Wednesday, July 30, 2003

Good article on the Medical Economics site evaluating how other countries handle their medical liability claims. The situation of a jury deciding a malpractice case seems to be fairly unique to the U.S. The piece goes on to discuss other factors; such as neutral experts, limiting contingency fees, and "loser pays" . The most lengthy exposition is on how a "no fault" system works in other countries. I find it interesting that in New Zeland that 10-15 percent of all cases are due to "medical error" and the rest are called "mishaps". Those claims still get paid, though. Point is also made that in other countries universal single-payor systems exist, so the plantiff and family do not carry a high financial burden providing for future care. It seems that medical liability problems are not confined to the U.S., but span the globe.

Tuesday, July 29, 2003

Looking at the grand pooh-bah's website, I see that the late for deadline for the Qualifying exam is in about two weeks. Newly graduated residents have asked me about taking a review course for the written exam. I myself took the Osler course the week before my written boards. The biggest benefit IMHO is that it gets you out of the office, away from your practice, for a week and allows you to concentrate on the exam. If you decide to take the Osler course in Chicago (actually Lisle/Napierville) may I offer a suggestion. Rent a car at the airport. The hotel in which the course is held is in the middle of an office park and is not very pedestrian friendly. Having a car not only saves in the cab fare from Midway/O'Hare (which is steep), but it also allows you to leave the hotel for dinner. The money you save on avoiding dining in the hotel restaurant and/or room service more than pays for the car rental.
Good Luck!!
I watched with great interest the serve-and-volley in Medrants last week about the (in)ability of a lay jury to comprehend and judge complex medical testimony. DB lauds an editorial in the New York Times by Phillip Howard about the need to remove the jury from medical malpractice trials due to the complexity of the information. I agree completely. Just for more tiresome review I would like to provide my commentary on how a panel of experts can provide a more reasoned result than a jury by examining the four components of a medical malpractice suit:
DUTY: Pretty much a wash here
BREACH OF CARE: Sometimes a jury has trouble separating a complication (which all procedures have) from a breach of the standard of care. In the cardiac cath case used in the discussion, a known and quantifiable complication of the procedure occurred. The discussion of such complications occurs when informed consent is obtained. The benefits of the intervention outweighed the risk of potential complication. Concerning the use of Mucomyst to decrease the risk a panel of experts could judge (rightly in my opinion) that use of this medication was not the standard of care. The jury, however, could latch on to the fact that this could have helped and avoided the renal failure. A panel having "walked a mile in their shoes" could recognize that despite great efforts on the part of a physician that bad outcomes can and will happen.
CAUSE: A panel would be less likely to be swayed by an expert's attempt to show flimsy causation or proximity of harm. The panel would be able to take into account the plaintiff's pre-morbid conditions and establish their contribution to the bad outcome. (You can't make chicken salad out of chicken ----)
HARM: Again, a panel could provide an objective look as to the level of harm. If the patient in the example only required IVF's, Lasix, and a longer hospital stay then little or no harm was done. If the patient required dialysis (and was exposed to the complications associated with it) then a greater level of harm has occurred. The panel could also examine the relation of the harm to any benefit obtained. If the cardiac cath found correctable disease, which could have led to MI or death if not discovered, does that benefit outweigh the harm done?
An example: A surgeon performing a lap appendectomy on a patient injures the iliac artery. The patient is opened and the artery repaired without difficulty. During exploration a carcinoid tumor is discovered and excised. The surgeon was sued for the artery injury. Did the good in this outweigh the harm?
An expert panel would help to eliminate the possibility of a jury's emotions clouding or outweighing the facts. The facts can exonerate the physician defendant but the jury sees harm and feels "someone should pay". That person is the physician.
The establishment of a "standard of care" is based on research and experience. A jury of laypeople does not have the experience necessary to establish what consists a standard.
More later....


Monday, July 28, 2003

Couldn't post alot over the weekend as I had to play Horace Homeowner and several cases today. I've been following the malpractice posts on Medpundit and Medrants and will have a post shortly with how a surgeon views the malpractice mess.

