Sunday, November 30, 2003

5000 VISITS....
Reached 5000 today, all while decorating the Christmas tree. Thanks to all who have come by over the past five months.

Saturday, November 29, 2003

Neither team played very well in Atlanta today. Tech's starting quarterback was pulled out of the game due to a "concussion" after an altercation involving Georgia's team orthopedist, Mixon Robinson. Due to Florida's loss the Dogs look to be headed to Atlanta next week to face LSU in the SEC championship game.

Friday, November 28, 2003

Beat to the punch again by DB with this post on the impact of surgeon volume on mortality. The original paper appeared in the November 27th New England Journal of Medicine. The authors reviewed the records of 474,108 patients that had one of eight procedures done during 1998-1999. The procedures were: carotid endarterectomy, aortic valve replacement, coronary artery bypass grafting, esophagectomy, cystectomy, pancreatectomy (for cancer), lung resection, and elective aortic aneurysectomy. The goal of the study was to try to measure the impact of the experience of the surgeon on outcomes, separate from the experience of the hospital.
What they found was that the volume of the surgeon and the volume of the hospital affected procedure outcomes differently based on the procedure:

When surgeon volume was assessed as a continuous variable, it was inversely related to operative mortality for all eight procedures (P=0.003 for lung resection, P<0.001 for all other procedures). The strength of the inverse association between surgeon volume and outcome varied markedly according to the procedure in terms of both the absolute operative mortality rate and the adjusted odds ratio for operative death .....When hospital volume was assessed as a continuous variable, it was inversely related to operative mortality for seven of the eight procedures (P=0.20 for carotid endarterectomy, P<0.001 for all the other procedures). After adjustment for surgeon volume, however, higher hospital volume remained a significant predictor of decreased mortality for only four procedures (repair of an abdominal aortic aneurysm, cystectomy, lung resection, and pancreatic resection).

Or in other words:

It is not surprising that the relative importance of surgeon volume and hospital volume varies according to the procedure. In the case of carotid endarterectomy, for example, technical skill and the use of specific intraoperative processes (e.g., intraarterial shunt insertion and patch angioplasty)21 — processes used at the discretion of the operating surgeon — are important determinants of the risk of operative stroke or death. In contrast, other hospital-based services are relatively less important. Most patients undergoing carotid endarterectomy do not require intensive postoperative management, and the length of stay is typically just overnight. For these reasons, the preeminent role of surgeon volume in the outcome of this procedure has strong intuitive validity. In the case of lung resection, in contrast, patients rarely die because of direct technical complications of the procedure itself (e.g., bleeding or leakage from a bronchial stump); they die from cardiac events, pneumonia, and respiratory failure. Hospital-based services (e.g., intensive care, pain management, respiratory care, and nursing care) are very important, and the average length of stay is relatively long. Thus, it is not surprising that hospital volume was more important than surgeon volume in determining the outcome of this procedure. Of course, these two procedures represent the extremes. As suggested by our analysis, factors related to both surgeon volume and hospital volume seem to be important for most high-risk procedures

So if you're going to have an endarterectomy done, your best bet is to go with the experienced surgeon, while with a lung resection you do better with a high-volume hospital.
With a pancreatic resection outcomes are equally affected by surgeon and hospital volume. Of the eight procedures listed the members of the Acme Surgical Corp only do two, endarterectomy and AAA repair. Our vascular trained surgeon falls into the "middle volume" of both (18-40 CEA/year and 8-17.5 AAA/year).
I think that the "spread" between low and high-volume surgeons would be higher if complications (esp strokes after CEA) were measured in this study, rather than just mortality. The vascular literature has good studies showing that the stroke rate is lower with experience, regardless of specialization.

Thursday, November 27, 2003

Bush Pays Surprise Visit to Space Station
via ScrappleFace
Gobble Gobble!!!!!

Wednesday, November 26, 2003


DB had a post a few days ago providing commentary on this story in American Medical News about the "clinical skills exam" that is to become part of the USMLE step 2 in 2004. I agree with Dr. Plested and DB on this subject. Burdening medical students with additional fees is a severe hardship, especially when they are also faced with the expenses of residency interviews. While DB exerpted a large portion of the article on his site this is the strongest argument against it IMHO:

Finally, and most importantly, there is no evidence that this exam will produce the results that are desired, i.e., fewer state license actions for misconduct, negligence and incompetence. These are legitimate interests of the state, but overwhelmingly take place after many years of practice. Ironically, in this day of evidence-based medicine, those who would tell us how to practice the profession, for which we have trained extensively and exhaustively, have yet to consider any evidence for the requirements they so pompously heap upon us.

