Tuesday, April 29, 2008


"Would you do it again?'

That was a frequent question this weekend at my medical school reunion. The answers were, surprisingly, a pretty uniform "yes." Everybody had a qualifying "but" to add, but affirmed their initial decision to go to medical school in the long run.

Which leads me to the next question --- why? Why go to medical school back in the late 80s, knowing what we know now, with the future of medicine not looking terribly bright? I think a clue came from listening to the fond memories we shared of our time at The Best Medical School in the Country®. It was fun. It was like sipping a fine wine with friends --- if you like to sip your wine from a fire hose.

College, for me, was like sipping a glass of wine, or drinking a cup of tea on a nice sunny morning. Relaxing, enjoyable, with the time to savor the experience. Medical school? Oh, it was a wee bit more involved. The increase in workload over college was pretty substantial, with a torrent of information to get through, absorb, understand, and have on hand to regurgitate on a moment's notice. As a result, there was no time to savor the experience --- we were all furiously drinking as much as possible from a fire hose, knowing all the while that every time we stopped to take a breath massive quantities of important information blew right by us, never to be seen again.

What made that seemingly impossible situation fun was that we were all in it together. A shared experience with like-minded folks under pretty intense pressure tends to bring out the best in people, be it their humor, humility, graciousness, or interest in helping others. I have closer friends from those 4 years than from any other part of my life, people who I can (and have) see once every decade and enjoy their company as if we had just seen each other yesterday.

So, yeah, I'd do it again. In a heartbeat.

Besides, you really wouldn't want to be reading a blog called "Aggravated CarSalesman."

Monday, April 21, 2008

We Don't Speak the Same Lingo

Hello. I'm a Hospital Administrator.

I'm a Doc.

A what? You aren't wearing your photo ID badge --- that's a JCAHO violation! What exactly do you do here?

You know, doctor stuff. Take care of patients, that sort of thing.

Uh, anyway, dude, I haven't met you before --- how long have you been here?

Oh. I just got here 6 months ago myself. Straight from my last 3 year stint at another hospital. Who exactly are you again?

Aggravated DocSurg. I'm a surgeon. I've been here for 15 years, taking care of a big chunk of your patients. Surely you've at least heard of my partners and I since you came here.


OK. What is it that you do?

I maximize profit! I integrate the system! I public-key zero administration functionalities! I help develop the innovative dedicated matrix!


By utilizing adaptive encompassing functionalities, I hope to develop a business-focused tertiary local area network consisting of a team of associates and providers!

Associates? You mean you are bringing in other hospital systems to work together?

Ho, ho! That's a good one! No, silly, "associates" is a euphemism for employees! We think it makes them feel more valued. Everybody is an associate -- nurses, CNAs, techs, etc. Well, everybody but us. We're administrators. We, well, administrate!

And providers are.....?

You! Don't you feel valued now, Dr. .....?

Billroth, Theodor. Come on, dude. How about this --- I'll feel "valued" if perhaps we can discuss ways to make patient care better here. You know, spend a little dough on things like improving staffing, buy a few new sets of OR instruments, that sort of thing. Maybe even we could talk about how to streamline patient processing, so it doesn't take 2 hours to get someone registered for outpatient surgery and another 2 to get them discharged. That way, I'm happy, the staff is happy, and the patients are happy --- and then you should be happy.

Uh, well, see, that's not what our consultants told us to do. The consultants told us that we needed to focus on improving our food. And that we need to buy another robot. We value their input, Dr. ..... er, what did you say your name was?

DeBakey, Michael E. You know, another robot isn't going to help you with the majority of your patients. How about adding a few new ORs and increasing the number of staff in Admitting to help get folks registered ---- you even had some consultants tell you that!

Well, that's what last year's consultants told us! Ha, what a hoot! You don't expect me to go by last year's consultant report! I just got here 6 months ago!

No offense, but, that's sort of silly. Why spend the money on consultants just to ignore their advice?

So that we can keep hiring them! That way, I'm eventually assured of a job with a consulting firm!

Ooh. Strike that. Wasn't prudent to say, Dr. ......

