Tuesday, December 02, 2008

The Art of the Bump

Ask any surgeon, of any stripe, what bugs him or her the most about working in a hospital OR and you will almost always hear some variation the them of "wasted time." You see, for us, time spent waiting is valuable time irretrievably lost, which could be better spent in the OR, seeing patients, or getting home earlier. The root cause of most of our irritation is "turnover" time, i.e., the time that it takes to get the last patient out of the OR and the next patient in and off to sleep. Turnover time is routinely significantly longer in the hospital than in an outpatient setting, for a variety of reasons (staffing, motivation, sicker patients, "it's the way we've always done it," etc.).

But there is one physician-initiated problem that wreaks havoc in the OR schedule --- the bump.

What is "the bump?" It means that a surgeon has decided that his or her patient needs to get to the operating room NOW, with no ifs, ands, buts or excuses, and that the next room that is available needs to have its schedule "bumped" to provide this accommodation. The larger the OR, the more likely that there will be a room finishing up in time to get the urgent patient squared away in a timely fashion. Of course, the larger the OR, the larger the hospital, and thus the more likely that there will be such a circumstance on any given day.

So, imagine a full day in a busy OR. You may have a room full of total joint replacements, which were scheduled months in advance; a couple of CABGs that are these days almost always semi-urgent; a room full of cataract surgeries; a general surgery room with colon resections, cholecystectomies, and the like, added to the schedule within the past week or so; a room with a couple of robotic prostatectomies, likely scheduled within the last few weeks; and so on. At 8:30 AM, a patient with a ruptured AAA hits the ER, and the scramble is on ---- who gets bumped? Which room has the most give in the schedule? Which room will finish first? Which surgeon will scream the loudest if he does get bumped?

Unfortunately, though the last question should not have any bearing on how the schedule gets massaged to accommodate an urgent or emergent case. But, as with many other situations, human nature is to take the path of least resistance, and the staff running the OR desk will often avoid the hornet's nest in Room 1 and bump the nice guy in Room 2. However, in true emergencies, most surgeons are more than willing to allow their room to get bumped......and then they go to work on the front desk to try to get the remainder of their cases shifted to another room. After all, it is very inconvenient for the patient who has gone through the rigmarole of preop evaluation, prep, labs, and paperwork to reschedule an elective or semi-elective operation.

There are two other ways to "do the bump," however, that don't fall strictly in the category of dire emergencies. The first is what I would call the "semi-urgent" bump --- this is the case of a patient with a bowel obstruction with possible bowel ischemia, perforated appendicitis, perforated diverticulitis, etc. These are patients who need to get to the OR sooner rather than later, and if they are forced to get in line and wait until the end of the day they would potentially have a worse outcome. This is where the surgeon needs to develop "the art of the bump," namely the ability to go hat in hand to another surgeon and plainly state "I'm sorry, but this guy really needs surgery, and I need to bump your room." What is helpful is to have enlisted the assistance of the front desk and have already arranged a way to minimize the disruption to that surgeon's OR day. Once again, almost always the "bumpee" acquiesces to the "bumper" with a minimal amount of grousing. This is common courtesy on the part of both surgeons, and serves the interests of the patients involved. Like the disco ball, it is a bit less than elegant, but serviceable nonetheless.

The last type of bump is what I would term the "bump of convenience." This is the case when a semi-urgent case needs to get to the OR, but the timing is rather suspect. This occurs when a surgeon demands to start a case, and bump whoever needs to be bumped, only as soon as his office is done. Or when the room needs to be bumped to do a case that could easily wait until the schedule could accommodate the patient because he has other plans --- a meeting, a dinner, theater tickets, etc. As long as I have been in practice, I have never seen this type of bump accomplished with a friendly request to the "bumpee." In these situations, the bumpee generally discovers the truth of the issue only later on; speaking from personal experience, this sets me to a slow burn, and it is hard to maintain a level of professionalism when dealing with the bumper.

Every OR has 2 or 3 of these types of surgeons, and they cause headaches for the rest of us. They are practicing a bait and switch type of con game, but rarely come out ahead in the long run --- most OR front desk managers are adept at figuring out who is honest, and who is just a hustler.

So, when a surgeon must bump the schedule, a little bit of finesse is required. If you will pardon my '70s background and disco references, expertise in the "art of the bump" involves a bit of a dance, with the give and take of a lead dancer and a follower, and the grace necessary to both ask for and allow someone to "step in" when needed.