Also would you want to see Kramer as your "patient"?

In a similar vein, the latest issue of Medical Economics carries a story on the increasing requirements of board recertification. As Dr. Alice has posted it has taken her a good deal of time (and money) taking the "modules" required for recertification. The use of chart reviews and patient surveys (what say you, HIPPA?) would become key portions of the recertification.
Such things as chart reviews and patient surveys would have little use for a surgical practice, based on the limited interaction that we have with most of our patients (preop visit, operation and postop visit). A surgeon in my city has a brother who is on a committee trying to come up with additional recertification requirements for surgeons. The ideas have ranged from videotapes of surgery, "educational modules", and (gulp!) repeating the orals.
One reason that the "powers that be" perhaps are eager to impose new tests and requirements is that they can become a steady source of income for the NBME, ABS, or the ABIM. The "Step 2 clinical skills" exam will set back the MS4' s of the world $975. The ABS requires you to pay $1675 to become certified and $675 for recertification. The ABIM ticket costs you $950 for certification. The website would not allow me to find fees for the modules or recertification. The American Board of Pediatrics charges $1260 for the first time. I'll stop here, since as you can see that taking boards is an expensive endeavor. Just to do the math, given the 13,300 seniors that matched (assuming the number of graduates remain constant) last year, at $975 a head, comes out to $12,967,500, and this doesn't include the fees from the written portion of step 2. A tidy sum to say the least.
There is little enthusiasm about increasing recertification requirements amongst the physicians I know. There is a "town and gown" division in surgery about this (and other things, such as per diem payment for trauma services) the community surgeons see this as the academics imposing their will from the ivory tower on the peasant masses.
Well I have to go help Mrs. Parker get some things ready for Thanksgiving dinner tomorrow, as her father and stepmother are coming tomorrow. As always, your comments are welcome.

Tuesday, November 25, 2003

Haven't been able to post for the past week as my job has gotten in the way of my blog. I was very busy over the weekend and my older child had surgery today (everything went fine). I hope to be more active now with that being over.

Tuesday, November 18, 2003

While not medically related this story in last Monday's Atlanta Journal Constitution caught my eye about how students at my alma mater are engaging in "creative academics" to keep their HOPE scholarships intact. The story goes into great detail about how students schedule light loads, withdraw from classes, and use the "key" to find which professors give out the most "A"'s in a class, (a tool that was sadly not available in my day).
But what really grabbed my attention was this:

Bill Melton, a seventh-year senior at the University of Georgia, said he dropped several classes, took extra semesters to graduate and changed his major -- in large part to try to keep his scholarship.

A seventh-year senior?
When I was attending UGA it was "fashionable" in a way to hold off graduation until after fall quarter to be able to attend through another football season. But being in college for seven years without graduating? If the HOPE scholarship wasn't picking up the tab for this do you think there would be many seventh-year senoirs? I know that many students have difficulty in obtaining classes that are requirements to graduate (when I was there the hour requirement for a B.S. degree made it impossible to graduate after four years taking a full-time load each quarter), but there seem to be other motivators as well.
The administration of the University is taking notice as well:

Because funding is based on the amount of credit hours each student takes, the University is losing a total of $6 to $10 million a year because students are staying beyond four years to fulfill graduation requirements.
"We've let a (lax) attitude slip in," he
(University president Adams) said. "That's why we are thinking of some disincentives," such as possibly not selling fifth-year seniors football tickets at student rates.

As Bluto said in Animal House "Seven years of college down the drain!!"

Go dogs!!! Sic'em WOOF WOOF WOOF!!
The Washington Post has a story today describing one parent's journey through the diagnosis of pyloric stenosis. The child described in the story had experienced several weeks of vomiting that did not respond to changes in formula, which evolved to projectile vomiting when the child was seven weeks old. The child was diagnosed, underwent his operation (a Ramstedt pyloromyotomy) and got all better.
A pyloromyotomy is one of my favorite operations as it is usually done on otherwise healthy infants and the improvement is almost immediate. My most interesting case was a pyloric stenosis in a patient with situs inversus, so the incision was on the left side. That child presented with much the same story as the infant in the story, with a language barrier as well (the parents spoke only spanish). This child was suffering from severe failure to thrive, and required two weeks of TPN, in addition to full PO intake to maintain a stable weight.

Monday, November 17, 2003

An international reader, who is also a first-year medical student emailed me this....

I am thinking about becoming a surgeon. I would like to ask you why you have become a surgeon, because it can help me in making a decision.

