without having valid consent to do so.

And that, my friends, is a far more harsh way to learn "New Math" than the way I was instructed in school. There is no insurance coverage for that sort of verdict, and no amount of "spin" can make this most unseemly deal look even remotely redeeming. You can read a less mathematic account of this very real case in Surgery News (bottom of page 4). Having experienced this type of behavior first hand on more than a few occasions, I wonder what the effect of this ruling will have on physicians who have more than a medical relationship with other specialists, or with labs/x-ray facilities/outpatient surgery units etc, for that matter. News of this case has hardly had a wide audience, and I suspect many who currently practice in this manner have yet to hear about it. They would do well to heed the warning given by the attorney involved:
William F. Gately, attorney for the Bargars, said that the verdict was "thoroughly and entirely appropriate. For any physicians to do to a patient what this jury found that these two physicians did to Harry Bargar is obscene."
I'm sure he's available to sue those who refuse to let their patients choose their own specialists -- and that will give you a headache that is worse than anything a Diff. Equations professor could ever dream up. And, no, wearing the dunce cap will not suffice as punishment (although it might be a a worthwhile addition!).

Tuesday, February 14, 2006

Chewing gum -- A good habit in the hospital?

If you are going to have a colon resection some time in the near future, it may be a good idea to take a few packs of gum to the hospital along with your toothbrush and books. An article in February's Archives of Surgery shows that gum chewing appears to speed the return of bowel function after elective colectomy. The article, entitled "Gum Chewing Reduces Ileus After Elective Open Sigmoid Colectomy," is from the Santa Barbara Cottage Hospital; the abstract is not yet available on-line, but will be here soon.

A total of 34 patients were randomized into 2 groups: a gum-chewing group (n=17) or a control group (n=17). The patients in the gum-chewing group chewed sugarless gum 3 times daily for 1 hour each time until discharge....The passage of flatus occurred on postoperative hour 65.4 in the gum-chewing group and on hour 80.2 in the control group (P=.05). The first bowel movement occurred on postoperative hour 63.2 in the gum-chewing group and on hour 89.4 in the control group (P=.04)....The total length of hospital stay was shorter in the gum-chewing group (day 4.3) than in the control group (day 6.8), (P=.01).
A considerable amount of research has gone into the issue of postoperative ileus, including pharmacological stimulation and sham feeding (wouldn't that just tick you off!). There have been many proponents of early feeding, but many surgeons, including myself, have found that most patients do not tolerate it well. Gum chewing may be a more palatable and easy to implement alternative to sham feeding -- the mechanism of action of sham feeding and gum chewing is presumed to be stimulation of the cephalic-vagal system, resulting in increased levels of neural and humoral hormones that stimulate bowel motility in the GI tract.
An added bonus? It's cheap! While gum chewing may not be a great option for patients with a prolonged ileus, it may be a pleasant way for many patients to shorten their hospital stay. Unfortunately, the gum we provide may not be quite as enticing as Willy Wonka's:

Willy Wonka: Don't you know what this is?
Violet Beauregarde: By gum, it's gum.
Willy Wonka: Wrong. It's the most fabulous sensational gum in the whole world.
Violet Beauregarde: What's so fab about it?
Willy Wonka: This little piece of gum is a three course dinner.
Mr. Salt: Bull.
Willy Wonka: No, roast beef. But I haven't got it quite right yet.

Please, just don't leave your old pieces stuck to the underside of the bed control.

Monday, February 13, 2006

'Nuff Said

Get yours at Cafe Press!

Boom -- What Hapens with Suicide Bomb Blasts

I wish I had ready, searchable access to World War II or Vietnam era surgical journals to see if anything similar to this was published during a time of major conflict. An article entitled "Surgical Lessons Learned from Suicide Bombing Attacks," from the Department of Surgery and Trauma Unit, Hadassah University Hospital, Jerusalem, Israel, was published in this month's Journal of the American College of Surgeons (subscription required, but abstract accessible).