Monday, December 01, 2008

Giving more than my share of thanks

Pancreatitis. Oh-my-God pancreatitis. Pancreatic cancer. Esophageal cancer. Colon cancer. Rectal cancer. Undifferentiated cancer with metastatic disease in the abdomen. Melanoma. Really, really bad melanoma. Cholecystitis. Choledocholithiasis. Cholangitis. Gastric cancer. Bleeding gastric ulcer. Bleeding duodenal ulcer. Perforated duodenal ulcer. Appendicitis. Perforated appendicitis. Diverticulitis. Diverticulitis with abscess. Perforated diverticulitis. Perforated diverticulitis with septic mesenteric venous thrombosis. Post-CABG ischemic bowel. Incarcerated inguinal hernia. Stab wound to the abdomen. Cecal volvulus. Mid-gut volvulus. Small bowel obstruction. Small bowel obstruction with gangrenous bowel. Alcohol withdrawal with DTs. Boerhaave's syndrome. ITP. Hypersplenism. Ruptured spleen. Ruptured diaphragm. Incarcerated paraesophageal hernia. Achalasia. Traumatic brain injury. Massive trauma with hemorrhagic shock. Massive trauma with hemorrhagic shock and DIC. Carcinomatosis with bowel obstruction. Postoperative wound dehiscence. Postoperative bleeding. Postoperative pulmonary embolism. Spontaneous adrenal hemorrhage. Breast abscess. Breast cancer. Abnormal mammogram. Colonoscopic perforation of the bowel. Traumatic pneumothorax. Iatrogenic pneumothorax. Multiple rib fractures with hemopneumothorax. Flail chest. Respiratory failure. Ulcerative colitis. Ulcerative colitis with dysplasia. Ulcerative colitis with invasive colon cancer. Crohn's disease. Crohn's disease with enterocutaneous fistula. Alcohol or drug dependence complicating surgical care.

Yup. I have seen them all in the past 12 months, and more. And even though it's a little past the official "date," I am certainly more than happy to give thanks that neither my family nor I have had to suffer from any severe health problems in the past year. That is, until my brother the Googlemeister decided to break the cardinal rule of Christmas decorating --- never, I mean never, get the stuff out of the attic until after December 1st! So, in addition to the above, I can now officially state that today I am thankful that I am not my brother:

For the uninitiated, there is a fracture extending up from the elbow (which is dislocated) linearly in the humerus, basically splaying it out like a tripod. Fortunately, he's way smarter than me, and doesn't have to make a living with his hands (he'll have to switch from a keyboard to a Blackberry for a while, though). And as bad as this fracture is, what he doesn't know is that it could have been worse. Most folks tend to think of fractures only in terms of the broken bones:
Those that play tennis know that there are a host of muscles and tendons in the area. However, there is a little bit of expensive real estate here as well, mainly the artery and nerve trunks heading towards the lower arm and hand:

One of those shards of bone could have easily lacerated an artery or nerve. So, all in all, I have to say I need to "give thanks" yet again, on his behalf.

So, my dorky little (over 40 still doesn't count) brother, best wishes for a speedy recovery!

Wednesday, October 15, 2008

Rub a Dub Dub

Quite a bit of attention has been paid to the prevention of surgical site infections over the past few years --- and this is one area that CMS/Medicare is targeting in its ever expanding "never event" list (I have ranted a bit about this before). From the CMS web site detailing a July 31, 2008 press release:

In last year’s final rule, CMS listed eight preventable conditions for which it would not make additional payments. In this year’s proposed rule, CMS identified nine potential categories of conditions, but based on public comments, is finalizing three of these. The new additional conditions in this year’s final rule include:
  • Surgical site infections following certain elective procedures, including certain orthopedic surgeries, and bariatric surgery for obesity
  • Certain manifestations of poor control of blood sugar levels
  • Deep vein thrombosis or pulmonary embolism following total knee replacement and hip replacement procedures
    Simply put, we strive to ensure that each patient presenting for an elective operation has the lowest possible risk of developing a surgical site infection. There are a whole host of factors which contribute to the risk of a wound infection, many of which are out of the physician and hospital's control --- obesity, diabetes, etc. Some, however, are well within our purview, such as appropriate use of perioperative antibiotics, proper prepping and draping, etc. One idea that was previously en vogue, but which has fallen out of favor in recent years is the preoperative shower.

    NO. That does not mean that the surgical staff takes a group rinse-off on a Slip 'N Slide just prior to operating. It means that the patient takes a shower using an antimicrobial soap before coming to the hospital. In the good old days, when patients came to the hospital on the night before surgery, this was de rigeur. I know, the whole idea of sitting around in a hospital room, idly awaiting surgery the next day, seems like something straight out of the Farmer's Almanac, but it did indeed happen that way just a few short years ago.

    Those of you paying attention are probably thinking, "What a load of ACORN voter registrations crap! Taking a shower, at home, then putting on your regular clothes and having surgery a couple of hours later? No way will that decrease your risk of a wound infection." To you I would say "Thank you for paying attention. But, au contraire, you are mistaken." The reason the preoperative shower is supposed to work is because we ask patients to use an antimicrobial soap, which has been shown to decrease skin bacterial count even after a few hours in normal clothing.