Ah yes, the question that I ask myself every time I get up at three in the morning to go see a trauma patient, or a belly pain, or am up operating...but I digress.
Ever since I was in grade school I wanted to be a doctor (yeah, sounds hokey I know). With the execption of a month or so in high school that desire remained constant. So I got into medical school and then began to think about what I wanted to do. During college I worked in a local emergency room and met physicians who would let me tag along with them in the OR, hospital rounds, and their office. I saw multiple aspects of orthopedics, family practice, cardiology, pulmonology, radiology, and general surgery. During medical school vacations I would continue to do so. So in addition to being a medical geek I had a good insight to various specialties prior to medical school.
I wanted to do something that allowed me to make an immediate impact on a patient's life,and thought that a procedure-oriented specialty would allow that. I found during my "busman's holidays" and my third-year rotations that a primary care career wasn't for me.
What turned me on to general surgery was a resident who took me under his wing and let me do lines, manage the ventilator, and write TPN. I discovered that general surgery allowed me to diagnose a problem, provide an immediate solution, and manage acute problems. It allowed me to do this without being bogged-down in routine management of chronic health problems. Orthopedics would not allow me to manage critically-ill patients. Cardiology and pulmonology had the burden of requiring an internal medicine residency.
Surgery also is changing and growing as new technologies and procedures that take advantage of them are developed.
At the end of the day I think I have made a difference in people's lives (hopefully for the better) and I enjoy what I do (for the most part).
It is hard work, and surgery residencies are some of the hardest out there (80 hour work-week regardless). And fewer people are going into surgery (at least in the states) so that is something that you should consider.
Best of luck in your studies and I hope this was helpful.

Sunday, November 16, 2003

"Mom Finds Out About Blog"
From The Onion.
1-800 #$@-&*^!
Was in Athens this weekend for the 26-7 Georgia victory over Auburn. Had a great time, and I was even on a tailgate show broadcast on local TV in Savannah. CBS broadcast the game, and all during the game, taunting me from the skies above Sanford Stadium... was the 1-800- medicare blimp. Medicare reimbursement is likely to fall again, and the wise heads at Medicare have gotten themselves a blimp for $60,000, out of a $30 million "education" program. Government at work.

Apparently I'm not the only one that thinks so.


Wednesday, November 12, 2003

I've been busy with the resident service and playing Call of Duty which arrived the other day, so I haven't been able to post much. I'm on call tomorrow so if it isn't too bad I'll find something to blather about.

Monday, November 10, 2003

The GruntDoc had a post about a postoperative death after a gastric bypass. The hospital was blaming a stapler "malfunction" for the problem. Well from this story that Ross has found, this has happened before:

Another of Lautz's patients complained to the board late last year about his handling of her obesity surgery. She developed complications after surgery and complained she could not reach Lautz despite repeated phone calls, according to board documents. The board sent him a letter saying "communication is a key to any successful patient-physician relationship." In that case, Lautz said a staple gun misfired on him, and the patient also developed a stomach leak.

Gastric bypass carries a high risk overall:

But patients face serious risks, sometimes death. In gastric bypass programs at most academic medical centers, like Brigham, about one in every 200 or 300 patients die of complications from surgery, said physicians at one-half dozen hospitals. Three patients, including Simonelli, out of 750 operations have died since the mid-1990s, at Brigham, Zinner said.

In comparison, Zinner said, fewer than one of 1,000 patients die from gall bladder surgery, while two or three patients of 100 die from coronary bypass surgery, one of the riskier procedures.

So based on the above statistics, the program at Brigham is about average. A gastric leak is a recognized complication of a bypass operation. And apparently, according to the story, a problem was recognized at the time of surgery:

During Simonelli's surgery, Lautz noticed that staples in one row had popped out, so he converted the operation to a traditional open surgery, Whittemore said. Lautz closed that portion of her stomach with traditional hand sutures, Whittemore said.....During an autopsy, doctors discovered another part of a staple row had come undone and that some of her stomach contents had leaked out, Whittemore said.

Doesn't say if it was the same staple row, or one of the others. This answers the question I posed in my comment on Grunt Doc's post. Not knowing all the details it seems to me that conversion was the right thing to do, given the circumstances presented in the article. Then this:

Her surgeon, Dr. David Lautz, has performed hundreds of gastric bypass surgeries, so Zinner does not believe lack of training was to blame

I don't think so either, but doing "hundreds" of any procedure does not immunize one from complications. Every surgeon has complications from time to time and you need to know how to recognize them and correct them. As I often say when I hear about a colleague's problem, "There but for the grace of God go I." I haven't done a gastric bypass in years and have no desire to start doing them again.

