Thursday, December 13, 2007

EHRs --- The AMC Pacers of the Computing World

Although I am a surgeon, I have enjoyed using computers since I was a teenager. My father worked with computers for IBM, and was so excited to one day open a box and set up a Radio Shack TRS-80 computer on the kitchen table. The "Trash-80" was no favorite of my mother, but despite her desperate attempts, it lived in the kitchen -- on a TV tray -- for quite a while. It was cool -- with a 4 MHz processor and 4K of RAM; today, that kind of blazing speed will maybe be enough to run an old sprinkler system.

Soon thereafter, I took my first computer course as a freshman in high school. As I recall, there was a Univac machine the size of a DeSoto in a corner room of my high school, and we would type up simple programs on keypunch cards to get it to calculate the square root of 42 or other such nonsense --- we were "programmers" in the sense that a guy changing his oil is a mechanic. But, it was fun, and kept me interested in the potential of computers.

Fast forward a few years to 1984, when I was about to enter the best medical school in the country. IBM had introduced the PC, and I just had the overwhelming urge to plunk down a good 5 grand of hard earned money to buy me one -- with two floppy drives, an AST expansion board (fully loaded down with a screaming 384K of RAM), and a color monitor, no less. Smokin'!!

What would that baby do? Well, after booting it up, I could use the good old WordPerfect word process software I had purchased to, well, word process. And word process I did, to the tune of $30 per medical school lecture to help pay for the darn computer (and buy beer) ---- because we had a lecture note taking service, and some folks just really didn't like to type up a lecture for distribution. Not only did I make a few bucks, but I learned the material a bit better by listening and taking notes, and then typing them up while listening to the lecture tape all over again. And, in the process, I learned quite a bit more about computers, with an awareness of how they could become much more functional in medical care in the future. Then came residency. Zoom -- the computer world completely passed me by, as I had no time to take care of bodily functions on a regular basis, much less screw around with bits and bytes.

Why do I write this? To tell you, and remind myself, that I am no technophobe. I bristle when I read in blogs and newspapers that physicians simply are too technophobic to "accept" electronic medical records. I love the functionality of computers, the simplicity of e-mail programs, the elegance of my Microsoft Excel spreadsheets, and yes the word processing prowess of Microsoft Word. I can use HTML --- OK, I'm a real novice --- on this blog and two websites that I have had to maintain. I can navigate my way around most programs and within a few minutes figure them out so that I can be functional.

I'm not a computer dumbass, dammit!

Except, of course, in the narrow minded world of the electronic medical record programmer. The systems that I have seen are so non-intuitive, so counter-productive, and so blinking difficult to navigate that they make other business world programs seem so advanced that they were given to us by time travelers who had spent time with Captain Kirk. Some of them have the feel of a potpourri programs forced to work together but which were written in different programming languages in different decades, and they look as elegant as the interior of an AMC Pacer (why do I know what that looks like? Don't ask, and please don't ask my wife).

Doesn't this thing have drop down menus? Well, yes, but only on certain screens, which you must access by retyping your password, but this time with "caps lock" on (don't forget to turn off "caps lock," though, because otherwise you sometimes get frozen out of the system). Can I just click here to get to the next piece of information? Er, no. Hit F12. F12?? What program for average people still uses the function keys??? Quicken? Nah, didn't think so.

How about this. I need to look at all of my patients' vital signs and ins & outs for the past 24 hours, can I do that? No, because the system hasn't been programmed to recognize anything other than a midnight-to-midnight time frame. We hope that will be patched in the next version --- which might be upgraded to include Pong if we're lucky!!!

How about my 128 character sign-on password that must include capitals, small letters, at least a dozen numbers and the symbol for that guy who used to be called Prince --- do I really need to change it on alternating Tuesdays and every new moon? Oh, yes. And don't forget -- if you leave the computer for 3.7 nanoseconds without any activity, it will shut you out and you need to sign back on. After, of course, you have called the help(less) desk and waited on hold for approximately the length of time Mars has been in phase with Jupiter for the past decade and begged forgiveness.