Saturday, July 26, 2003

I guess this is one way to avoid being typecast. Good thing my kids can't read yet
This is turning into quite a circus.
Will she ban SUV's?
Will it be a family feud?
Via Drudge

Thursday, July 24, 2003

Poking around the othe medblogs and came across this post about "pimping" at Force of Mouth. While written from an internists standpoint it strikes a chord with me and my experince in residency as pimping is described as how the "shame-based motivational system of medical education is applied". See, a surgical residency is at least five years of shame based motivation. Surgeons can be sadistic bastards with very little encouragment. I mean, how many students have been driven from medicine teaching rounds in tears because they cannot answer questions. Seen it twice on the vascular service where I trained. In addition to the categories described in the piece, there are some pimping situations unique to surgery:
HEY, WHAT'S THIS? The most basic pimping in the OR. The living anatomy lesson.
WHY ARE WE DONIG THIS OPERATION? What other options are there? This and the anatomy quiz described above are student and intern-level pimps.
WHAT CAN YOU DO IF YOU....cut the ureter, divide the common bile duct, find cancer everywhere.,ect...? This is a midlevel/Chief Resident level pimp. Usually there are five solutions to each problem, and if you can only name four you receive a butt-chewing so bad you need a colostomy.

The above games are simply a warm-up for the weekly pimp-fest that is the SURGICAL MORBIDITY AND MORTALITY conference. This is where you get up in front of all of the attendings an residents an present your complications. Lots of blood in the water here. Best part is where the attending of the case presented : 1.Disavows you ("Well, thats not how it really happened......") or 2. Nearly comes to blows with another attending over how the case was handled. "Bluffs" as described in the post usually result in the hapless resident being led down a path that results in the death of the patient in a spectacular fashion.

All of this is supposed to prepare the budding surgeon for his AMERICAN BOARD OF SURGERY CERTIFYING EXAMINATION or THE ORALS. This is you and about thirty other poor souls in suits sitting in hotel rooms being slow-roasted by examiners. And you pay $800 for the pleasure. Bluffing is treated as above, but you also fail the exam and get to pay to take another beating in a year's time. According to the board the pass rate for last year was 83 percent.

There are a multitude of books to assist the student/intern/resident in the pimping game. The best for surgeons (IMHO) are here and here.
Enjoy rounds today!!

Monday, July 21, 2003

Having lunch in the Doctor's cafeteria the other day when another surgeon and I were asked our opinion of a recent journal article. After giving us his sage opinion on the issue at hand he proffered this...
"A surgeon uses the medical literature much the same way a drunk uses a lamp-post, much more for support than for illumination."
My pet peeves post has certainly generated alot of traffic....
Dr. Smith sent along this gem...
Same pet peeves. But I don't feel so insulted by the phone/television issue ever since I saw a patient do the same thing to her priest.
She was in the ICU, so I had a full view of her room from the nursing station where I was writing her transfer orders to send her to the floor. She was talking on the phone and watching television while the priest gave her the bread and wine of the Eucharist - on Easter Sunday. And as he walked away from the room, she was still chewing on the Host as she talked on the phone. Unbelievable.
This led to an interesting comment on another site about the theological problems can can be brought on by tele-communing (heh). I think you get to spent eternity in an exam room. With only a paper gown. With the thermostat at 60 degrees.
Dr.Rangel also expands on the pet peeves...
For many patients you would never have thought that they had ever had the modern convince of having a personal phone (to say nothing of a cellular phone). To a certain extent this is understandable since hospitalization is often a very stressful and lonely experience but considering that fact that they have almost nothing to do for hours out of the day it is always astounding that at the exact moment I walk into a patient's room they are engaged in a personal conversation that just cannot be interrupted, even by their physician! Then you are faced with an uncomfortable situation. How long to you stand at the head of the bed waiting for the patient to grant you an audience as if they were the King of Siam? Often I will wait about 30 - 60 seconds and then start talking. If they missed what I said then too bad. I'll be back in the morning. Maybe then they will be off the phone.
even better....
The most dangerous family member is the one with just enough medical training or background to be annoying and not enough knowledge or understanding of the care of the medical patient to completely grasp and appreciate the complexities and limitations of modern health care. In my experience this usually involves family members who are ancillary medical professionals such as physical therapists, respitory technologists, LVNs, lab techs, or anyone who has spent too much time looking up medical information on the internet. They often appear to feel that they are qualified enough to critique every detail of the patient's medical care. It's not that I don't appreciate the attention and concern that they have for their family member but when they become confrontational it can undermine the trust and security of the doctor-patient relationship. Ironically I have never had a problem with family members who are themselves physicians. I think that this is because we are on the same level and they understand these issues involved.
The GruntDoc sent this in.....
1) The Holiday Nursing Home Dump: concerned relatives visit granny/uncle Whoever in the Home and are Shocked! Shocked! how bad they look; it's only been about 6 months since they saw them last. The NH staff cannot stand in the way, and the NH doc isn't coming in for any reason. To the ER! Huge, pointless workup = back to the NH, after the family goes home.