Given the immediate circumstances surrounding this young lady's unfortunate death, I believe it was a pulmonary embolus that was a cause of her demise:

Afterward, Simonelli did well her first day. On the second day, she sat in a chair in her room and asked a nurse for help getting into bed. The nurse left the room to fetch wound dressing, Whittemore said, and when she returned, Simonelli had no pulse and was not breathing.

But that's just an educated guess. I think that the hospital is bringing unwelcome attention to itself by blaming the stapler for this problem, but I guess they feel the need to defend themselves in the court of public opinion.

UPDATE: Was doing some more thinking (a dangerous thing to do, I know) when I did the math. Given the 103,200 gastric bypass operations expected to be performed this year, and the 1/200-300 mortality rate, this means that, statistically, one patient having a gastric bypass dies every day.

Saturday, November 08, 2003

DR. MOM...
I've been the domestic god the past two days as Mrs. Parker finally cashed in her gift certificate to a local day spa (yesterday) and is gone today to get fitted for a bridesmaid's dress in Big City. So it's me, my two toddlers, Noggin, Nick Jr. and a cloudy day threatening rain keeping us inside.
Posting has been light over the past few days as I was on call Monday and Thursday, as well as serving my time as the attending of the resident's service. I can understand how Doc Shazam feels, riding herd over junior housestaff.

Added new links Azygos and Psychscape.

Check out Overlawyered and this post about physicians being sued by patients in class-action suits without the patient knowing about it.

It's quiet...too quiet. I'd better go see what's going on.


Thursday, November 06, 2003

In yesterday's WSJ a story about aortic aneurysm, and why they are often misdiagnosed. Multiple examples are given, mostly young people who presented to their ED with chest or back pain and once "ruled out" for an MI they were either sent home or languished in the hospital until they died.
Some interesting statistics: (from yesterday's story as well as from January 13, 2003)

A common misconception among physicians is that aortic disease is rare, when in fact it kills an estimated 25,000 Americans a year. That is a larger toll than that of AIDS and most kinds of cancer

The National Institutes of Health will spend $2.77 billion for research on AIDS this year, along with $732 million on breast cancer and $408.3 million on prostate cancer. The amount for abdominal aneurysms is just over $6 million.

About eighty percent of aortic aneurysm deaths are from abdominal aorta, the remainder are those in the chest. The young people mentioned in the story almost certainly had a genetic cause for their aneurysms, such as Marfan or Ehlers-Danlos syndrome. These usually present in the chest. The most common aneurysms occur in the abdominal aorta, and these occur most often in older individuals with atherosclerosis.

There are many advocates for ultrasound screening especially for men over the age of sixty with vascular disease or tobacco abuse.

A huge British study provided some last fall. After following 61,000 men aged 65 to 74 for an average of four years, it found a 42% drop in risk of death from abdominal aortic aneurysm among those who had been screened. Their aneurysm death risk was 1.9 per 1,000, vs. 3.3 in the others. "Screening can significantly reduce mortality rates associated with abdominal aortic aneurysms," concluded the study, published Nov. 17 in The Lancet, the British medical journal.

There is some debate over whether this is cost-effective. I think it is because (and I know this is anecdotal) every patient with a ruptured aneurysm that I have operated on had no idea they had any problem.

Ruptured aneurysms carry a mortality rate of 80-90 percent. An attending where I trained wouldn't even repair a free rupture because they had no chance of leaving the hospital alive. Elective aneurysm surgery carries risks as well. Renal failure, MI and limb loss may occur. Colonic ischemia can be especially problematic. Even years later the patient may have an aorto-enteric fistula, a diagnosis that should be high in the differential in any patient with a history of aortic surgery and a GI bleed (the fistula may be primary, or form the aneurysm itself)

Newer endovascular techniques are helping to eliminate the physiologic complications from open aneurysm repair. Some of the earlier devices had problems which the company covered up and now they are getting to meet the lawyers. The company will (justifiably) get punished, but I feel that this is a bit much.

Tuesday, November 04, 2003

Lisa Williams has decided to take me off of her blogroll at Learning the Lessons of Nixon. I will be the first to admit that it is Ms. Williams' right to run her blog as she sees fit, but I must object, to what I feel, is her putting words in my mouth.....

Today I delisted a couple of blogs from my blogroll. I thought I'd comment on why, and give them a farewell link. I delisted a medlog, Cut to Cure, because I got tired of its cheerleading for the "patients are lazy, patients are greedy, patients are stupid" wing of the medical weblog universe. This attitude saddens and angers me and I don't want to pass it on to my readers anymore.