Why have we gotten here? Why do we have elegant, well-written programs to allow us to do everything from blog to run the books at major corporations, but the medical system has programs that might have been adequate in the 70s? I think there are a few reasons, and since nobody else will listen to me, I feel justified in inflicting my opinion on those 2 people who have gotten this far:
  1. All hospital computer systems were originally written for one purpose -- billing. As a result, the folks that have been the most heavily involved in getting us new programs start with the premise that billing is the most important function of the code that is to be written.
  2. Money, part one --- hospitals decided they needed to act just like other businesses, and adopted one of the corporate world's worst attributes, the constant worrying about this quarter's projected budget and last quarter's revenues against the projection. Not net loss or gain, mind you, but imaginary numbers that must be met, or heads will roll. How are you supposed to outlay a lot of cash for a new computer system if you are worried about this quarter's budget?
  3. Money, part two --- hospitals, and doctors, rightly see that their income is going down, so unless a new computer system can pay for itself over the long haul, why bother? And if CMS says you have to have one, spend the least money for it.
  4. Janet Reno and Bill Clinton --- my pet theory is that Bill Gates and that giant group of smart people in Washington could write a great program that would work for every hospital in the land, make it easy to use, and make it affordable. And they'd make a ton of money doing it. But, of course, the Clinton Justice Department jumped all over them a few years back for creating a "monopoly," which obviously never existed, so why would they bother with creating a potentially real one? So, Mr. Gates took his money overseas to help folks with malaria.
  5. Last, but not least, there are not a whole lot of physicians who write code in their spare time, so getting a program that fits the needs of docs, hospitals, nurses, et al is a tall proposition.

So, what to do? Most nights, I dream of short circuiting the hospital's computers so we can have nurses go back to actually taking care of patients instead of poking on keyboards. Most mornings, I have to restrain myself from hurling hot coffee at the computer screen. And most evenings, I leave the hospital resigned to the fact that there is nothing that I can do, and that really ticks me off. So, again, what to do? I guess have a martini and forget about it.

Thursday, December 06, 2007

St. Looney Tunes Hospital

Ah, youth. It never surprises me how certain people and situations bring long-hidden memories instantly to mind. Unfortunately, in the hospital I am frequently reminded of childhood cartoons, rather than the inspiring novels I read in my teens and twenties. Just for an introduction, let me familiarize you with the cast of characters that inhabit my --- and every other --- hospital:

Foghorn Leghorn --- This is the older surgeon, used to getting his way, who treats any surgeon younger than he as an underling, ready and willing to do his bidding at any time of the day or night. "Boy! I say, boy!" is his constant refrain, as in "Boy, take this call night for me," or "Boy, I need you to see my patients this weekend (even though we don't share call)." Likes to hear the sound of his own voice -- as in "That's a joke... I say, that's a joke, son". Means well, but one can get very tired of him very quickly.

Chickenhawk --- The other end of the spectrum from Foghorn Leghorn. The young surgeon, fresh out of training, for whom the term "dogmatic" was invented. Never backs down from a challenging case --- an admirable quality at times --- but sometimes needs an older, wiser physician to hold him back a bit.

Daffy Duck --- To paraphrase the Looney Tunes official description, this is the middle-aged doc who has become so frustrated at the idiocies he experiences every day that he as become "more self-analytical, competitive, peevish, paranoid, and neurotic. Eventually, (the doc finds) himself more and more at the mercy of a (hospital) that seemed to favor everyone but him. So why do (patients) love him? Despite his failures, Daffy, like the Greek hero Sisyphus, is a victim of injustice who continuously protests. And it's his refusal to surrender his will to the whims of the conspiring universe that makes him heroic." This is the doc who blows his top occasionally, but only when some stupid hospital policy has the potential to cause harm to his or her patient. Irascible, but lovable.

Bugs Bunny --- everybody loves Dr. Bugs Bunny. Funny, able to pull the wool over the administration's eyes, and in the end smells like a rose. Never -- I mean never -- can there be a Bugs Bunny surgeon. Such flippancy is erased the first time a surgical complication occurs. No, Dr. Bugs Bunny is usually an infectious disease doctor, or an anesthesiologist. Loads of fun to talk to.

Tweety Bird -- pardon the sexism, but Dr. Tweety Bird is a female physician. This is the type of lady doctor who is always unflappable, never sweats under pressure, and always looks cute and put together (even in the middle of the night). A delight for older male patients.

Marvin the Martian --- the hospital CFO. Nice, eager, and totally clueless about how we take care of patients in the hospital. Eager to submit the whole place to his will of cost cutting, but unable to achieve that goal because of the wildly bizarre personalities that make up a hospital.

Taz --- the hospital attorney. 'Nuff said.

Yosemite Sam --- the staff blowhard. A physician of any specialty who views the administration offices as his personal spot to blow off steam. Bad food? Go yell at administration. OR not running on time? Ditto. Like Sam's guns, he's frequently on the mark, but his misses are so wild that no one pays him any real attention.