2) We have TV's in some rooms. I just turn them off, tell them I cannot stand the extra noise. Nobody has complained yet. I turn them back on when I leave, cuts down on the nurse calls.

3)My biggest peeve: "Do you have any samples"? What I hear: I can't pay for the meds, why should I pay you? (No samples).

4) Back in the Resident days, on Trauma, we'd tell them: elect a Spokesperson, give them a list of questions, we're not going to have 15 briefs a day (which they all get something different out of, compare notes, and decide you're giving different stories to different people).

I did some moonlighting in a small ER about 45 minutes from where I trained. It was the scene of many a Sunday nursing home dump. Same circumstances as above. But I found it really hard to send them back when they came with a packed suitcase. I worked as a unit clerk in an ED while in college and the nurses hated the televisions in the room because the patients would come in and "camp out".
Even the paramedics had something to say.
So with great fanfare I CONTINUE THE LIST.....

6. THE NINTENDO/PLAYSTATION/X-BOX: Same as THE TELEPHONE but with a different age group. Just pause the game!!

7. THE ABSENT PARENT/GAURDIAN/MPOA: I try to get to see a consult within an hour or two of my being called. If I am going to be late I call the nurse's station. I go up to see a minor or a patient who cannot make a medical decision themselves and there is NO ONE THERE. This involves a trip back to the hospital room when someone shows up. Under a very limited set of circumstances (emergency, great distance) I will handle this over the phone. Most often I set up a time to meet someone and discuss it.

8. SURPRISE!!! I'M YOUR SURGEON: I go see a consult...and the patient has no idea I am coming to see them. Really bad when I am consulted for operative management of a malignancy, and their primary care MD has not told them of the diagnosis. I have to deliver enough of my own bad news, I'm not going to be the heavy for someone else.
Thanks for all the feedback!!
I tend to agree with the latter view in this article. Foutunatley I don't have to deal with the issue of placing adults (or children) on these medications. Quite a few of my pediatric and adolescent patients are on medications for this. They (and their parents) tend to fall into the pet peeve categories described earlier. While I agree that some patients benefit from this medication I think a great many are put on it because it is an easy out. I mean it is much easier for teachers and school administrators to force parents to put their kids on Ritalin or Adderal or ..... than for them to set limits and discipline their kids. Why don't we all just line up and take our soma? How would this classic model of teenage angst sound on Ritalin?

Sunday, July 20, 2003

I've collected some comments on my "pet peeves" post and will post them with my comments tomorrow...
Thanks to GruntDoc for the blogroll addition.

Friday, July 18, 2003

Out of town and posting from an "undisclosed location". Many thanks to Dr. Rangel and Mr. Hoffman for the links. Almost makes me regret not doing that marketing survey for WebMD....
Both Medpundit and Professor DB have commented on this Wahington Post editorial. As outlined in a previous post I agree with the editorial and their comments. I have a sad feeling that it is going to take some crisis before serious Medicare financing reform is acomplished. The government is not much into the ounce of prevention line of thinking

Wednesday, July 16, 2003

Haven't had time to post over the past few days. On call over the weekend, operating post-call on Monday until 7pm (oh to be a resident again!!). In the office all day yesterday and on call again today.
I sent this email to Neal Boortz last week concerning his position on licensure of physicians. He has not replied.
Mr. Boortz:
I wish to start off stating that I enjoy your show and visit boortz.com on
a daily basis. I am writing in response to the section of your program
notes from July 3, 2003 entitled "You Just have Yourself a Wonderful Fourth
of July"
and specifically this paragraph:

Inform your representatives that you want to be free to make your own
consumer choices, and that includes choices of which professional you want
to use for medical and legal services. Tell them that you are perfectly
willing to rely on your own judgment, or the judgment of private accrediting
agencies when it comes to selecting an attorney or a doctor. You might add
that you don't like the idea that you have to go to the government to ask
who may and who may not clip your fingernails.