Halsted, William Stewart. OK. Let's try talking about something else. I think it would be good for the morale of the staff --- sorry, associates --- if they actually saw administrators around in the evenings and weekends every once in a while. You really can't appreciate how hard certain arbitrary rules can make things on the associates until you see the tornado effect of a major trauma in the ED and OR, for example. While I certainly don't claim to be an administrator, I do have some insight into your world from the meetings I attend with you.

Ho, ho! Another good one. You really are a laugh a minute, ...... er, what was your name?

Schweitzer, Albert. Let's try a few simple questions. Why do I and all of your associates have to change our computer passwords every other Thursday and whenever the cafeteria serves pasta for lunch?


And why are there 6 different versions of the surgical consent form in the hospital, dating back to 1978?


OK. What is the reasoning behind hiring two new nursing administrators for the ED and GI lab, but decreasing staffing by 15% in the same areas?


What day is it?


Gotcha. Loud and clear. Let me turn on my Bullshit generator and see if it helps......Accelerated policy solutions! Synergize mission-critical networks! Orchestrate enterprise partnerships! Did that help?

Whoo! Thanks! Nothing like a good jolt of industry buzzwords to get me back to myself! JCAHO and HIPAA on the brain, dont' ya know, 24 - 7.

I think it's pretty clear we don't speak the same lingo, 24 - 7. But I'll try one more time. How about a martini?

Gotcha. Loud and clear. Are you buying?

Saturday, April 12, 2008

The Five People You Don't Meet in the Hospital

Quick --- name the five types of people you meet in a hospital! Almost everybody comes up with the same answers:

  • doctors
  • nurses
  • nurses' aides
  • the folks doing the paperwork
  • "techs" -- respiratory techs, X-ray techs, lab techs, etc.
Well, I'm going to let you see a little bit more of the hospital. Let me introduce you to The Five People You Don't Meet in the Hospital®, the people who work (hard) behind the scenes to make sure things go well for you in ways that are not always apparent.
  • The dietary staff --- cooks, dishwashers, dietitians, etc. These are the folks in charge of getting you that much maligned hospital food. Green Jello! What a treat! In reality, they do the best with what they have, and are usually the most cheerful crew in the hospital.

  • The pharmacists --- miracle centers need to have miracle drugs, and these guys are in charge of purchasing, measuring, mixing, and delivering said miracles. They are there 'round the clock, and their responsibilities include double checking folks like me to ensure my patients get the right doses of the right meds at the right time. In. Di. Spensable.

  • The Medical Records staff --- let's say you take Granny to the ED at 10PM, and Granny has been in the hospital 3 times in the past few years, and she takes enough medications to clog a downspout. But, let's be honest, you really aren't sure whether she had a cardiac catheterization or an echocardiogram last fall, and those medications are all in her medicine cabinet. How is a hard-working ED physician or nurse to figger that stuff out? The send out an SOS to Medical Records, and some poor soul has to search through a warehouse of charts that could swallow a blue whale and come up with the right one. Voila! And for my next trick, I shall pull a rabbit out of zee insurance executive's nether regions! And, please, don't harbor the illusion that electronic medical record systems are on their way to eliminating these folks -- that's a pipe dream smoked mainly by politicians.

  • OR Techs/Scrub Nurses --- I have a soft spot for the members of the operating room crew, which should come as no surprise given my line of work. However, I'm not only the President of the Surgery Club for Men, I'm also a customer! To date, I have had sharp instruments plunged into my body 6 times, so I am acutely aware of the need for a competent group of folks helping with surgery. Having surgery early in the morning? Late afternoon? Middle of the night? These guys are there and ready. This is generally, without a doubt, the most fun group of hospital employees with which to "hang" (sorry, ED crew -- you're way overexposed on TV anyway).

  • Last but certainly not least, the Housekeeping and Maintenance crew --- without a doubt, the least appreciated members of the staff, they tend also to be the most quiet, unobtrusive, and efficient group as well. The hospitals and EDs in my town are chronically overcrowded --- as quickly as one patient leaves another needs the same slot, putting pressure on the housekeepers to get the rooms cleaned and ready to be used as rapidly as possible. The hospital is nothing if not a high traffic area --- it often reminds me of DFW airport --- and does not have the luxury of having areas or equipment that is not usable, so the maintenance crew is constantly busy. Both groups deserve our thanks and kudos for a job well done.
Several years ago, working late on a weekend night, one of the private practice surgeons involved with our training program remarked that he felt that his closest friends in the hospital were not the other doctors, they were the folks listed above. Those of us who spend our waking (and often sleeping) hours in the hospital should do our best to earn their respect.