Elmer Fudd --- this is a surgical blog, right? That means I can make fun of internists! Elmer Fudd is the caricature of the physician who is more interested in chasing zebras when he hears hoofbeats than in rounding up the horses around him. Serves as the butt of many jokes from surgeons, intensivists, gastroenterologists......but, does catch the silly wabbit on occasion!

Porky Pig --- the hospital CEO. Calm, but somehow that calmness seems to come at the expense of any realization of what exactly is going on elsewhere in the building. And just when you need him to do something important, it's "that's all folks," and he's off to be a CEO at another, larger institution.

Pepe lePew --- the nearly-retired doc who is in love with himself. This poor guy remains stuck in the world of 1972, when he was top dog at some now-shuttered academic institution, and has not read a journal article since the Ford administration. Tolerated, not well liked, and avoided in the doctor's dining room.

Hippety Hopper --- the quietest, smartest doc in the hospital. Most often a pathologist. Says almost nothing, but like the baby kangaroo, never ceases to kick those around him in the head when coming up with the right diagnosis.

Gossamer (AKA Rudolf) --- the staff pushover. Looks fierce, but in the cartoons let Bugs Bunny run roughshod over him, making him look like an idiot. In the hospital, he never says no, even when other docs or the hospital are dumping on him.

Rhode Island Red --- Foghorn Leghorn's rival in the cartoons, also his rival in the hospital. Mr. Smooth, the surgeon who seems to handle every untoward occurrence with grace and elan, whose patients love him, and whose complications always seem to turn out just right. Lasts about 3 years at every hospital he's worked in, because by then his schtick has worn thin, and bigger problems with his patient care start to surface.

Sylvester -- me. Sloppy in appearance, dogged in pursuit of an ever elusive goal -- which, in the cartoon, was Tweety, but in my case, some sign that the hospital administration "gets it" in regards to physician relations.

That's just an intro. We'd need to expand our list of cartoon characters to include the cranky ED doctor, the exasperated chief medical officer, or the heard-but-never-seen radiologist, to name a few. Just remember, though, that if you ever find yourself caught in the hospital, that everybody that works there has at least a little Bugs Bunny inside him or herself. Laughter, after all, really is the best medicine.


Counterintuitive: coun·ter·in·tu·i·tive (koun'tər-ĭn-tōō'ĭ-tĭv, -tyōō'-) adj. Contrary to what intuition or common sense would indicate

For some time now, the Powers That Be® have been stating that in the brave new world of the 80-hour residency work week we would have better rested, more motivated residents willing to tackle the challenges of training with vigor, good humor, and as much or more dedication as their predecessors. And for just as long, curmudgeonly surgeons such as myself have called BS on that idea, feeling that it takes a whole lot more than counting hours in training to make a complete surgeon -- or physician of any stripe -- concerned that the residency training system would eventually turn out fewer numbers of adequately trained surgeons. However, the Powers That Be® have more clout than simple surgeons such as myself, and have made persuasive arguments that the 80-hour work week would increase the number of students willing to go into general surgery in particular.

Do they have any data to back that up? Well, not quite. And, just because I like to throw cold water on social engineering masquerading as good medical policy, I'd like to share a little data with you that might come as a surprise.

In this month's American Journal of Surgery there is an interesting article entitled General surgery resident attrition and the 80-hour workweek. The authors sent a simple, seven question survey to all 252 ACGME accredited general surgery training program directors, and received responses from 124. Basically, the survey asked about attrition rates for categorical general surgery residents (those who entered the training program intent upon completing a 5-6 year course of training in general surgery) over a 4 year period starting just prior to the 2003 institution of the 80-hour rule. Now, it would seem intuitive to expect that attrition rates would go down, or at a minimum stay stable, following the implementation of the 80 hour rule. Of course, theories based upon intuition need to be tested and validated --- what was found was the opposite (from the abstract):
One hundred twenty-four of 252 programs (49%) responded, reporting a loss of 338 categorical residents. The total attrition rate increased from .6 residents lost/program/y to .8 residents/program/y (P = .0013). Lifestyle concerns were the most commonly reported reason for residents leaving during surgical training. The majority (56%) of those who left surgery entered other fields of medicine (ie, Anesthesia and Family Medicine most commonly).
Makes you go "Hmmm," doesn't it? Training programs, and their governing bodies, have gone out of their way to make general surgery training "easier," less time-consuming, and supposedly more attractive as a result, and what happens? Fewer residents complete surgical training!