I have also heard you mention on your program that you do not feel that
physicians should be licensed by the state. I am a licensed physician in
the state of Georgia and I must tell you that I disagree with you on this
Let us compare a medical license with the most common license issued by
the state, a driver's license. To obtain a driver's license one must pass a
test on the rules of the road and pass a driving test. This is done to
insure a basic level of competency before one is allowed to possibly
endanger one's self and others behind the wheel of a car. To obtain my
license to practice medicine I had to provide documentation of my education
and training. This was to insure that I had at least gone to medical school
and done additional training before I could possibly endanger some poor soul
who had become my patient. This is also to insure a basic level of
compentency. By requiring licensure, the state fulfills a duty to protect
the citizenry against potential harm.
In the paragraph above you advocate the use of private agencies to
monitor and provide accreditation of physicians. The danger in this is
that, as the cliché states "Who watches the watchers?". Physicians have the
choice to submit to further examination in their field of specialty and
become "board certified". Board certification is not required for licensure
or for admitting and treating patients in some hospitals. If private
agencies are responsible for accrediting physicians then a group of
physicians can get together and form a new board or "private agency" who
will then sign off on them, even if they cannot become certified by an
established specialty board. You can see the potential danger this brings
But what about the judgment of the individual? Medicine is very complex
and if a physician states he is "certified by the xyz board of specialists"
the patient may accept that as adequate. At the least a patient would have
to do some research to determine if that is a legitimate accrediting board,
or something thrown together by some physicians of dubious credentials.
By requiring licensure the state also provides accountability. A
physician must meet certain requirements to maintain a license. Patient's
may complain to the Board of Medicine and an investigation may be initiated.
The physician may have his license revoked or put on probation. A
"private agency" may be reluctant to discipline one of its' own (dues
paying) members, and if it did, what would stop the physician from starting
up his own "Board of abc specialists"? The civil litigation system would
not be a good policeman either, as the physician in question could simply
operate without insurance. This would remove the "deep pocket" of the
liability underwriter, making the financial benefit of a case minimal.
I agree that some of the professions that require licensure and their
boards are a method to limit competition (real estate agents and funeral
directors come to mind), but professions that require specialized expertise
(physicians, dentists, plumbers, and yes even lawyers) licensure is a method
to insure a basic level of education and compentency.
Bard Parker

What do you think?
Send me your opinions and your pet peeves!!

Sunday, July 13, 2003

What a weekend.

Friday, July 11, 2003

Sven changes with Bjorn, Bjorn Changes with....
Reminds me of something that Lewis Grizzard wrote about washing underwear. Apparently after one of his many divorces he wrote he would go to the K-Mart, buy a months worth of underwear, wear them all once, maybe a second time and then throw them all away when he got tired of walking through them. Via Opinion Journal
While fulfilling my on call duties today I have experienced some of my biggest pet peeves I experience as a physician. Let me share some of them with you.

1. THE PATIENT'S TELEPHONE: This is far and away my biggest annoyance. Standing in a hospital room. I am taking a history, examining, or explaining my plan to the patient and family....and the phone rings. It is answered and instead of "The doctor is here, let me call you back." I am sidelined as the patient/family member carries on a five-to-ten minute conversation while I stand there. If it is a family member on the phone and I continue to examine or discuss plans with the patient, the telephone talker always asks me to re-explain things when they get off the phone. I've walked out of rooms before when they won't get off the phone, I tell them I'll be back when they aren't so busy.

1b. THE PHONE, REDUX: Slightly less annoying is when I walk in and the patient is talking on the phone, and doesn't hang up. Yes they were on the phone before I walked in, but they aren't in the hospital to talk on the phone. I've left the room during this one too.

2. THE PATIENT'S TELEVISION: Patient would rather watch Jerry Springer than discuss their care. Even better when combined with the telephone as described above. Have actually had to turn TV off before.

