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 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.