This study begs the question "why?" Fear not -- as unusual as it is for me to offer an opinion, let me make a few observations. First of all, making an educational experience less rigorous does not necessarily make it more attractive. I subscribe to the idea that things worth having are worth working hard to get --- like SWIMBO, for example. Secondly, when surgery residency is advertised as "fun, and now easier!" it does not necessarily attract the type of applicant willing to put in the hard work it takes to end up as a practicing surgeon. After all, if "anyone can do it" is a good way to advertise for applicants, why isn't that posted on a sign at the base of Mt. Everest?

Last of all, we should all recognize that this happens because of the Law of Unintended Consequences --- whenever we make policy decisions with a social engineering intent, rather than based upon rational thinking, what we end up with rarely resembles a desired outcome.
And, since we all know there is no going back, the best we can hope for is a little more rational thinking in the next few years to ensure that good surgical resident training is preserved as much as possible.

Thursday, November 15, 2007

To CT or Not to CT? Another Salvo

Common things being common, anyone who has spent a little time perusing medical blogs has read a few posts about the value, or lack thereof, of CT scans in the evaluation of suspected acute appendicitis. I'll outline my opinions below (Opinions? Moi?), but there has been another salvo fired in this skirmish, this time aimed against the "CT everyone" crowd.

A study published in this month's Journal of Gastrointestinal Surgery from the University of Wisconsin asks the question Computed Tomography in the Diagnosis of Acute Appendicitis: Definitive or Detrimental? This was a retrospective study of all adult patients treated for acute appendicitis at their institution over a three year period. Any imaging results were correlated with operative findings, including the presence or absence of perforation of the appendix.

Results During a 3-year period, 411 patients underwent appendectomy for presumed acute appendicitis at our institution. Of these patients, 256 (62%) underwent preoperative CT, and the remaining 155 (38%) patients did not have imaging before the surgery. The time interval between arrival in the emergency room to time in the operating room was longer for patients who had preoperative imaging (8.2 ± 0.3 h) compared to those who did not (5.1 ± 0.2 h, p < 0.001). Moreover, this possible delay in intervention was associated with a higher rate of appendiceal perforation in the CT group (17 versus 8%, p = 0.017).
Although retrospective, this study gives a bit more ammunition to the "CT very selectively" crowd. It appears that CT scanning delayed operative intervention in most patients, and that was the supposed reason for a higher rate of perforation in the patients who underwent CT. Ergo, they say, use CT scanning less in cases of suspected appendicitis. Sounds logical, no?

Hold your horses, Kemo Sabe. There's a whole lotta supposition going on there, so let's look a little deeper into the data, shall we? In the article, a few interesting things become apparent:
  • While the majority of patients were male, a higher percentage of those undergoing CT were female. That's just plain reasonable, because women have those little things called tubes and ovaries that can be troubled and cause symptoms like appendicitis.
  • Those patients who had an "indeterminate" scan were lumped in with the "negative" scan patients. This is because the scan in those cases did not enhance the ability for the clinician to make a diagnosis.
  • 8% of those diagnosed with appendicitis on CT had a normal appendix removed at surgery. That's plain interesting, because CT has been touted as nearly perfect at diagnosing acute appendicitis when it's called "positive" by the radiologist.
  • 14% of those taken to the OR for presumed appendicitis without preop CT had a normal appendix. I'd say that's within historical norms, and actually a bit lower than I would have anticipated --- plus, it's not statistically different than those that had CT scans.
  • 7 of 14 patients with negative CT scans were ultimately found to have appendicitis; as a result, when evaluating both the negative and indeterminate CT scan results together, the negative appendectomy rate was 37% (leaving us, for those with statistical interest, an overall sensitivity of 92%, specificity of 68%, accuracy of 88%, and a negative predictive value of less than 40%). Hmmm. What we don't know is the true denominator of this number -- this is a small sample of patients who had a negative CT, as presumably the majority were sent on their merry way and never had any difficulties. It is interesting, however, that 14 patients with negative CTs made their way to the OR for presumed appendicitis, and half of them had it despite the CT findings.
  • The majority of perforations were not identified on CT. That's reasonable, as most of the time a small perforation is found at surgery. What is not spelled out is how many patients had a CT because of generalized peritonitis, which could have a variety of possible causes and for which a CT is often a good idea.
  • Interestingly, the study did not identify patients thought to have appendicitis on CT, who were found to have some other pathology. That is presumably because they only looked retrospectively at those patients identified by procedure codes as undergoing appendectomy.
Well, let's think a bit about this. At least at the University of Wisconsin, a CT scan is reasonably accurate for diagnosing appendicitis, but it sure ain't perfect. Well, what's an ED physician to do? IMHO, it's time to put a little common sense back into play --- the immediate availability of an abdominal CT scan does not justify its (over)use, so here are the Aggravated DocSurg guidelines for diagnosing appendicitis, with and without CT:
  • Young men with right lower quadrant pain, tenderness, and an elevated white blood cell count need to be poked and prodded by a surgeon, not sent through an irradiating donut.
  • Young women with right lower quadrant (not pelvic) pain, tenderness, and an elevated white blood cell count need to be poked and prodded by a surgeon, and then possibly sent through an irradiating donut.
  • Older men and women with right lower quadrant pain, tenderness, and an elevated white blood cell count need to be poked and prodded by a surgeon, not sent through an irradiating donut.
  • If there is any other combination of symptoms --- pain not in the "classic" location, a normal white blood cell count, a suspicion of diverticulitis/nephrolithiasis/PID --- by all means get a CT.
  • Never, ever (ever!) get a CT of the abdomen without oral contrast when there is even the slightest possibility that the patient may have GI tract pathology, including appendicitis (for some reason, that's en vogue in my hospital) --- it's worthless, and may require your patient to undergo a second round of radiation.
  • Last but not least, when in doubt, get a CT.
Wait a minute. Didn't someone who sounds a bit like me just say, "the immediate availability of an abdominal CT scan does not justify its (over)use?" Er, yes. And I also just said, "when in doubt, get a CT." I'm sorry, I know that makes me sound a little like Zaphod Beeblebrox, but one has to keep in mind that not every patient has read the textbook and presents like "classic" appendicitis. And I would prefer that ED physicians feel that the CT is a readily available part of the armamentarium they have at their disposal in evaluating abdominal pain --- but they should also should stick to their guns and ask surgeons to come evaluate patients who have likely appendicitis, and not be cowed into obtaining a CT every time just because the surgeon insists on it.

