Sunday, June 22, 2008

Many Fathers but just One Dad

Father's day was last Sunday, and it was wonderful at chez DocSurg. The day was gorgeous, I got to relax, and I was able to do some fun stuff with the Surglings. Spoke with my father, who was also doing well. All in all a good day. The whole idea of Father's day got me to thinking, however. I probably need to remember those men who, while they are certainly not my father, had much to do with shaping who I am as a physician -- and specifically as a surgeon. So, here are a few "alter-fathers" that I should acknowledge:

Dr. G --- a cardiac surgeon, the father of a high school friend, who was one of the most gentle people I ever met. He was kind enough to let me spend a day with him in the OR, where he transformed into almost a different person --- direct, demanding (in a gentle but firm way), efficient, and unquestionably in charge.

Dr. P --- my closest friend's father, a very successful and hard working nephrologist. When that friend and I decided for certain in college that we would be going on to medical school, he offered us a reality check ---- a full day of rounding with him. We started way early, and ended way late, following him as he saw an enormous number of patients first in the hospital, then in the clinic, then in the dialysis center, and then completed the circle back at the hospital. I had no illusions at the end of the day that my working life would resemble the laid back time I was having in college. I think the disempaction in the ED that he had to perform also had something to do with my chosen career (his son went into radiology).

The Saint --- Dr. Saint (real name) was the third year general surgery resident with whom I worked during my third year surgery rotation at at The Best Medical School in the Country®, spending untold hours on the wards and in the OR at Parkland Hospital. I learned an absolutely unbelievable amount of clinical medicine at "The Lands," and much of this came by observing The Saint. Despite the fact that as the 3rd year resident he worked harder than anyone else on the team, he was cheerful, happy to be there, and never lost his patience with the clumsy medical students on his tail. His good humor really infected the whole team on an incredibly busy service, so that though I was tired, I never felt that I was too tired to learn or help out.

Dr. Royce Laycock --- the attending surgeon on The Saint's service while I was there. A man from a small town in West Texas that had a way with words --- and people --- that put everything in perspective. And a mighty fine clinician to boot.

Dr S. --- I started my residency at a large private hospital that was involved in the resident training for the Univ. of Utah School of Medicine. Dr. S was someone I immediately recognized on my first day there, as he had been a chief surgery resident at The Lands while I was a third year student. He was still new to private practice, but had the patience and willingness to let me help care for his patients, both in and out of the OR, and helped me perform my first operations --- a painfully slow process --- without a quibble. A great guy, and someone who has rightfully become successful.

Dr. B --- a notoriously late and often strange attending during my residency. Sometimes, you become wiser by learning what not to do and how not to behave. 'Nuff said.

The Dom --- a private practice surgeon who had a great interest in teaching residents. I learned that spending time with patients and their families pays great dividends, both in terms of ensuring that they understand what is happening but also in the great warmth that can come from honest interaction with good people under some degree of stress.

Dr. Jeffrey Saffle --- a burn surgeon, and someone who I initially saw as almost overbearing and too demanding of his residents' time. What I learned from Dr. Saffle was that if you are to care for very, very sick patients, you must be similarly demanding of your own time and resources, and to never let hospital bureaucracy stand in the way of patient care. As an added bonus, he has a wicked sense of humor and a sharpened eye for irony.

The Greever --- Dr. McGreevy was the surgery program director where I trained. Quite honestly, I thought he hated me for the first three years I was there. I simply didn't understand that he simply waited to see how his junior residents shaped up in the first few years before making any judgements. Passionate --- about everything --- he became a good mentor for my time there.

There have been others --- and at some point I'd like to write about patients who provided a poignant lesson or two --- but to these I would like to wish a "Happy Alter-Father's day."

Friday, June 13, 2008

Unconventional Wisdom

Subversive. Alternative. To put it as a cliché, "outside the box" thinking. That's what it sometimes takes to get the good ship US Medicine to change course. Over the past decade, a juggernaut composed of the US govermnent, large employers, insurers, and folks like the Leapfrog Group have been pushing a variety of changes and outright demands on physicians and hospitals. Many of these have some common sense foundations, and they all achieve the ever-important status of "feeling right," but most have never been widely tested.......this is simply following conventional wisdom. Nonetheless, we must comply (or else), with the US Medicine forced to follow the approved heading, which is may not always be the correct course.

One issue that has gotten little press but a lot of emphasis is the timing of prophylactic antibiotc administration for surgery in the prevention of surgical site infection (SSI). CMS, my good friends at JCAHO, and the CDC have basically outlined standards, following consensus guidelines, that prophylactic antibiotics should be given within 60 minutes before the incision to achieve therapeutic levels. This is the kind of guideline that nobody ever gripes too much about, because it makes logical sense --- give the prophylactic antibiotic on time, achieve therapeutic levels to achieve appropriate prophylaxis, and decrease your patient's risk of getting a wound infection. Sounds great!! Sign me up!!