3. THE WEEKEND FAMILY: This is why I must finish rounds on Sunday before church lets out. Family members who are nowhere to be found during the week make their "social visits" on Sunday afternoon. Lots of questions and complaints. This all after I've been on call since Friday morning and I just want to get rounds done.

4. THE OUT-OF-TOWN FAMILY: Taking care of a patient...established rapport with family....then the OUT-OF-TOWNERS show up. Usually a sibling or child of the patient. Usually with some medical/legal training that they use to browbeat nursing staff and other family members. These people go through the best-laid discharge plans like Godzilla through Tokyo Harbor. These people also fit into the category of WEEKEND FAMILY.

5. THE SPOKESPERSONLESS FAMILY: This is also a problem for the nurses. Large number of family members, each calling and asking the same questions. A REAL big problem with trauma patients.

These are only a few. I invite your comments and your own pet peeves. Happy rounding!!
Good piece by Daniel Henninger in todays Opinion Journal. The story of the Bijani sisters is one of great courage. They knew the risk that they faced, but their desire to live apart was greater than any fear of death they had. The old paternalistic model of medicine is (for the most part) no longer applicable. My method has been to always lay out the options for treatment, carefully explaining the risks and benefits of each. The choice is theirs. If they ask which I would choose I state if they were my wife/child/mother/brother that I would do X or Y, and explain. However, obliging the patient's wishes in high risk procedures, even when the alternative to surgery is death, can be harmful to your liabilty carrier's health. I mean this patient certianly had to know the risk of the procedure. But, on the other hand, what sort of choice does on have when the alternative to surgery is death.

UPDATE: The suit has been settled.
On call this weekend. Blogging will be sporadic

Thursday, July 10, 2003

and fighting for the Bubba vote.

Wednesday, July 09, 2003

What they're doing.
Why they're doing it.
Vote coming soon....
Dean vs. Edwards vs. Bush
In Slate today. I just don't think that Senator Edwards is to the left enought to get the nomination, in addition ot the factors below. But I agree with Mr. Saletan, it will be fun to watch.
Silly question? Well what got me started was the continued growing buzz over Howard Dean and his campaign's fund raising prowess over the internet. The sum of money raised means that Dean cannot be ignored, poor Sunday morning performance notwithstanding. Dean has really mobilized the democratic faithful, which makes him the opponent that the Republicans hope secures the nomination. But what does the Georgia flag have to do with it? Well the flag above lies over the political body of someone who could have been a serious contender for the nomination, a centrist southern democratic governor that doesn't have the baggage of another centrist southern democratic governor. The political career that the flag killed was that of former Georgia Governor Roy Barnes.
What about the other candidates? Well, lets take a look:
Senator John Kerry: No President has been elected from the Senate since another junior Senator from Massachusetts did it in 1960. Wishy-washy on the war in Iraq. Integrity problems (claims to be healthy...has prostate surgery, tosses another vet's medals onto White House lawn).
Senator Joe Lieberman: See above. Also tainted from losing effort in 2000
Senator John Edwards: See above. Little name recognition outside of North Carolina. Trial lawyer. Easily confused with this John Edward.
Senator Bob Graham: Health problems. What's with the notebooks?
Representative Dick Gephardt: Old news. Slow to raise money.
Sharptonkucinichmoseleybraun: (Thanks to Opinion Journal) Enough said

With the last four out of five presidents being governors, Dean does carry some advantage in that department. Even the Presidents on TV were governors. The political columnist Bill Shipp wrote about Governor Barnes' rising star as a Democratic nominee in March 2001. However things fell apart and Mr. Barnes was defeated in November 2002. While some other factors contributed as well (displeasure with education reform and the "Northern Arc") the flag issue mobilized a lot of emotion in rural areas of Georgia and a tremendous amount of those voters expressed their displeasure by electing Georgia's first Republican governor since reconstruction. For his efforts Governor Barnes won a Profiles in Courage award from the Kennedy library. Mr. Shipp provides an excellent analysis of his remarks here.
I think that Governor Barnes did the right thing in changing the flag. It was a divisive symbol and not representative of a state who's capital is the "City too Busy to Hate". I think the Kennedy library rightly rewarded him. But the unintended consequences are present today.
Dean has the momentum right now, and the others are going to have to hustle to catch up. While Dean and Kerry will do well up north, the real test will come in South Carolina. If Barnes were in the race then he would be well positioned to blunt Al Sharpton's advantage amongst black voters in that state. Without Barnes, however, Sharpton will be a formidable force throughout the south.
And the Democrats well remember the last time they ran a northern governor against George Bush.