Thursday, April 10, 2008

Mark Twain and Bikinis

Statistics are funny things. They can be manipulated, to be sure, in a manner not unlike an impressionist painting -- to give an impression of the facts, without an accurate rendition of the same. For the artist, this allows a wide range of expression and resultant interpretation on the part of the viewer. For the person generating statistics, it allows all sorts of shenanigans, whether intentional or not, that can result in dissemination of "facts" that are a bit shady. Unfortunately, we see this from a variety of sources in medicine today, with reams of data being mined, folded, twisted and mutilated to generate a given data set to support a particular position....or particular advertisement. A couple of recent articles may help illustrate this dilemma.

What Constitutes a "High-Volume" Hospital for Pancreatic Resection is a study from Johns Hopkins, itself an excellent facility with a very high volume of pancreatic surgery for malignancy. Basically, these folks looked at a five year collection of data from the Nationwide Inpatient Sample (itself a sampling of 20% of hospital discharges) to evaluate mortality rates for pancreatic resection --- with an eye towards determining some threshold below which mortality increased. The results (from the abstract):

Based on analysis of 7,558 patients who underwent pancreatic resection, median annual institution resection volume was 15 (range 1 to 254), and overall in-hospital mortality was 7.6%. The best model of “high-volume” centers was an annual institution resection volume of 19 or more, as determined by goodness of fit (r2 of 5.29%). But there was little difference in data variance explained between this best model and other “high-volume” models. The model without any volume variable had a goodness-of-fit r2 of 3.57%, suggesting that volume explains less than 2% of data variance in perioperative death after pancreatic resection.
Let me repeat. "(surgical) volume explains less than 2% of the data variance in perioperative death after pancreatic resection." The best model that fits with the data is defining "high volume" centers as those that perform 19 or more pancreatic resections per year --- hardly what an outside observer would The conclusions of the authors :
Very little difference was observed in the explanatory powers of models of “high-volume” centers. Although volume has an important impact on mortality, volume cut-off is necessary but insufficient for defining centers of excellence. Volume appears to function as an imperfect surrogate for other variables, which may better define centers of excellence.
Hmm. For the last several years, we have been treated to a variety of articles and policy proposals aimed at creating "centers of excellence" based upon the idea, and some supporting data, that higher volumes of certain surgical procedures leads to better outcomes. But when trying to retrospectively identify the threshold for what is "high enough," the data here don't match up well with the preconceived notion. Oops. As much as I suspect this same result might be seen if we looked at other procedures proposed to be regionalized into high volume centers, I don't expect the captains in charge of this ship to change course. My translation of this study's conclusions would read a bit differently --- we can't show that there is a volume threshold, but we still think it's important, so we'll find something else to focus on to prove our point.

OK. Bear with me. More statistics, but I promise not to have a quiz at the end. The next article is actually my favorite kind of journal piece -- it validates common sense and sticks it in the eye of folks who manipulate statistics inappropriately. Entitled The Zero Mortality Paradox in Surgery, it addresses the way data can be carved out to create a favorable impression of an institution.