All I ask is for the ED physician to let "surgeon versus CT evaluation" cross his or her mind a little more frequently before asking for a CT. At least according to this study, it will save your patients time and possibly avoid an increased risk for perforation if the surgeon is involved early ---- plus, you can always punt the question of CT or no CT to him after he evaluates the patient.

Tuesday, November 13, 2007

The Speech

Every physician and every nurse in the country knows they type. Young, brash, frequently stoned, covered with gang tattoos and enough piercings to set off a metal detector at 20 paces. They show up in the ED with the same stories, the same injuries, the same attitudes. They have been stabbed, beaten, shot, or run over, and expect nothing short of an effort worthy of a Congressional medal to save their lives. Of course, we've all heard the same comments: "I got jumped by two dudes;" "I wasn't doing anything;" or, my personal favorite comment, "......" --- as in, "I ain't sayin' nothin', because I'm such a bad ass."

Of course, every physician and every nurse in the country knows otherwise --- the real bad asses are the cops tough enough to bring these jerks in, as well as the soldiers we are fortunate to have serve our country. My problem is that these frequent hospital clients get under my skin like botfly larvae and cause me heartburn worse than my teenagers. For years, I would just shut my mouth, take care of them, and send them on their way. But it always bothered me that while I could help with their physical problems, these young men were on a path to a place that no one ever dreams of ending up.

So, even though I'm sure I am rarely heard, I came up with The Speech™. This allows me to at least tell myself that I have given all of the medical warnings relevant to the situation. It goes something like this:

So, have you been in prison yet? No? Well, that's just great. Except that, given your present situation, with police officers in the emergency department than nurses on the night you decided to get my sorry butt out of bed at 2:57 AM, I would say that prison just might happen to be in your future. And, since I get the delightful opportunity to see young men just like you who are or have been in prison, let me introduce you to a few facts of your future life.

Let's start with anal warts. What? Never heard of them? That's right, they sound pretty disgusting, and they are. And, no, they don't result from sitting on the john in a dirty cell. They are sexually transmitted ---- yeah, that's right, some other man is going to give them to you. Sort of a little gift, courtesy of yourself, that often results from prison rape. Let me tell you, when you do get out of prison, nothing says "Hey ladies, I'm back and I'm ready for a little action" like a few warts on your butt and your Johnson. And don't forget about the potential for a colostomy should you resist a little too hard and it gets rough.

How about Hepatitis C --- know anything about that? Well, the prison mambo is one way you'll get the opportunity to experience this little treasure. Cure? Uh-uh, sorry. And if you are planning on adding a few "prison tats" to that collection of ink on your skin, there's another little chance to roll the dice with your liver.