Tuesday, July 08, 2003


Monday, July 07, 2003

Terror Alert Level
Isn't the internet a wonderful thing!!!
Via GeekandProud
When the people find they can vote themselves money, that will herald the end of the republic.
Benjamin Franklin
Watched Justice O'Conner and Justice Breyer on This Week. Fascinating stuff. I wonder how the inner workings of the Renquist court compare to that of the early days of the Burger court.
Medpundit today has an exerpt from a column in the Charleston Gazette-Mail describing doctors fleeing from West Vriginia to Ohio. The remainder of the article describes public relations efforts by the coal industry and trial lawyers, and includes the parody. I did some of my training in West Virginia and the liability insurance problem is a big mess. The level one trauma center in Charleston had to downgrade itself to a level three because they could not get orthopedic coverage due to liabilty concerns. Surgeons have already staged a walkout which is credited with delivering passage of a tort-reform bill. West Virginia is a state with an aging and somewhat unhealthy population. With physicians in established practice leaving, and new physicians looking elsewhere to train and work the state cannot afford to lose physicians. Hopefully the tort reform will help.

Sunday, July 06, 2003

Looks to be quite a challenge. This passage caught my eye :
The surgeons were making their own preparations ahead of the long surgery, he said: getting enough sleep and not drinking too much liquid.
For an operation projected to possibly last four days, thats a long time without a bathroom break.
A belated "Thank You!" to Dr. Smith for the link.

Saturday, July 05, 2003

Different Medicare drug benefit / reform plans passed the House and Senate last week and are headed to a conference committee. They have different limits in coverage and deductibles. Both will greatly change the way Medicare is funded and run. I haven’t seen much on any increase reimbursement to physicians, however. If the payouts to physicians, hospitals, pharmacies or “private insurance plans” cannot keep pace with expenses, providers will start to opt out of the system. Many physicians are refusing to see Medicare patients or cutting back on their Medicare practice because it is not economically feasible for the to do so. The same can be said for “Medicare HMO”’s that are getting out of the business.
But do all seniors need a drug benefit? Under the Senate version everybody will get the same level of assistance, regardless of income, thanks to Senator Kennedy(D.MASS)
The benefit levels are:
HOUSE: 80 percent of a person's drug costs up to $2,000 a year, after payment of a $250 deductible paid for by the government. No further benefits would be paid until costs reach $4,900 for the year.
SENATE: Half of the drug expenses would be paid after a $275 deductible, to a maximum of $4,500. The individual would be on the spot for all of the drug expenses until they reach $5,800. The government would pay 90 percent of drug expenses above costs above that amount.
So what is so bad about means testing that the senior Senator from Massachusetts, the AARP and labor unions are against it? Why have they killed the idea in 1997, 1999 , and 2003?
THE REPUBLICAN VIEW: They view it as a tax increase on well-to-do elderly.
THE DEMOCRATIC VIEW: They feel all seniors should be treated fairly and that initiating means testing would diminish widespread support for Medicare.
I can agree with the republican position on its’ face more readily than I can the democratic position. Why is that? Well, let’s take a look:
FAIRNESS: If the democrats are so concerned about the well-to-do seniors why don’t they let them keep more of their income? Given the percentage of income taxes paid by those making $50,000 or above (scroll down), wouldn’t those people make out better keeping more of their money from the tax man than having the government pay for their prescription drugs under the plan outlined above?
SUPPORT: I think this is where the rubber meets the road. The fear would be similar to the ones about privatizing social security. That is, those who could afford their own drugs and be ”means tested” out of a drug benefit would be reluctant to pay for someone else’s. Don’t think this could happen? Lets look at school taxes. Those are taxes collected on property to support public schools in one’s community. There are multiple “tax credits” given to elderly people to offset those taxes they pay. (here,here,and here) This is done since the elderly “don’t have children in school”. How long do you think that it would take before well-to-do seniors would object to the increase of premiums to subsidize drug benefits? Remember Dan Rostenkowski being chased down by seniors angry about premium increases in 1988?
I think that Medicare is broken and needs to be fixed. It needs to be less complex and needs to reimburse physicians fairly. I feel that if we are going to keep the system then some sort of means testing will have to be added. A prescription drug benefit is nice, but if you can’t find a physician to accept you as a Medicare patient, what’s the use?