Several changes that occurred over the past 2 decades have made the explosive devices more lethal in Israel. The explosive material, which used to be composed of homemade, low-grade material, has been replaced by high-grade military material. The shift to high-grade material has enabled the attackers to add a large amount of heavy shrapnel to the bomb, intensifying the effects of penetrating trauma. Detonation through delayed timers or remote-control has been replaced by precise timing by the attacker. A final change is the location and position of the explosive device. The explosive device, which was once concealed under seats and inside garbage bins, is now carried at chest height, and detonated in the center of a crowd. These changes have brought about a marked increase in the number of fatalities per attack and the severity of injuries. For example, the number of fatalities per attack after bombings aboard buses in Israel has increased from a median of 3 in the 1980s to 9 in the 2000 to 2004 Intifada.

Primary blast injury is caused by the rapid outward spread of the shock wave. Injury to gas-containing organs, such as perforation of the middle ear and blast lung injury (BLI) are most common (22.1% and 18.2% of victims, respectively). Of all patients with BLI, 82% of victims aboard buses and in semiconfined spaces will suffer from moderate and severe forms of BLI compared with 33% of victims in open spaces. S econdary blast injury is caused by penetrating missiles that are propelled by the blast wave. More than 85% of victims of suicide bombing attacks (SBA) suffer from penetrating shrapnel and debris, most commonly to the head. Tertiary blast injury results from a patient’s body being displaced by expanding gases. Burns are termed quaternary blast injury and are also notably more common after explosions inside confined spaces compared with open spaces (33.9% versus 5% of victims, respectively). The hallmark of injuries after an SBA is the combination of blunt injury, multiple penetrating injuries with extensive soft tissue damage, and burns. Half of all patients hospitalized will be seen in a trauma unit setting and the same proportion will be admitted to an intensive care unit. Victims of SBAs are more severely injured compared with other trauma victims. Typical injuries include penetrating injury to the head (55%), extremities (49%), and torso (40%), burns (27%), open fractures (22%), and BLI (18%).
It certainly gives one pause, as an American living in a free, open, and safe society, to understand that the Israelis have dealt with suicide bombings long enough to have their national trauma registry reflect that fact. As a trauma surgeon, I fear the day is coming when we may need just this type of information.

Sunday, February 12, 2006

Open the Pod Bay Door, HAL

Every once in a while a trauma call night is quieter than usual. It's an unexpected treat, though one that usually leaves me sleeping fitfully and checking both the clock and my pager with every noise in the night. Last night was just such a night, and when I finally made my way to the call room I decided to see what was on TV -- news (not much new), Olympic coverage (not in the mood), NBA basketball (yuk). However, I did find that TCM was broadcasting, without interruption, one of my top 5 favorite flicks.
While one can say that this movie has a few too many psychedelic flairs at the end, and it leaves many an idea dangling, one cannot state that this film is anything other than sensational and groundbreaking. I had not seen it in more than 15 years, and several things struck me upon a fresh viewing.

  1. The film is so measured and paced that today's audiences might be turned off; but, that slowness allows one time to absorb what is shown --- including the hard to comprehend vastness of space.
  2. The visuals remain crisp and arresting, even better than I remembered; George Lucas owes much of his success to what Stanley Kubrik created.
  3. As I have gotten older, I was much more drawn in to the images at the end, of man facing his own progressive aging and death, than when I saw the film years ago with much younger eyes.
  4. The music, especially The Blue Danube, is a wonderful complement to the film.
There remains much left to the imagination in this piece of work, much like as with a painting or poem. As Kubrick himself remarked:
"You are free to speculate, as you wish, about the philosophical and allegorical meaning of "2001.""
This movie holds a certain charm for me, one of the few that withstand repeated viewings. I can only say that about the others in my "top 5" - Doctor Zhivago, Lawrence of Arabia, & Jean de Florette and its companion piece Manon des Sources. I would include Out of Africa as well, though the last time I viewed it, the Robert Redford character seemed to me to be such an arrogant and selfish SOB it was hard to watch.

To get one person's idea of what "2001: A Space Odyssey" means, check out this site (works only with Internet Explorer). For the "Lego" version, go here for a chuckle.