    This practice was already waning to some degree when a collective review sort of put a stake through its heart:
    Six trials involving a total of 10,007 participants were included. Three of the included trials had three comparison groups. The antiseptic used in all trials was 4% chlorhexidine gluconate (Hibiscrub). Three trials involving 7691 participants compared chlorhexidine with a placebo. Bathing with chlorhexidine compared with a placebo did not result in a statistically significant reduction in SSIs; the relative risk of SSI (RR) was 0.91 (95% confidence interval (CI) 0.80 to 1.04). When only trials of high quality were included in this comparison, the RR of SSI was 0.95 (95%CI 0.82 to 1.10). Three trials of 1443 participants compared bar soap with chlorhexidine; when combined there was no difference in the risk of SSIs (RR 1.02, 95% CI 0.57 to 1.84). Two trials of 1092 patients compared bathing with chlorhexidine with no washing, one large study found a statistically significant difference in favour of bathing with chlorhexidine (RR 0.36, 95%CI 0.17 to 0.79). The second smaller study found no difference between patients who washed with chlorhexidine and those who did not wash preoperatively.

    This review provides no clear evidence of benefit for preoperative showering or bathing with chlorhexidine over other wash products, to reduce surgical site infection. Efforts to reduce the incidence of nosocomial surgical site infection should focus on interventions where effect has been demonstrated.
    Hmmm. That's a lot of data that doesn't push the preop shower agenda, but it goes against a raft of non-clinical data showing a decrease in bacterial count when a preop shower is utilized. As CMS is pushing with vigor to avoid paying for surgical site infection complications, perhaps another look at this is worthwhile. Sure enough, a study was published in the August edition of the Journal of the ACS entitled Preoperative Shower Revisited: Can High Topical Antiseptic Levels Be Achieved on the Skin Surface Before Surgical Admission? These authors compared liquid 4% chlorhexidine gluconate (CHG) and a pre-made cloth containing 2% CHG; three groups were studied [1] evening shower alone; [2] mornign shower alone; and [3] morning and evening shower (each group was subdivided into use of each of the two forms of CHG). From the abstract, we learn:
    Effective CHG levels were achieved on most skin sites after using 4% CHG; gaps in antiseptic coverage were noted at selective sites even after repeated application. Use of the 2% CHG polyester cloth resulted in considerably higher skin concentrations with no gaps in antiseptic coverage. Effective decolonization of the skin before hospital admission can play an important role in reducing risk of surgical site infections.
    OK, again for those paying attention ---- didn't the first review we talked about conclude that there was no clinical difference when a preop shower was used or not? Why, yes! So, what have we learned with this new study? Unfortunately, nothing that we can state is clinically useful, because this study did not enter the real world of clinical results.

    So, that sort of begs the question......er, why do this kind of study in the first place? The answer may just be in the disclosure at the bottom of the article:
    Disclosure Information: The following disclosure has been reported by the author: Dr Edmiston received an unrestricted research grant as an investigator for Sage Products, Inc. No one derived personal compensation from this grant. The grant was used, in part, to purchase supplies such as the 4% CHG and the 2% CHG cloths along with other material used in the study. These monies were also used to support other research activities in the laboratory that are not related to any skin-prepping product.
    Who is Sage Products? They make these things:
    OK. I am not finger-pointing here. Really. In fact, I am on record as being supportive of industry-sponsored medical research. I think that in the long run, it is a good thing, and certainly more cost-effective and less subject to political winds than government-sponsored research. But let's be brutally honest --- a study like this that gives us essentially no new information, but which throws the possibility of clinical relevance into its title and discussion is really not helping anybody.

    "OK, Mr. Smarty Pants," you may say, "what can the average patient who is scheduled for surgery, or the average surgeon, make of this study?" Even with the reservations I spoke of, and even with the multi-study review stating otherwise, I have a hard time arguing against the idea of a preop shower with an antimicrobial soap or cloth --- because with the "never event" harassment hanging over us, hospitals and physicians may have to start producing reams of proof that they have done everything in their power to prevent a surgical site infection. Even if there is no data to support it.

    Want some of your own CHG cloths for your upcoming surgery? I've done the research for you -- Walgreens is cheaper than Wal-Mart.

    Tuesday, October 14, 2008

    Reinterpreting Dylan in the OR

    For many years now, I have (unsuccessfully) tried to understand the creative process -- especially in music and writing. I am a fairly one-dimensional, black-and-white kind of a guy, and it is difficult for my underdeveloped right brain to reach its tiny tentacles out and get a grasp on, say, songwriting. My daughters, graced with the musical talents their father so plainly lacks, can explain the rudiments of music theory to me, but that's sort of like showing a watch to a pig. I have read an interview with Stephen King, who once stated that at one highly creative point in his life, he simply could not type the words tumbling out of his brain fast enough. Joan Baez described Bob Dylan at one point as a songwriting machine:

    Even in the summer of 1964, when they were enjoying an idyllic affair, Ms. Baez notes, ''He was turning out songs like ticker tape, and I was stealing them as fast as he wrote them.''
    Somewhere along the line, that process slowed -- I don't believe these folks run out of creativity, but perhaps they become a bit more selective in what they choose to produce.
    Back in April 1991, Dylan told Paul Zollo that "there was a time when the songs would come three or four at the same time, but those days are long gone...Once in a while, the odd song will come to me like a bulldog at the garden gate and demand to be written. But most of them are rejected out of my mind right away. You get caught up in wondering if anyone really needs to hear it. Maybe a person gets to the point where they have written enough songs. Let someone else write them." (source)
    Just as interesting, and frankly just as opaque to me, is the process of adaptation --- reworking another's song or story and making it uniquely your own. Dylan's songs have probably been retooled more times than any other songwriter in the past few decades --- an aching and plaintive song, "Make You Feel My Love," has been covered by Billy Joel, Garth Brooks, Neil Diamond, Trisha Yearwood, Joan Osborne, Timothy B. Schmit, Bryan Ferry (sorry, but this is the worst of the lot), some British pop tart named Adele, and Lord knows who else. In some ways, I would say that when truly successful this is perhaps harder than writing a song of one's own --- the best example of this I know of is Lyle Lovett's version of the Tammy Wynette classic "Stand By Your Man" (trust me, it's quite a piece of work). If you are anything like me, it is often the first version of a song you hear that becomes your favorite.

    I wonder, though, how musicians react when they are given a truly difficult --- maybe even awful --- song that they absolutely must perform. And then what would they do if, rather than their own finely tuned instruments, they were given K-Mart Blue light specials? If you will pardon my stretch into the creative world, I would like to make the case that such is the fate of the average surgeon.

    Take, for example, the right hemicolectomy. This is standard fare for lower level surgical trainees, an operation that is relatively common and which generally requires the application of straightforward surgical principles, regardless of whether it is performed laparoscopically or with an incision. And, when everything goes as planned --- the uninitiated would say "as expected" --- it is nice, elegant procedure. What could be better?

    Let's change the scenario, just enough to get a surgical "musician" off key, perhaps. Add 75 pounds to the patient's frame, and you turn a relatively straightforward operation into one which will take longer, is more difficult, and has a higher likelihood of postoperative wound infection. Adhesions from previous surgery can obscure the "score" the surgeon must read from, requiring a bit of improvisation; anatomic variations call for more of a virtuoso performance, appearing without warning and generating confusion.

    You see, not every patient arrives in the OR with a body straight out of a Netter drawing. And complicating factors such as diabetes, sleep apnea, heart disease, anticoagulation use, and the like means that the average general surgeon may be less like a virtuoso than a journeyman musician who has to play whatever instrument he is handed on any given night --- which may be a Stradivarius or a plastic ukulele.

    Don't let me fool you into feeling sorry for me. This is, in large part, what makes my job interesting. And it is about as creative as I ever expect to get.

    Friday, September 26, 2008

    Unwelcome "Tiny Bubbles"

    So, the big debate is on right now, and as I would rather not start blasting my TV with an over/under 12 gauge, I thought I would do a little random typing. About poop. And urine. Sort of what has been being flung around with glee during this political season.

    As I may have stated before, I don't really go in for much of the esoteric when reading surgical journals --- just give me a straightforward presentation, preferably of a condition I am likely to encounter, and add something to the available data at my disposal. Here is a nice example -- Management of the Bladder During Surgical Treatment of Enterovesical Fistulas From Benign Disease. I know, the title alone is enough to drive the average person --- let alone an internist --- to sleep without a hot toddy, but indulge me.

    An enterovesical fistula is basically an unnatural communication between a piece of the intestine and the bladder. EEEEWW! That's right, it allows poop and gas to pass from the inside of the bowel to the bladder. Its presence is heralded by recurring Oh-My-God urinary tract infections and somehing we physicians euphemistically refer to as "pneumaturia." Yeah. Google that one and then squirm a little bit, why dontcha. Let's just say that while urinating it makes one sound like a little kid blowing bubbles in the bathtub. "Tiny Bubbles" they may be, but certainly not the kind Don Ho sang about.

    Why on God's Al Gore's green earth would somebody develop an enterovesical fistula? Three main reasons: cancer, inflammatory bowel disease, and diverticular disease. Since this article is about non-malignant causes, let's deal with cancer first and then ignore it from here on out --- basically, a tumor (usually colon) can erode from one hollow body part into another, setting up an abnormal communication.

    Inflammatory bowel disease is another matter altogether. This name encompasses two conditions, Crohn's disease and ulcerative colitis, only one of which is associated with enterovesical fistulas ---- Crohn's, which is described in great detail here. Suffice it to say that the intense inflammation in Crohn's can result in abnormal communication between a loop of bowel and another loop of bowel, the ureter, the skin, the bladder....... Not pleasant, and in some patients it is a true scourge.

    Diverticular disease of the colon is quite common, and can result in enterovesical fistula development due to episodes of diverticulitis (Lord help me, but I cannot type that word without thinking of Joe Piscopo and Robin Duke - "But we've got di-ver-tic-u-LI-tis!"). This is the most common cause of an enterovesical fistula in my practice, and I see about 1-2 cases a year where there is bladder involvement with diverticular disease.

    The mainstay of treatment for an enterovesical fistula, everyone agrees, is to "remove the offending organ." Simply put, take out the piece of intestine causing all of the aggravation. The bladder is an innocent bystander here.....but, you know, when you take out the loop of bad bowel, there is a hole left there in the bladder. What is the upstanding surgeon to do with it?

