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.

Monday, July 21, 2008

Oops, the P4P slip is showing

The immutable Law of Unintended Consequences cannot be ignored, even by those who think they have a better way of paying for health care --- "Quality Improvement Incentives May Backfire on "Safety Net" Hospitals."

Between 2004 and 2006, the hospitals with the highest proportion of Medicaid patients -- which had the worst performance on the three measures to begin with -- also saw the least improvements in quality. Hospitals that achieved the most improvement had the smallest proportion of Medicaid patients...
"Pay for Performance" initiatives simply are a euphemism for "decreasing your reimbursement" for these hospitals. They do not have the ability to refuse care for the sickest and poorest patients, who will have less than ideal outcomes at times. P4P may be seen as a solution to some, but I do not see that it does anything other than aggravate a multitude of problems.

Saturday, July 19, 2008

The tale of the very expensive hernia sac

Posting from the Inxpot in Keystone this morning.....sunny skies, cool mountain air, glorious!

One cannot pick up the newspaper, surf Al Gore's invention, listen to the radio or catch a bit of the news without some dire warning about the expense of medical care spiraling out of control. Despite the feelings of many in Washington, most of us on this end of the scalpel (or stethoscope) really aren't interested in pursuing costly therapies without significant benefits. Sometimes, the academic guys do a bang-up job of dropping the hammer on once promising treatments which have questionable value. Here's a case in point:

Abdominal hernia repair with bridging acellular dermal matrix --- an expensive hernia sac (gotta love that title) is an article in this month's American Journal of Surgery. Before getting into the meat of the article, a lttle background is in order. Let's walk through a very real scenario:

30 year old male is brought to the ED via private vehicle and is unceremoniously dumped at the door. When discovered by the security staff, he is found to be clutching his abdomen, and there is something other than salsa dripping through his shirt. By the time he is whisked into the trauma room, he is cool, diaphoretic, tachycardic, tachypneic, and has a BP in the 60s. In short, he is dying from a gunshot wound to the abdomen.

All of the usual activity ensues --- lines, foley, quick chest X-ray, fluids, and blood. In the OR, he is found to have an injury to the left iliac artery and vein, the ureter, and sigmoid colon. Oh, poop. And he remains pretty unstable to boot. Time for a little damage control surgery --- stop the bleeding, basically, and do everything possible to warm him up and resuscitate him. No sense in dealing with the other injuries, because the more time spent diddling around the higher the chance is he won't survive --- Mr. Freeze is not the desired result, as a cold, underperfused patient in the OR is a patient who may need a celestial transfer. The colon is stapled off and the ureteral injury is drained. There remains one small problem. You can't close the abdominal wall.

When I talk to non-surgical types about this, they usually look at me with the kind of stare that says "boy, you must have gotten your surgical training at the University of Phoenix!" But this is a real phenomenon -- the body is desparately trying to hold onto fluid in an attempt to save itself from shock, and we are giving it as fast as we can to do the same thing. Unfortunately, there is no "perfect balance," and the shock state (for lack of a better way of explaining it) allows a boatload of fluid to escape the friendly confines of blood vessels and into tissues everywhere. This causes at times massive swelling, including of every cell in the abdomen. Putting the chitlins back in at that point is like trying to stuff my rear into an extra small pair of Lycra bike shorts --- it just isn't possible, and it looks pretty ugly while you are trying. If we actually succeed, then the patient will likely suffer from abdominal compartment syndrome --- basically, too much pressure in the abdominal cavity to allow blood to return to the heart and to perfuse the kidneys, and with enough upward pressure on the diaphragm to prevent adequate ventilation. Imagine me turning blue with a pair of XS Lycra bike shorts on, and you've got the picture.

At this point, there are a variety of weapons at the surgeon's disposal. I like to think of them in a stepwise fashion, depending on the severity of the situation. First, to reduce fluid and heat losses, it would be nice to achieve some kind of closure, and the skin will sometimes come together even if the underlying fascia won't --- and we can close it rapidly with a basketful of sharp towel clips (photo from More often than not, however, we need to leave the abdomen open, and provide some sort of protective barrier covering the noodles. Options here include a VAC-Pack or a sterilized IV bag with towels and drains on top (for ease of use, the VAC is great). These can be readily changed either in the OR or at the bedside, and when the patient's stability allows, the remainder of his injuries can be addressed. These types of patients often consume many hours of OR time.

Eventually, with luck, the patient will improve and reach the point where a more definitive closure is possible. However, getting the fascia closed may be a quixotic task. This means that several months down the road, the patient will be faced with a fairly large abdominal wall hernia --- which means repeat surgery, which itself may be pretty darn difficult.

Now we get to the point of the article. Some enterprising folks have developed products to help us with this problem. They reasoned that if they could develop an acellular substrate that the body would not only not reject, but which the body would incorporate, we could use this material as a bridge to abdominal wall closure, and the patient would heal without a hernia. Cool. While there are a variety of these products, probably the one most well known is AlloDerm.

The authors used this material in a series of patients who were in a bit of a different set of circumstances than our fictional gang banger --- they had a large hernia, had infected mesh, or had an enterocutaneous fistula. Their results, unfortunately, were less than stellar.