Oh, yeah, one more thing. I know how much you have enjoyed this little hospital visit for your stab wounds. Just remember, you are one wrong look, one mistaken word, one friendship with the wrong guy from being stabbed again...and again....and again.

I don't like having these little chats any more than you do. So, do me a favor. Cut the crap, get a job, and get a life, because right now, everything I have laid out for you is all you have to look forward to. And I don't want to see you here ever again.

Have a nice day.
Am I being judgmental? You bet your ass, and I'd say it's high time we all got a little judgmental with these guys. I know it falls on deaf ears. But, if it sinks in, then maybe I will have done something better than just patch them up and send them out the door.

Sunday, November 11, 2007

SurgeXperiences #108 -- Snow White and the Seven Surgeons

When I accepted the invitation from the Monash Medical Student to host this edition of SurgeXperiences, I initially thought "No problemo, dude! Only one night of call during the week leading up to it; I should be able to knock it out with time to spare." Life as a surgeon has taught me that first thoughts are often wrong, especially when it comes to my free time! Anyways, after a hectic week, here are a few categories of surgical submissions offered for your approval --- with a little Disney flare.

First up is Grumpy -- we all have a little Grumpy in us, and surgeons have a well-deserved reputation for belly-aching. It must be all of the stale coffee we drink between cases. Dr. Alice lets her grumpy side shine in How to Not Run an OR. She shares her experience in a hospital that seems to lack the understanding that the absolutely most important person in the operating room is .... the patient. Not having the proper equipment available to take care of said patient is, well, a major no-no. From Surgeonsblog comes a well-written critique of the problem we face as surgeons in terms of training new physicians, gaining appropriate experience, and obtaining credentials -- Are You Experienced? Of course, for a surgeon, nothing makes us quite so grumpy as a case gone sour -- especially one that starts off difficult and heads downhill from there, as described by Bright Lights, Cold Steel.

Next in the door is Sneezy -- quite frankly, a dwarf with a bit of a handicap when it comes to wearing a mask in the OR. Well, these posts are really nothing to sneeze about. Bongi at Other things Amanzi describes the difficulty in dealing with patients who present with advanced problems because they initially sought care from a traditional healer in an undeveloped area. And the Evil Resident has learned that sometimes people do the strangest things.....and end up with some unintended consequences. Should one sneeze about asking just who is operating on you at the local training hospital? It's all discussed at the MedFriendly Blog.

And then there's Doc, who somehow carries that moniker without ever having taken an MCAT or passed a board exam! This week, there are a few unquestionably "Doc" posts. Dr. Schwab at Surgeonsblog offers a great description of an old-fashioned open cholecystectomy in Mini-Steps. Bongi, up for reading a second time, describes a rather different experience with the same operation.

All of us who practice in the realm of medicine outside of academia are well-versed with the sometimes strained relationships we may have with the closest Miracle Center. We have mixed feelings about them, and quite certainly they feel the same. A few "Doc"-like posts in this vein come from the Buckeye Surgeon, who delves into the problem of bed shortages, and again from Dr. Schwab, whose own name for the local academic facility is The BFH --- you can draw your own conclusions from that acronym.

Where would surgeons be without our anesthesia colleagues? Sleepy, you are being paged! Dr. Keamy from a great collaborative anesthesia blog gives us some insight into the significant role a good anesthesiologist -- and a good anesthetic -- plays in the delivery of good surgical care. Not to be outdone, at Counting Sheep we hear what it's like to spend one's days always behind a mask, as an almost unseen partner in surgery. And the Anesthesioboist gives a great introduction into pain, and how to make it go away during surgery.

Bashful?? Hell, not in the OR, if you want to learn anything or get anything done. From Flatus and Stool we learn that bashfulness needs to be thrown out the window in training --- never let a little thing like social propriety get in the way of asking a patient about their bowel habits! And a healthy lack of bashfulness, and appropriate confidence, is sometimes rewarded -- just ask the Buckeye Surgeon.

There's a little bit of Dopey in all physicians as well --- if you don't get a little dopey during training, you just aren't human; some of that needs to stay with you to stay sane during practice. Dr. Campbell, an academic ENT physician who spends a considerable amount of time dealing with malignancy, had his Dopey sensors up when he spotted T-shirt on a recent patient --- this one you need to read to get a great sense of the irony we deal with frequently. And what is more "dopey" than superstitions? All surgeons --- myself included --- must admit to our own little superstitions ("appendicitis cases come in threes"), a little secret that Make Mine Trauma lets everyone in on.