    Well, the bladder is part of a fairly low pressure system --- unless you really, really have to go. Drink a little coffee, and soon urine trickles from the kidneys down a pair of thin tubes called ureters into a reservoir that will expand (up to a point, depending on one's tolerance) to accomodate it. This is not like the arterial system, where blood is forcibly pumped through muscular arteries. So, some would say just leave a catheter in the bladder to keep it decompressed for a while and let things scar down. We do this in trauma settings when patients have a ruptured bladder..... but not when the bladder has ruptured into the free abdominal cavity. Others, including me, don't really like to see a hole, well, just left there for everybody to see! And so, my habit has been to close it with a few absorbable sutures, and leave a catheter in for about a week. It's an approach that has always worked, so why mess with it, right?

    Well, these nice folks noticed that there was this minor discrepancy in practice patterns, and decided to retrospectively look at the outcomes of 74 patients over an eight year span. Basically, they found that regardless of the approach, as long as there is no huge defect in the bladder that mandated closure, simply leaving a Foley catheter in place for a week is all that is required. Simple, no muss, no fuss.
    Oh well, I've wasted enough time, and hopefully have saved my TV from destruction again tonight. But there are two more of these debates, so SWIMBO will have to hide the shells.

    Saturday, September 20, 2008

    A Cultural Chasm

    Kevin, M.D. recently highlighted an article in the Washington Post by a physician which outlines the difficulties faced when physicians and hospital administrations collide. It is an interesting take on things, and is, on balance, rather balanced. While pointing out the problems administrators face from a financial standpoint, it also describes the vexing issue of striking the right balance with a hospital's physician workforce. Appropriately, the author draws out some key distinctions between the physicians and administrators involved:

    It's a basic cultural divide, says David Nash, a physician who is chairman of the department of health policy at Thomas Jefferson University Hospital in Philadelphia. Doctors, he told me, have a "single-patient worldview with a focus on clinical culture which emphasizes autonomy," while administrators have a "management-culture focus that emphasizes teamwork and integrated worldview."
    OK. I can buy that. There is no question that physicians are taught from an early stage to emphasize that the care of their patient(s) is paramount. And when push comes to shove, that is where my allegiances always will stay. I think patients probably want us to act that way, but I also understand that sometimes this can be taken to extremes --- fighting to keep outdated medications or equipment when other, more cost-effective alternatives are available, because "I have always had success with this" is an anachronistic attitude in today's cost efficient hospital. However, I would argue that many times administrative decisions adversely impact patient care, and it is my responsibility as a physician to fight against those decisions.

    What to do? The article proposes that physicians bear the brunt of the responsibility here.
    The solutions to these kind of problems are not taught in medical school. Physicians have little training in management and teamwork skills, says Kenneth H. Cohn, a practicing surgeon and an author of "Better Communication for Better Care: Mastering Physician-Administration Collaboration." He says that strategies such as structured dialogue and inquiry that avoids finger-pointing can help.
    In a word, bullshit. I am sorry, but I do not think that "structured dialogue and inquiry" means anything other than sitting in meetings with administrators on my time while they decide whether or not my opinion is worth listening to. Sorry, been there, done that, have the bald spots and gray hair to prove it. Going to meetings is what they do, it's what they get paid for --- it's all a donation of a (large chunk of) my time without reimbursement, and in my experience my input gets relegated to the circular file. And why is this only our responsibility; don't administrators need to move a bit as well to achieve harmony? We don't have a cultural divide, we have a chasm the size of the Mariana trench.

    IMHO, one of the most important differences between the physician and administration cultures is one of commitment. I tend to view top level hospital and hospital system administrators as a series of revolving temps; at times it seems that our top management is nothing other than a bunch of Kelly girls. It is hard to have a "structured dialogue" about plans for a big institution with people who have been here a short time, and who will be looking to leave before the next new moon. One hospital nearby me is getting its fifth CEO in 14 years. That's not the type of long-term commitment that is exhibited by the physicians and staff at that facility, those that have a stake in its long-term viability and quality of care delivery.

    Here is my terribly biased and profoundly unfair portrait of this type of hospital system administration:

    OK, I know, that's simply ridiculous. But I use it to make a point. If administrators are interested in having a "structured dialogue," and want physicians to undergo "training in teamwork," perhaps it would behoove them to take some of their unpaid time to do a few things that would open their eyes a bit:
    • Spend every Friday night with the 11PM-7AM shift in the ED for a month
    • Follow a patient from the ED waiting room, to the ED, to the CT scanner, to the OR, and then to the ICU
    • Show up at the scheduled "start time" in the OR, and then spend a few days sorting out why "start time" is always in quotes
    • Stay up most of the night with a physician on call, receiving all of the same pages, getting out of bed to go see patients, and then go to that "dialogue" meeting at 7AM.....and then to the office to see a full day's load of patients
    • Go to one of the wards at 2AM to find out where the nurses get something to eat on a dinner break when the cafeteria was closed at night due to budget cuts
    • Make rounds in the ICU, and find out how many nurses don't always get a meal break, as they must cover more than their own patients as other nurses cart the critically ill down to radiology
    The administrator who does some of these things gains a perspective that cannot be gleaned from reading or listening to reports in the comfort of a boardroom. He also gains something far more important, I would hope --- the respect of the staff working at the hospital, and an understanding that a long-term commitment to success is a better approach to make a hospital (or system) successful for the long haul. That guy I would "dialogue" with.