Between January 2004 and December 2005, 11 patients underwent complex ventral hernia repairs with bridging ADM. Indications for repair included resection of enterocutaneous fistula, infected mesh, and/or ventral hernia repair. A mean of 175 cm2 (range 8 to 456) of ADM were used. Mean follow-up was 24 months (range 18 to 37). One patient died on postoperative day 20. Eight of the 10 (80%) remaining patients had recurrences, and 7 underwent further surgery for repair. One patient reported laxity but refused repair. The total cost of ADM alone for these 11 patients was $61,926; the cost for the 8 patients having recurrences was $40,776; and the total mean cost was $5,100/patient.
Nice idea, but not all nice ideas have great outcomes. Now, getting back to the top of the post, let's talk about cold, hard cash. This stuff is expensive, as you can tell from the numbers. If physicians were as they are portrayed by the media and folks in the Massachusetts legislature, money grubbing and wholly under the sway of reps passing out pens, this type of data would be totally ignored. BS. This was an expensive product to develop, and it was aggressively marketed to physicians seeking a better solution to a difficult problem. It hasn't worked out well (this is not the first article on this topic I have seen), and most surgeons have stopped using this type of product except in some situations where it is the best of an admittedly lousy set of options ---- because it is expensive and because it doesn't work as well as we had hoped.

Physicians as a whole are neither economically stupid nor so unethical that drug and equipment reps control them like puppets -- those who think otherwise are simply fooling themselves about what goes into caring for patients.

Time to finish my coffee --- I hope you don't think less of me if it is in a "Prozac" mug.

Thursday, July 10, 2008

Gratuitous Bike Trip Plug

For the third summer in a row, I have been fortunate enough to take my son on a mountain bike trip. This year, as in the past, we had an absolutely fabulous time, thanks to the wonderful people at Western Spirit Cycling. Last year, one of my son's friends came along; he came again this year, as did another friend and his father. This year's trip was to the Black Hills of South Dakota --- green and lush, but don't let the name "Hills" trick you into believing this was anything less than strenuous! A lot of climbing, but also a lot of screaming downhill riding as well.

This is a picture of the usual view I had of my son -- now 14, and on his bike nearly continuously, he can climb like a goat and is always ahead of me.

I cannot recommend this company highly enough. Over the past three summers, I have been with 10 separate guides, all of whom are exceptionally friendly and fun-loving. If you have kids that are in the age range where they haven't completely given up on hanging with Mom & Dad, but who are up for fun and a challenge, check it out.

Tuesday, July 08, 2008

Sara's Smile

She was a vibrant, friendly, outgoing and thoroughly lovely young lady, I have been told. I did not meet her -- let's call her "Sara," to simplify things --- until she was around 50, but all of those qualities were present in abundance when she came to my office the first time. That was not quite 10 years ago, and I recall her warm smile and easygoing manner as something uncommon in a surgeon's office.

Sara had quite a history. Diagnosed at 27 with a deadly disease, ovarian cancer, that took much from her in her youth. She had been a nurse at my hospital, and by all accounts there had been an an outpouring of support during her initial treatment. My partner and a gynecologist had operated on her, followed by intraperitoneal chemotherapy, systemic chemotherapy, and further surgery. Though she never spoke of it, she was quite ill with treatment.

And then, something wonderful happened. Time didn't stop, but somehow not all the grains in her hourglass continued to fall. She continued to be a lively, lovely, warm and vibrant young lady, but one who I am sure awakened at night wondering if the next day would bring evidence of recurrence. But she continued on, amazingly healthy, and as the years passed, so did her fear of what may lie ahead. She raised her children, laughed, loved, and lived her life to the fullest.

The day I first met her is one not easily forgotten. A new patient on my schedule, I knew nothing of her past; there was just a note requesting a cervical lymph node biopsy. I was greeted with a warm hello and a welcoming smile. Sara explained the particulars of her medical history, with now something new --- certainly, it couldn't be related --- a somewhat enlarged lymph node at the base of her neck, in the hollow just above the clavicle.

There is something indescribable about the sick feeling one gets in the operating room making the diagnosis of a malignancy simply by feel. It is as if the room goes completely silent, and whatever little thoughts that are racing around in the subconscious stop, take notice, and respectfully go away. It didn't take long to make the diagnosis clinically, but I wasn't sure what type of malignancy we were dealing with until the pathologist called with the frozen section results. He had been the same patholgist who had read her original slides, 22 years before, and described essentially a déjà vu type of experience. After a long hiatus, her ovarian cancer had decided that it was time to return.

I don't really know how I told she and her husband. There are not words in the dictionary that can relay that information gently; I felt as if I was hitting them with a sledgehammer while trying to give them some sort of supporting hand.

I saw Sara intermittently over the next 9 years --- placing a port here, evaluating her for abdominal recurrence with partial obstruction, etc. Other than that first day, I never saw her downcast. She carried herself with an uncommon dignity and grace, and I never left her without wondering what part of her generated that beautiful smile. It was if her soul was shining through, as if she wanted to make others feel better about her lot in life.

Much can, and did, happen in nearly a decade. I don't know all of the particulars of her life, but clearly Sara did not simply stop being herself once her recurrence was established. I would hear snippets about how she was doing from her oncologist, or from whatever other specialist had been recruited to help with her care. Not once did those conversations fail to include some mention of what a truly nice person she was.

About a month before she died, I spotted her husband on the oncology ward, and he was kind enough to ask if I would stop in and say "hello." "Sara really trusts you, and has always said how much she appreciates the care you have given her." What a far cry from how I really felt --- that all of my interactions with her brought misery, pain, or both. It was clear that she was not going to live much longer, and though her eyes were tired, they still burned brightly when she graced me with one last warm smile. Mine burned with wet salt.

I was not Sara's husband, close friend, sibling, or anything other than someone who occasionally cared for her. But I did feel close to her with a simple bond that does not exist outside of a patient-physician relationship. That's the way it is for physicians --- outside the "normal" circle of folks who grieve the loss of a loved one, we still share enough feelings at times to grieve silently alongside them. And so I will miss Sara, her liveliness, her warmth, and her smile. I will definitely not miss having to cause her further pain in trying to treat her disease.