Thursday, July 03, 2003

The new hour limits went into effect nationwide on Tuesday, but in New York State they have been a way of life for several years. Following the death of Libby Zion in a New York City hospital the state initiated work hour limits for their residents in all training programs, amongst other things. In the April 2003 issue of Annals of Surgery (abstract only) link Whang et.al. report a survey of surgical residents’ opinions of work hour limits. Some findings:
63.8 percent stated that the changes somewhat or much improved how rested they felt
65.7 percent stated that the changes somewhat or much improved their life outside the hospital
How very nice, now for the other edge of the sword:
50.4 percent stated the number of operations they participated in were much or somewhat fewer, 43. 5 percent said there was no change.
34.9 percent stated that the quality of care was somewhat or much worse, while 44 percent stated no change.
60.4 percent stated continuity of care was somewhat or much worse, 33 percent stated there was no change.
Even more revealing is a schism that is seen between junior and senior residents. Senior residents, at sometimes close to a two-to-one margin state that life in the hospital, quality of training, and quality of patient care were somewhat worse or much worse. Some of this may be due to more exposure to “surgical machismo”, old fogeyness (walked to the hospital barefoot in a blizzard uphill both ways…ect why can’t the new kids), or the fact that the senior resident’s workload has INCREASED with work hour limits.
But how can that be??
The junior members of a surgical service occupy themselves with the “scut-work” that we all know and love (changing dressings, pulling drains ect…), while the senior members went off to the operating room. Since the junior residents have to leave post-call, this work falls on the senior residents. I have heard many complaints from the residents where I trained about this (my program initated limits about nine months earlier). The senior residents are even doing cases usually reserved for the younger residents (hernias, breast biopsies) because of hour limits.
One problem with the survey was the response rate, only 319 of 1037 reponded to the questions.
I feel that residents need some relief from the non-clinical aspects of their training, and not be used as cheap labor by training hospitals. But when case numbers, quality of training, and patient care suffer, the residents and their future patients are going to pay the price.

911 IS A JOKE....
So this guy thinks. www.palmbeachpost.com/localnews/content/news/0702calls.html I find the results of the survey with the article disturbing. The time wasted on answering these calls not only puts other lives at risk but wastes a good deal of taxpayer money. But if this fellow could make 200 calls in one day maybe he has been answering the survey himself. (via Drudge Report)

