Friday, April 24, 2009

Publish or ... get tattooed by your department

In my never-ending quest to be the most evidence-based surgeon out there, just to keep you ├╝ber-informed, I pore through a stack of surgical journals every month thick enough to choke Rosanne Barr.

Just wanted you to picture that for a sec before moving on.

While it comes as no surprise to my medical colleagues, I must state for everybody else's benefit that there is, well, quite a bit of "filler" in medical journals. Articles that are really not quite up to snuff, so to speak. Ones that impart about as much knowledge as Ward Churchill on a bender. The kind of articles that leave you wondering, "Why was this even submitted for publication? And why in God's name was it accepted?"

We all know "filler" when we see it, whether it is in the newspaper, a magazine, or TV Guide. But medical journals are supposed to be full of scholarly stuff, right? Well, these journals need to fill their pages in some manner, and sometimes there just aren't enough quality submissions. Besides, us docs are just as eager to see our names in print as everyone else.

"Avoidance of tattoo disruption: a further benefit of laparoscopic surgery" is a bit of filler. The title pulls you in, sort of like a train wreck, but you know that there will be nothing of significance in the meat of the text. From the abstract:

Introduction Tattoos are increasingly common in both male and female patients. Abdominal skin tattoos may be present at the site of proposed incisions for conventional surgery whereas laparoscopic port site placement can be adjusted to accommodate tattoo constraints.

Methods Patients with tattoos were questioned by face-to-face interview to determine how long ago they had their tattoo, financial cost of the tattoo, and potential degree of distress caused by disruption of their tattoo (on a scale of 1–10). Consultant and higher surgical trainee general surgeons were asked by e-mail survey whether they had encountered a patient with a tattoo at the site of a proposed incision, did they avoid incising the tattoo during surgical intervention, and had they received a complaint from a patient about tattoo distortion.

Results Ninety six patients (50 male, median age 29 years) were questioned. Median cost of the tattoos was £35 ($70). Female patients were more likely to be distressed and complain than men about tattoo disruption (p = 0.0003) and there was a significant inverse correlation between time from tattooing and distress (p = 0.02). Most (79%) of the general surgeons questioned (n = 107, response rate 82%) had encountered tattoos at proposed incision sites; 61% had avoided making an incision through it and 4% had received a complaint about tattoo disruption by a patient.

Conclusion Tattoo disruption by surgical incision may cause distress especially in female patients who had their tattoo recently. Tattoos should be avoided where possible by alternative port site placement.
Perhaps I am too crusty and old, but I had two immediate reactions to this article. First of all, is this a pressing medical issue? Are we being deluged by patients irreparably harmed by having their tattoos altered as a result of surgery? Does this rank up there with, say, techniques to avoid bowel injury during laparoscopy in importance? Why, in fact, is this even something to write up, other than the fact that nobody else had done so yet? And secondly, if you are going to go to the trouble of asking the patients and doctors these questions, there are three that were conspicuously absent ---
  • (for the patient) On a scale of 1-10, what would have been more distressing, having the operation or not having the operation and leaving your tattoo intact? This is not a trick question, especially if the operation you had was an urgent one.
  • (for the patient) On a scale of 1-10, what would have been more distressing, having the surgeon struggle because he was trying to avoid your tattoo, or having him disrupt the tattoo to do the operation with as little trouble as possible?
  • (for the surgeon) What, exactly, takes precedence? Concerns about cosmesis, or concerns about doing the right operation the right way?
I'm not so crusty and cold-hearted that I won't work around a tattoo.....if it is the right thing to do .... but I hardly think that this rises to the level of a publishable activity. In academic medicine, there has long been an imperative to "publish or perish," so perhaps the authors wanted to be sure that theirs was the definitive article for "evidence-based medicine" in the realm of tattoo avoidance.