    Black Holes, Alternate Universes, and My Belly Button

    Even though I have not followed the news closely, I can personally attest to the fact that the Large Hadron Collider has been completed and turned on. Finely tuned into the universe as I am, I have been able to feel its effects......rather keenly. This behemoth of scientific wonder is thought to be capable of, among other things, creating little black holes and finding alternate universes. It seems that in recent weeks I have toured those alternate universes: I have taken one Surgling daughter to college, and then another to my alma mater for a college visit.

    There was no single emotion felt when my oldest child -- a daughter, no less -- was left behind as SWIMBO and I drove away. Love, fear, depression, joy, pride, and an overwhelming sadness that defies description. My little girl isn't, well, my little girl any more. As I drove away, the sensation in my gut was one of having my intestines wound up by a windlass, like St. Erasmus. The feeling passed, but recurs in small spasms at completely unexpected times. Hopefully, with time, it will settle into a pattern more akin to Ignatius J. Reilly's problem with his "pyloric valve" than the torture of Erasmus.

    Taking Surgling #2 to Lubbock would be, I thought, a bit more fun. And it was, with a long drive giving us time together to talk about all manner of interesting and mundane topics. Rather than a painful experience, however, walking around my old campus haunts on a tour was rather surreal. I felt as if the inside of my umbilicus had been firmly grasped and I was pulled simultaneously into a past universe and pushed beyod the present one --- sort of like being pulled inside out from the bellybutton. I did not understand how I could be both young enough to still feel like I had "just" graduated from college and old enough to be the father of a high school senior on a college tour! It has to be a result of one of those black holes escaping from the LHC.

    Without a doubt, the most difficult thing in both of these situations for me were the memories.....the false ones, from alternate universes. Walking with my oldest daughter to her dorm, I heard the false echoes of things I wish I had said at one time or another as she grew up. On the college tour, I experienced vivid memories of things I wish I had done when I was in college, but failed to do. Things left unsaid, deeds left undone, rattling around my empty head as seemingly real as the keyboard at my fingertips. And accompanying them are enough regrets to fill an ocean.

    All is slowly reverting to normalcy, and I no longer feel as if I am being folded, spindled, and mutilated from the inside. And as for regrets, I certainly have none about asking SWIMBO to marry me and having such wonderful children.

    Sunday, August 03, 2008

    PAC Cash for Doctors Howard, Fine, & Howard?

    As you might have guessed, I am not a big fan of the AMA. Actually, let me be a bit more clear --- I think the AMA is an organization that is doing its best to destroy the best medical care system in the world. What many folks outside of medicine do not know is that although the AMA counts only about a quarter of US physicians amongst its members, it controls every county and state medical society in the country. It's sort of a pyramid scheme --- to belong to the national organization (the AMA itself), one first must be a member of one's county and state medical societies. That way, everybody's palms get greased along the way up the ladder, and policy positions are passed back down the ladder.

    Now, I don't really want anything to do with the AMA, which promotes political positions that are far to the left. In fact, I would prefer not to belong to my state medical society for the same reasons. However, the only real malpractice insurance carrier in the state is one that works hand-in-hand with the state medical society.....and they charge an extra premium for non-society members. I wrote the president of this non-profit organization about this, asking a very simple question: am I a better risk for them as an insurer simply because I may belong to the state medical society? The answer I received, in almost three typed pages, was no.....but that didn't matter. If I quit the state society, I'd pay about $5,000 extra per year; of course, once again, that means I must remain a member of the county society as well, for reasons outlined above.

    Most of the time, this stuff is just an irritant, a pebble in my shoe. Occasionally, the state society does something really stupid, and the pebble feels like K2 (image source). Here's a case in point --- an e-mail I received from the state medical society's political action committee:


    Will there be a Doctor in the House? Not if the trial lawyers get their way.

    Our colleague and Democratic candidate for the state House of Representatives, Dr. Vinny BoomBots, is being hit hard by a challenger who is largely financed by personal injury lawyers.

    This is a text book campaign tactic, an 11th hour full court press by a well-heeled adversary who will attempt to flood the district with negative attacks on the eve of the primary, leaving little time for Vinny to raise sufficient funds to counter.

    Time is short, the election is August 12 and a lot is at stake. Vinny can't raise overnight the funds from his supporters to match a handful of wealthy trial lawyers who can generate campaign cash with a card swipe at an ATM.

    Vinny needs our help. Now. Please send your personal check TODAY (corporate checks are prohibited by law). The suggested contribution is $400.00 (maximum allowed by law) but we know that Vinny will appreciate any amount you can give.