One. Little. Problem. This hasn't ever been tested in the real world. That's kind of a big issue, because compliance with this guideline is going to be posted on the internet and will in the near future be tied to reimbursement. As well, the same regulatory agencies are now mandating which antibiotics are to be given, with somewhat conflicting data to stand on. Given the whole idea that Medicare and a variety of insurers are going to start refusing to pay for certain "never events," even though they do not describe how to prevent some of them (that's worth another month of posts), it is not a stretch to imagine the day when a surgical wound infection will fall into that category. Hence, a little data would be helpful.

I guess I wasn't the only one with this conundrum. Some folks from a variety of VA system hospitals actually looked at over 9,000 elective operations in 95 VA hospitals, with the premise that patients receiving timely prophylactic antibiotics should have lower rates of SSI. What they found was very interesting.

The study population included 9,195 elective procedures (5,981 orthopaedic, 1,966 colon, and 1,248 vascular) performed in 95 VA hospitals. Timely PA (prophylactic antibiotic administration) occurred in 86.4% of patients. Untimely PA was associated with a rate of SSI of 5.8%, compared with 4.6% in the timely group (odds ratio = 1.29, 95% CI 0.99, 1.67) in bivariable unadjusted analysis. Patient level risk-adjusted multivariable generalized estimating equation modeling found the SSI risk score was predictive of SSI (p < style="font-weight: bold;">SIP-1 (following the 60 minute guideline) was not associated with SSI. Hospital level multivariable generalized linear modeling found procedure mix (p < 0.001); SIP-1 was not associated with SSI. Hospital level multivariable generalized linear modeling found procedure mix (p < 0.0001), but not SIP-1 rate or facility volume, to be associated with facility SSI rate. The study had 80% power to detect a 1.75% difference for patient level SSI rates.

OK. Prophylactic antibiotics are good; that has been very well established with a large number of well designed clinical trials. But is there something magical about the time frame that we are being told to follow religiously or face public ridicule, loss of reimbursement, shame, scorn, and be forced to spend a weekend listening to Al Bore Gore? Well, no. As the authors of this study put it,
These data do not dispute the efficacy of timely PA administration for surgical procedures, but do call into question whether this process measure is the right metric for hospital quality of care for surgical patients. There are several explanations as to why we did not observe an association between timely antibiotic administration and SSI. The first is that timely antibiotic administration does not diminish SSI risk. This is an unlikely interpretation. There are numerous randomized controlled trials and observational studies that demonstrate the efficacy of prophylactic antibiotics in reducing SSI for various surgical procedures. Randomized controlled trials often have strict inclusion and exclusion criteria and a strict protocol that standardize the care with regard to management of the wound, and as a consequence, limit the external validity of the study. Our study included all patients undergoing indicated procedures for the quality measure. A more likely explanation is that the metric for timely antibiotic administration is too restrictive to be able to discriminate between prophylactic antibiotic practices that have a clinically meaningful effect on SSI prevention.Most patients in our study did get a prophylactic antibiotic; some just did not receive it in the timely window.
In the discussion that took place after this paper was presented, one of the authors made an interesting comment --- of those patients who did not receive their antibiotics in the "60 minute window," most (80%) were given too early. It does not matter whether that means 5 minutes too early to CMS or JCAHO; it's too early. But, as this study nicely points out, from a clinical standpoint, it doesn't matter (unless you are worried about getting paid) as long as the patient actually received the antibiotic.

Now, please don't get me wrong. I'm so stinking anal retentive that I never leave the OR to scrub after my patient is asleep until I have asked the anesthesiologist whether the patient has had their antibiotics (if needed), and checked to make sure they have received prophylactic subcutaneous Heparin or Lovenox (if needed), and checked to make sure they have SCDs on. That's at least what I feel is good medical care. But I do agree with these authors that if we are really going to hammer hospitals (and doctors by extension) for not following guidelines, it's pretty dang important to make sure that we have appropriate guidelines backed up by appropriate data.

Tuesday, June 03, 2008

Ode to Joy JCAHO

In my last post, I put forth the notion that in the present world of American hospital-based medicine, we have reached the point where many regulators/administrators/lawyers etc. believe that process improvement is the most important goal ---- rather than patient care improvement. So, with profuse apologies to the late Mr. Beethoven, this is sung to the tune of Ode to Joy from his 9th symphony (taking certain liberties with the poem/hymn by Henry van Dyke). And, for some reason known only to the ancients, "JCAHO" is always pronounced "JAYCO."

Process, process über alles
Paperwork is lord of all;
Progress has no clout before us,
Patients go to hell, or worse!

"Process" lead the way before us,
Drive independent thought away;
"Process" leads to pleasant gladness
Stone-drunk, mindless in every way.

JCAHO's rules surround and keep thee,
From thy patient's bedside needs;
Nova of our adoration,
Process is the goal, say we.

Endless checklists to confuse you,
"Med Rec." forms that are inane;
Hide the saline before our arrival,
Or be flayed with great delight.

We give regulations plenty,
Ever sacred, ever crazed;
Center of our little world
We love "process" over patient lives.

You mere mortals cannot fight us,
JCAHO's whims overrule data;
We shall triumph with our "process'"
Over common sense for all.

We reinterpret as we choose to,
Every rule that we have made;
Happy to ignore your patients,
"Process" must prevail over all.

Why, now I feel like Gary Oldman!