Just as we are all a little Grumpy and a little Dopey, surgeons all have (hopefully) a whole lot of Happy in us as well -- after all, people actually let us operate on them, and sometimes they even ask us to!! At Suture for a Living, we learn about the little things that make us happy during a work day --- just the simple conversations that happen in the operating room. And although he was more than a bit bored by the end of the day, learning about brain surgery was quite a treat for this medical student.

What about Snow White? Well, unless somebody wants to talk about sexual reassignment surgery, I think I'll leave her for another day. Next up for SurgeXperiences is the Monash Medical Student, who will host on November 25th; get your posts lined up by the 23rd!

Thursday, October 25, 2007

A Monkey Wrench in the Ratings Machine

Interesting things, facts. Stubborn at times, when they are reviewed, and apt to make most reasonable people change their minds about subjects if they are studied and accepted. Of course, they often tend to be ignored --- unfortunately, in the wonderful world of Modern American Medicine™, the latter situation often prevails.

A case in point is the headlong rush to rate physicians' quality of care almost solely upon the volume of a specific procedure they happen to perform. It's a simple concept, really --- it would seem to make sense that the more frequently a surgeon performs a given procedure, the better their outcomes should be. That case has been frequently made, particularly on the part of large academic medical centers, for a whole variety of procedures -- sort of a Good Housekeeping Seal for surgery. These include pancreatic resection, esophagectomy, coronary bypass surgery, laparoscopic gastric bypass surgery, and carotid endarterectomy. There is a push for "centers of excellence" to be created for these procedures, with gastric bypass surgery centers of excellence already established. There are reasonable statistics to back up this idea, but very little investigation has been undertaken to evaluate the opposite proposition ---- what if some surgeons actually have good outcomes with a given procedure, despite performing that procedure at a low volume than has been arbitrarily picked as a threshold?

I would like to give kudos to a few surgeons at the University of Vermont who have decided to buck the trend and look a bit differently at their own data. Their study, entitled Credentialling for Laparoscopic Bowel Operation: There Is No Substitute for Knowing the Outcomes was published in the October edition of the JACS. Basically, they acknowledge that case volume has been utilized as a reasonable estimate for granting surgical privileges --- a point that I agree with completely --- but that it also has the potential to prevent some surgeons for gaining privileges. Bowel resections performed by four surgeons at their institution were reviewed; one of the surgeons had completed fellowship training in advanced laparoscopy, and a second had recently completed a colorectal surgical fellowship --- so, each had a large amount of laparoscopic bowel surgical experience in their training. Let's call them the Young Turks. The other two had completed colorectal surgical training prior to the advent of advanced laparoscopic training; we'll call them the Old Farts. Out of a total of 112 laparoscopic bowel resections performed, the Old Farts held their own, despite lower volumes and the obvious difference in training:

Six hundred twenty-four bowel resections were performed during the study period, of which 112 were performed laparoscopically. Of the four study surgeons, the percentage of laparoscopic versus open cases ranged from 8% to 56%. Individual surgeon complication rates varied from 9% to 47%. Surgical volume and training had no notable relationship to incidence of complications (19% high volume/fellowship training versus 10% low volume/no fellowship, p = 0.25). An inflammatory indication was a strong predictor of technical complications on univariate (p = 0.02) and multivariate (p = 0.01) analysis.
Well, looky there. The Old Farts actually had fewer complications than the Young Turks, though statistical significance was not established. Wouldn't you have liked to be sitting in on the faculty conference when this data was presented!

Well, what does this teach us? The most important take-home lesson for surgeons in the present-day world where hospitals, insurance corporations, health-rating companies, and Uncle Sam (or Aunt Hillary) want to rate, regulate, and limit surgical privileges based upon volume is:
Unfortunately, that's kind of hard --- it is time consuming, requires a lot of data collection and entry, and I can tell you from personal experience is not easily accomplished with presently available programs (including the one offered by the American College of Surgeons).

What this also may tell us is that there is something to be said for experience. I feel, and I pray that I am right, that I am a better clinician and a better surgeon today than when I first came out of training ---- despite the fact that that training was long, intensive, included a laparoscopic fellowship, and involved a whole lotta operating. Maybe we could say that physicians, like musicians, get better with age, experience, and practice. Don't believe me? Well, who would you rather see in concert:
this guy
or this one?

I know how I would answer that question, but I am an Old Fart, with an emphasis on the "Old" part of the description. Pharmaceutical enhancements aside, I think anyone who listens to the young Clapton and compares him to today's version understands that the man has learned a few tricks along the way.