I didn't know that there was a "patients are lazy, patients are greedy, patients are stupid" wing of medblogs. I haven't received my membership card, decoder ring, or secret handshake. I certainly am not their cheerleader.
In all seriousness, when I looked over my last months worth of posts this is roughly what I found:
Three posts on Bulldog football.
Posts on medical issues (Caval filters, compartment syndromes, common bile duct injuries, dialysis, and informed consent).
A post concerning changes in Georgia's helmet law.
Two posts on the Nobel prize for medicine.
Two posts on my trip to Chicago.
A post on the usefulness of the AMA.
Two posts on my being held in limbo to testify in an assault trial.
A post on how my kids eat junk food and watch too much TV.
Three posts on Medicare/Medicaid funding issues.
One post on the increasing numbers of uninsured (with a favorable comment from Ms. Williams).
One post on emergent cholecystectomies while on a waiting list.
And a post on the general surgical boards.
In none of those posts did I call patients lazy,stupid, or greedy.

But what about this post, about patients being arrested for not paying their medical bills. Did I imply something? Are patients lazy, greedy, or stupid? No. Irresponsible? Probably yes.
As I have said before, I wish everyone could become insured not only for the altruistic reasons, but because I do enough work for free as it is. That being said the providers of medical care cannot be held responsible for the "basic issues of economic inequity" as Ms. Williams puts it. The actions that are described in The Wall Street Journal story are drastic, and should be used only on those who will not pay versus those that cannot pay.
I would rant some more on this, but I was up all night operating and seeing my greedy, lazy, stupid patients in the office today.
At least I don't send them to this emergency room. Good night.
Thanks to all who submitted comments to my post about the Wall Street Journal story last Friday. (Although not all were happy, but more on that later) I asked Matthew Holt for his opinion on this from a health policy standpoint, and he graciously responded. While I may not agree with all of his positions, I respect them and find them well thought-out. Here goes:

a) While it's true that this is a tiny minority of patients, it is symptomatic of the problems many Americans have paying unexpected medical bills. It's extremely unlikely that the financial benefits of collecting some of this money are worth the bad publicity these institutions just got.

Hospitals are some of the most public-relations sensitive institutions around these days. As shown here, here, and here the hospital mentioned in the story is taking a beating in the press over this.

As is now quite widely known, the uninsured often get charged the highest prices by hospitals, as they do not have the ability to get discounts off the "list price" as do insurance companies. This "reverse" price discrimination isn't exactly equitable or ethical..... Hospitals used to write all this bad debt off, and would charge more to well-insured patients to make up the difference. Starting in the late 1980s aggressive insurance companies lowered their payments and got rid of the hospitals ability to cross-subsidize from "rich" patients to poorer ones. But of course apart from the DSH program for a few inner city hospitals who treat a lot of uninsured patients, no new system of cross subsidization has been created.

As I posted (scroll down to October 3)here in "the good old days" this debt could be written off without hurting the bottom line, since you could "balance bill" the rest away. Not anymore.

Mr. Holt then writes:

The best system of cross-subsidization is called insurance. The people shipped off to prison in the article (and another 42 million Americans) didn't have it usually because they are too poor to buy it (or not forced by law to buy it) and because the market for individual insurance is dysfunctional. I'd rather have our sheriff's deputies out preventing crimes, rather than acting as debt collectors for hospitals. The way for that to happen is for policy makers to create an insurance system that works for the working poor including forcing them to participate. Then hospitals wouldn't be bill collectors and patients wouldn't have to avoid needed care for fear of not being able to pay. Hospitals would be better off in the long run if they put their considerable political clout behind the creation of such a system.

I agree (scroll to October 1), as I quote myself:

1. Disassociate health coverage from employment. Individuals should be able to purchase insurance themselves, and take it from job to job. They should get the tax benefits that companies get now on the premiums.
2. Individualize plans. Why should a young, healthy twentysomething have a plan with drug coverage? One reason why plans are so expensive is that they all have to include coverage for things that a person may never need.
3. Require some level of basic coverage to be purchased. This applies to auto insurance in my state, and will help spread the risk pool.

As you can see from the ungodly hour that this is being posted, I am on call and now have to go operate. When does my 80-hour week kick in?

Sunday, November 02, 2003

The national title hopes of the Dogs faded away in Jacksonville yesterday. UGA will have to struggle now to get to the SEC championship game. The drought continues.
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