Wednesday, July 02, 2003

Yesterday the Accrediation Council for Graduate Medical Education's (ACGME) resident work hour limits went into effect. The goal of these, according to the ACGME is to prevent sleep-deprived residents from harming patients. The limits are:
1. Duty hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities.
2. Residents must be provided with 1 day in 7 free from all educational and clinical responsibilities, averaged over a 4-week period, inclusive of call. One day is defined as one continuous 24-hour period free from all clinical, educational, and administrative activities.
3. Adequate time for rest and personal activities must be provided. This should consist of a 10 hour time period provided between all daily duty periods and after in-house call.
There are more rules regarding on call duty:
1. In-house call must occur no more frequently than every third night, averaged over a four-week period
2. Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours. Residents may remain on duty for up to six additional hours to participate in didactic activities, transfer care of patients, conduct outpatient clinics, and maintain continuity of medical and surgical care as defined in Specialty and Subspecialty Program Requirements.
(from the ACGME www.acgme.org)
While call from home does not count in the 1-in-3 limits, each resident must be given 1 day in seven out of the hospital with no clinical or didactic responsibilities. And if the resident is called in, the 80 hour clock starts ticking. An exemption for an additional eight hours of time may be submitted but it requires a great deal of paperwork and effort.
One of the objections to this is the effect it will have on continuity of care. DB posted about this yesterday (www.medrants.com/archives/001811.html)There is a great deal of information that can be lost during the "hand-off" of a patient. The medicine program where I trained had a "float" system, and it worked pretty well, but I am sure that there will be some growing pains. However there are some special problems that surgical programs face:
THE "FLOAT" CALL SYSTEM: People prefer to work during daylight hours. That is why elective cases such as hernia repairs and cholecystectomies are done during the day. Night for the surgeon usually means trauma care and emergencies such as appendectomies and bowel perforations. Nowadays most trauma is non-operative (depending of blunt v/s penetrating ratio) rather than operative. The float resident then not only misses the elective cases during the day but stays up all night with trauma patients that don't provide any operative experience.
THE NUMBERS GAME: On average a surgical residency consists of five years of clinical work with some programs requiring or allowing time for research. During that time the resident must obtain sufficient operative experience in a wide variety of procedures. If one's hours are restricted then case numbers could suffer. There is a grain of truth to the adage "The only problem with being on call every other night is you miss half the cases"
THE FUMBLE: The possibility of disaster in a "hand-off" of a surgical patient can be much higher than in a medical patient. Serial examinations of a patient by a surgeon is an invaulable tool in the assesment of a surgical patient. When the first examiner signs off, subtle signs may be missed.
THE REAL WORLD: I am a surgeon in private practice and even witout all the "scut work" associated with a residency, I work about 65 hours a week. And this is in a six man practice. Will the hour-limited resident be able to function?
As opposed to earlier efforts to control works hours, this isn't being treated with a wink and a nod by program directors.
They know the ACGME is serious and will lay down the law, as they have done with some programs (ex. Yale). I feel that in a few years residencies will become longer to allow for caseloads to be adequate. Tomorrow I'll post on some resident opinions of work hours.
I submitted this to Medpundit about a year ago and Dr. Smith published it. Things haven't changed much.

Sometimes find myself ashamed and guilty of how I feel some times about such matters. One the one hand physicians are told that medicine is a "calling" and that we should devote ourselves above all to our patients. Medicine is somehow "special" in this devotion when compared to other professions. On the other hand physicians are described as "greedy" when issues of declining reimbursement or high liability costs are discussed. As my partner states, "No other business works solely on credit". When I perform a cholecystectomy I cannot demand payment up front ( as a plumber or even a lawyer can do), I am at the mercy of the patient's insurance company or Medicare/Medicaid (if they have coverage) to receive payment. If I am not paid, I cannot very well put the gallbladder back in. This is described as providing a "service to the community". However the community cannot and will not help me in paying my rent, salaries for my staff or my liability insurance. Society has forced physicians to look at their practices through the lens of a business model but then criticize us severely when we do.

The coverage of the closure of the trauma center in Las Vegas provides a case in point. When local circumstances cause the cost of business to rise to where expenses rise income, you have three options: 1. Work harder (see more patients) 2. Raise your fees or 3.Close and relocate. As you well know fees are set by the payors and do not rise at the appropriate pace. ( or as in the case of Medicare, they are falling). So physicians can either run a volume business or relocate. Seeing more patents means less time for each patient and again more dissatisfaction for the patients you do see. If you are an OB/GYN you pay a higher premium for seeing more patients. Thus the rise of "retainer" medicine as DB's med rants puts it. But if you leave you "just wanted to terrorize the community" by denying a service. I also find Assemblyman Perkins's statements, comparing the closure to a strike, to be amusing.

The public continues to demand that physicians act as selfless protectors of the public. But their actions have made being a doctor like having any other job. Residents, medical students, and those interested in medicine can see this. I feel that is why medical school applications are down, slots in general surgery remain open after the match, and resident work hours are under scrutiny. Survey after survey reveal that physicians retire as soon as they can and they are not encouraging their children to go into medicine. Soon the lines will meet and the fixes will have to be more painful and expensive.

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Well I finally did it. After faithfully reading and enjoying medical blogs over the past year or so I have now decided to take the plunge. As the subtitle indicates my blog will consist of a surgeon's perspective on a wide variety of issues both medical and non-medical. July is a month of new beginnings in medicine, as we know. I appreciate any feedback you can offer.
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