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.