Every surgeon knows that their next potential complication is only an operation away. Every surgeon has also seen journal articles touting things such as "2,000 consecutive whole body-ectomies without a mortality" --- which basically mean that the authors identified their two most recent deaths with a particular operation and counted the patients in between. Well, hospitals play that game too, and tout their successes with zero mortality in certain procedures in given years. These authors went a step further, and looked at such institutions in the years following a run of zero mortality for certain operations (from the abstract):
We obtained national Medicare data on five operations with high operative mortality (> 4.0%): coronary artery bypass grafting, abdominal aortic aneurysm repair, and resections for colon, lung, and pancreatic cancer. For each procedure, we defined zero mortality hospitals as those with no inpatient or 30-day deaths during the 3-year period 1997 to 1999. To determine whether these hospitals actually have lower mortality than other hospitals, we compared their mortality during the next year (2000) with the mortality at all other hospitals.
Now, to be sure, these are good institutions with an admirable track record --- lower than expected operative mortality for some pretty major operations. However, they soon came back down to earth :
For four procedures, operative mortality in zero mortality hospitals in the subsequent year was no different than that in other hospitals: abdominal aortic aneurysm repair (6.3% zero mortality hospitals versus 5.8% other hospitals; (adjusted relative risk [RR]=1.09; 95% CI 0.92 to 1.29); lobectomy for lung cancer (5.1% versus 5.3%; RR=0.96; 95% CI 0.80 to 1.15); colon cancer resection (6.0% versus 6.6%; RR=0.91; 95% CI 0.80 to 1.03); and coronary artery bypass surgery (4.0% versus 5.0%; RR=0.81; 95% CI 0.61 to 1.04). In the case of pancreatic cancer resection, zero mortality hospitals had substantially higher mortality than other hospitals (11.2% versus 8.7%; RR=1.29; 95% CI 1.04 to 1.59).
What goes up, must come down. Every run of good luck comes to an end. Use whatever cliché you'd like, but a zero mortality rate for these types of procedures is a laudable but impossible goal to achieve. Or, as my stock broker likes to say, past results are not necessarily indicative of future performance.

OK. I lied --- it's quiz time!

Question: What did we learn with this little dip into the statistics whirlpool?
Answer: Statistics are like bikinis. What they reveal is suggestive, but what they conceal is vital.

Question: So, how is the unsuspecting public supposed to interpret these kinds of studies?
Answer: With a jaundiced eye. As Mr. Clemens famously stated, there are "lies, damned lies, and statistics." The trick is to ensure you know as much about the data being presented as you can in order to interpret the results.

Question: Does all of this mean that we shouldn't believe data in medical journals?
Answer: Absolutely not. It is important to accurately assess things such as morbidity and mortality, and honestly look at data that show where we can improve. However, creating public policy or planning advertising campaigns based upon such data can prove to be a bit of a problem, because future data can turn around and bite you in the rear.

Tuesday, April 08, 2008

Give Me Twenty (-twenty hindsight)

Twenty years is a mere blink to the elderly, a sizeable chunk of time to the middle-aged, and an unfathomable span to the young. As of the end of May, it it also represents the length of time I will have been able to write "M.D." after my name. In a few weeks, I'll travel to Dallas to attend my 20 year reunion with classmates at The Best Medical School in the Country. We'll probably end up sitting around a table with a bunch of margaritas, bitching about what ails "Medicine" presently, complaining that the young whippersnappers being trained today don't have any appreciation of how hard we had it in our day, and generally starting to look and sound like the old farts we are becoming.

Twenty years after graduating from medical school, I'll be 46 years old, and I'll probably be looking at another 20 years in practice (unless I miss my bet and the government doesn't take over health care in this country, in which case I might be able to retire at around 62). So, let's call this the halfway point of my career, which means that I am legally allowed by The Society of Disagreeable Olde Men to start giving the type of advice that can only be gained by the use of a complicated instrument, the retrospectoscope.

The retrospectoscope is a curious device, made available only to us older types, and is mainly used by the male of the species. It allows us to say things like "Trust me, I've made that mistake before;" "Don't do it! You'll regret it;" and "You'll put your eye out" with a straight face. So, now that you know that this represents the beginning of the end of my mental faculties, let the Aggravated DocSurg Twentieth Reunion Hindsight Advice Delivery begin:

  • Listen -- listen to your parents, to your teachers, to your friends' parents, to anybody that is giving you any type of information or advice. You never know when it will come in handy or be comforting.
  • Smile -- it puts people off guard.
  • Read -- as much as you can.
  • If you are married, give thanks every day that she has the patience to stay with you.
  • If you have children, give thanks every day that no matter how bad you think you've screwed up, they are the best part of you.
  • Thank your parents. Often.
  • If you are a doctor (this is a medical blog, after all), be nicer to your patients than to hospital administrators or insurance folks. They are why we went to medical school in the first place.
That's it. That's the sum total of what I have learned as a surgeon in the past 20 years that can be put into little soundbites. I only hope I can put a bit of it into action in the next 20.

Oh, and one more little thing. I happened to get married just before I graduated. SWIMBO may be in the mood for an anniversary present, and I've been advised that a gray flannel nightgown is, well, not the best option. Suggestions are, therefore, most welcome.