Lest I be condemned for advocating continued practice by surgeons far beyond their prime in reasoning and physical skill, I admit that there is a point beyond which a physician loses skills necessary to good practice. It is impossible to tell when exactly that happens, and in the ideal world every surgeon would be able to recognize a diminution in his or her ability to adequately care for patients, and back off. And once again, we can turn to the world of music for a comparison. Who would you rather hear play:

this guy, on top of his game

or this over the hill, ridden-hard-and-put-away-wet guitarist who can't remember the notes?

I guess the trick for patients is to not let Keith Richards operate on you.

Friday, October 19, 2007

Indiana Jones and the Cult of the Consultant

There's a great IBM commercial out right now in which a man opens a door on a darkened room, discovering a slew of fellow workers lying in the dark, heads on pillows, doing absolutely nothing productive.

ideate from ax09001h on Vimeo.

What are they doing? They are ideating!! Innovating!! Changing how things are done!! Only, they haven't "ideated" just how they expect to accomplish these grand plans. This is a fabulous depiction of a company that has swallowed way too many glasses of Consultant Kool-Aid®. They are more interested in catching the next management fad than they are trusting their own observations and instincts in running a successful enterprise. The health care system is not immune from this particular form of indulgence --- in my experience, hospital corporations tend to imbibe Consultant Kool-Aid® with the gusto of a Hollywood pop tart just released from rehab.

Starting with est, it seems to me that the baby boomer generation ushered in a penchant for latter day gnosticism that has never gotten a proper smackdown --- there is no corporate or culture icon willing to call bullshit on the never-ending stream of business management fads. Large group awareness training (bullshit), neuro-lingustic programming (bullshit), Myers-Briggs (give me a break!), "team building" exercises (B.S.), personality typing based on "color wheels," ......... c'mon, let's be honest. This stuff is pure, unadulterated BS dressed up like the earnest, sweet homecoming queen from Tulia, Texas, but carrying the hidden costs and hangover of a Las Vegas marriage to a gold-digger from Highland Park (sorry, ladies, it just slipped out!).

This is, with apologies to Orac, corporate woo, or to put it in other words, the Cult of the Consultant. Unlike Indiana Jones, however, there is no self-respecting corporate leader willing to drop the whip, pull out the gun and put a bullet through its heart. I have unfortunately seen intelligent, well-meaning folks do everything short of sing Kum Ba Yah while holding hands in the name of "team building." Otherwise independent people reduced to sharing their most sheltered traumas feelings with co-workers so that "barriers can be broken down," notwithstanding the normal human need to share those experiences with only their closest companions. Adults -- ADULTS!!! -- reduced to acting like 9-year-olds on a soccer team when they are given a replica Topps® card with their name and picture on it after spending a day as "team members" of a local sports team (as if the pro teams don't already make enough dough, now they are cashing in on the management consulting BS machine). Wheeeeeeee! I have then had the opportunity to hear these very intelligent, motivated people return to the hospital, spouting whatever catchphrase happened to be en vogue at the most recent management retreat.

Perhaps in the spirit of helpfulness that is the sine qua non of the Aggravated DocSurg, it is time for me to start my own consulting firm. No, I won't butt in on the lucrative business of fleecing corporate America, I'll simply focus my energies on fleecing gullible hospital systems with my very own brand of merde du DocSurg, with a particular aim at getting as much cash as possible by putting on mandatory seminars requiring participants to sign up for Nigerian banking scams. In return, they will each get a 27 ¢ desk pen and pencil set emblazoned with one of those great motivational phrases seen on posters in cheesy mall stores: "ADVERSITY. That which does not kill me leaves me brain damaged and with one kidney." The money will fly from the corporate coffers with each new consultant phrase that comes so easily to the "scruple-challenged."

Or, I could be more altruistic, and speak the truth. It's not flashy, fancy, or anything to get excited about. But it is the truth. Most corporations --- hospitals included --- would do much better spending the grain silos full of greenbacks they now so generously pour onto new age consultant gurus on their employees and products. At the end of the day, a happy employee will be your best ambassador --- and that is particularly true in the hospital. Nurses, respiratory therapists, radiology techs, and an army of other folks interact with the customers --- i.e., patients --- of a hospital and influence their opinions to a far greater degree than any advertising campaign or feel-good management style fad ever can. Talk to them. More importantly, listen to them. And for goodness sakes, make sure they are on board with any new management scheme that you come up with. And the doctors? Treat them like business partners, not bratty third graders that need a new rule thrown at them on a weekly basis; act like you want their business, and they will return the favor.

As Edith Ann would say, "and that's the truth!"