    OK. Asking for campaign contributions is no sin. But I would have to say that asking me to give money to a candidate solely based on the fact that both he and I happen to have a medical degree is ludicrous. But I have absolutely no earthly idea what else this guy may or may not stand for.....and isn't that what we are supposed to be considering when we give money to a candidate? What if the guy happens to be an exceedingly competent physician but also a committed socialist? What are his positions other than those which directly affect medicine? Plus, as the e-mail noted, this guy is running as a Democrat and is making a stink about his opponent's financing coming from a core Democrat constituency ---- trial lawyers. Uh, you think the good doctor, as a Democrat, would be swearing off trial lawyer money if this was the general election? Not a snowball's chance in Hillary's Satan's lair.

    This got me thinking. What if other physicians in need of a few bucks for a campaign were able to get the state medical society's PAC to solicit funds from their colleagues? The e-mails might read like this:

    Doctor, Will there be a doctor in the jail? There will be if if the DA gets his way. Our colleague and murderer Dr. Jack Kevorkian is being hit hard by an attorney who is largely financed by the taxpayers of Michigan. This is a textbook trial tactic, a full court press by a well-heeled adversary who will attempt to flood the courtroom with facts, leaving Jack little wiggle room to stay out of the hoosegow. Jack needs an expensive lawyer to help; dig deep!

    Doctor, Won't you please help? Our colleague Hawley Crippen is running for the state senate, but he is being vastly outspent by a well-heeled opponent. We physicians need to stick together; don't let that nastiness that may or may not have take place in London cloud your mind. Give now, give the maximum, and get all of your friends to do the same. After all, he is a doctor, don't you know!


    Will there be a Doctor in the House? Not if the prudes get their way. Our colleague and canditate for the state House of Reperesenatives, Dr. I Got Charged with Solicitation while I was Chairman of the Dept of Surgery (yes, Virginia, this is the only true part of this story), is being hit hard by a challenger who is largely financed by law and order types. This is a textbook campaign tactic, a full court press by a challenger getting googobs of money from ordinary people who don't want a perv in the statehouse. Time is short, and our colleague could use all the cash you have on hand (especially $20 bills -- easy to use when he's lonely). Give, give, give!

    Bollocks! We as a society --- the US, that is --- are best off when we vote for candidates that reflect all or most of our values. Just because someone is a physician certainly does not mean that he or she is someone I would want to, or should, vote for. The same goes for any demographic you can think of ---- race, gender, occupation, etc. I am sad to say that my state medical society takes my cash and churns our rubbish like this. One day, I fully expect to get an email promoting these guys for high office:

    Saturday, July 26, 2008

    No sense in wading in the muck with a pig....

    I have been derelict in my duty. It seems that a certain medical school perfessor decided to rant a bit about doctors, and surgeons in particular -- I won't link to him, but Orac can fill you in. He began his rant by rightfully identifying the stupid behavior of one idiotic surgeon who decided it would be a great idea to put a temporary tattoo on a patient....without her knowledge. That surgeon is, to put it mildly, an ass. I think Mr. Gump would say "stupid is as stupid does."

    OK. Great thing to tee off on. Far be it from me to keep someone from ranting away; it isn't like I haven't done a little of that myself, even about surgeons.

    But, of course, this particular perfesser ain't the type to let it go there, and in the end accomplishes no less than a sweeping declaration about the arrogance of all doctors, especially those that wield scalpels.

    You know what? I could care less about Mr. Physiology Perfessor's rant. Quite frankly, he has shown himself to have the same qualities as the man he originally teed off on. A small-minded ass.

    After a bit of fallout, he made a semi-apology, but in reality only stepped a bit deeper in the cow excrement.

    So, in lieu of spending a couple of hours putting together a cogent argument, extolling the virtues of physicians, and surgeons in particular, while recognizing that yes indeed we have our moments (and our share of idiots), I think I'll just have a nice, cold martini. The the best way to deal with this type of arrogant idiocy (yes, while hammering on the arrogance of physicians, he laid bare his own arrogance) is to ignore it.

    The Aggravated Education

    Sometimes, I start to feel my age, deep down in my bones. This morning, I'm feeling it way down in my psyche --- I feel like the most curmudgeonly and crusty old fart alive today. Mais pourqois monsieur le DocSurg? Because of the idiocy of stuff like this.

    War games? Fake situations? What, are there not enough real sick people to care for? The opening paragraph is telling:

    With the advent of work-hour restrictions, many training programs are struggling to evaluate the education and competence of trainees in more exacting ways. The traditional role of the "house officer" consisted of extended hours in the hospital and minimal cross-coverage. This system has since evolved into shift work (i.e., night float) where residents are caring for larger numbers of patients whom they may not be familiar with. In this new environment, the ability of the clinician to rapidly assess and intervene in a situation, with little previous knowledge, is becoming more important. Additionally, the ability of junior clinicians to recognize the need for help is imperative.
    I'd like to offer a little re-write, to reflect the motives and reasons behind this kind of garbage:
    With the advent of work-hour restrictions Since the idiots in charge decided that we had to limit surgeons in training to an artificial limit of 80 hours per week, many training programs are struggling to evaluate the education and competence of trainees in more exacting ways figure out how to cram as much knowledge that time permits into their trainees in order to give them some degree of clinical competence. The traditional role of the "house officer" consisted of extended hours in the hospital and minimal cross-coverage, i.e., extended hours in the hospital caring for their patients, and cross-coverage was minimal; this ensured both that the trainee received a lot of clinical experience and that patients had someone available that was familiar with their problems. This system has since evolved into shift work (i.e., night float) where residents are caring for larger numbers of patients whom they may not be familiar with covering patients that they have never seen, never operated on, and do not know. In this new environment terrible system foisted upon us by attorneys and so-called education experts, the ability of the clinician to rapidly assess and intervene in a situation, with little previous knowledge, is becoming more important dangerous, because now have a whole host of well-meaning residents who may be wholly unprepared to care for a patient they barely know. Additionally, the ability of junior clinicians to recognize the need for help is imperative because the junior residents are getting so little training, the senior residents and attendings will need to be readily available to take up the slack (without an artificial 80 hour work week restriction).
    These residents don't need "war games" to prepare them for emergencies. What they need is time on the wards, caring for their own patients, sometimes being called back in to assess their fresh postop patient to see if they need to return to the OR....and then being the one in the OR with the patient. It's pretty hard to be a surgeon without taking an "ownership" stake in the outcome of your patients. I fear that the "professional educators" are pushing medical education over a cliff, from where it may never recover.

    Maybe we should ask one of these "educrats" a few questions.......

    Hi there, I'm Nancy Nanny, MD, RN, BSN, MS, PhD, director of resident education at Western Elbonia State University (the "College of Knowledge") {W.E.S.U.C.K.} Medical School. You can call me Dr. Nancy!

    I'm Aggravated DocSurg. You can call me Aggravated. Really aggravated.

    Well, now, what seems to be the problem?

    Well, Nancy, ...

    (cough) Doctor Nancy...

    Yeah, Dr. Nancy. I think you are taking surgery residency education in a direction it was never intended to go. If residents are restricted from seeing patients the night after they were on call, how are they going to know if they made the right clinical decisions?

    Those poor, tired dears! How are they going to read if they have to work the day after call? How are they going to prepare for the ABSITE? We can't have them perform poorly on standardized tests, now can we?!

    Read? They can read when they get home; that's why God invented coffee. And what about the idea of continuity of care? How are they going to learn the responsibility of caring for patients they have operated upon?

    Oh, Aggravated, you are a such a card! Continuity of care? That's an obsolete notion foisted upon us by the old bourgeois medical hierarchy which has no place in modern medical training. We work as a team to provide the ultimate patient care workplace. Concepts such as patient ownership, "captain of the ship," and the like have no place in today's brave new world of resident training.

    Er, OK. I'd say that your residents are in for a rude awakening when they get into the real world, where the ultimate responsibility for patient care rests with them. Their malpractice carrier will, I'm sure, let them in on that little secret.

    You mentioned the ABSITE. Since we are supposed to be making our clinical decisions on "evidence-based medicine," can you tell me how well the ABSITE scores predict residents' ability to care for patients?


    Alrighty then. Let's try another subject. Has the 80 hour work week provided a better clinical learning experience for surgery residents?

    Oh, my, yes! Residents are happy with the changes.

    Um, Dr. Nancy, with all due respect, you didn't answer my question; any sane person would be "happy" doing less work. Let me give you a little information.

    Since the advent of the residency work hour restriction, surgery residents are performing about the same total number of cases in training, but one study demonstrated a 40% decrease in technically advanced procedures with a 44% increase in basic procedures. The study also demonstrated a 54% decrease in the operative volume as first assistant. Operative continuity of care by residents decreased from 60% to 26% of cases. Other studies have found similar issues. And as for decreasing error rates.....sorry, not so much.

    But they're happy! And they have time outside the hospital!

    Since when did happiness and time outside the hospital equate to quality patient care? I may be an old fart, but there was a time in my training when I was made happy by learning how to take better care of my patients.

    But you are missing the point! We must ensure that our young trainees receive training in the Core Competencies mandated by the all-seeing, all-knowing ACGME:
    • Medical Knowledge
    • Patient Care
    • Practice Based Learning Improvement
    • Systems Based Practice
    • Professionalism
    • Interpersonal and Communication Skills

    Male bovine droppings! "Practice Based Learning Environment?" "Systems Based Practice!!??" You're making that shit up!


    Let me guess. The data to support this tripe is......?

    Zippo. Nada. Zilch. The big goose egg. A little bit is better than nada? Uh-uh, not here, buster.

    But you insist that residency programs follow this because......

    Actually, because we can!

    I think I'm going to be sick. Actually, strike that. I hope I don't get sick, especially as I get older, because we may be inundated with poorly trained physicians who need a whole lotta on the job training after they have completed their training.

    Well, fortunately I'm done with all of that. The educrats can't get to me now.

    Oh, you clueless little man. You. Have. No. Idea.

    Here's what we have planned for you!


    Uh, you're shitting me joking, right?

    (cough) (smile)

    It's not a martini, but it'll have to do.