Saturday, January 31, 2004

Some in south Florida feel they are the victim of price gouging at their local Miami hospital.

Decrying hospitals for charging the uninsured up to six times what insurance plans pay, a consumer group issued its final report Thursday on Miami-Dade County, saying that it had received the most complaints about Kendall Regional Medical Center.
''There's no reason they should gouge patients like this,'' said K.B. Forbes, head of Consejo de Latinos Unidos, a California-based group.
One example at the press conference: Rina Murillo, a 33-year-old unemployed mother suffering from kidney stones who ran up a $25,000 bill over five days at Jackson Memorial and then was billed about $45,000 later for several out-patient treatments. She never had surgery.

The hospital position is as expected, but this fight is nastier than most:

Linda Quick, president of the South Florida Hospital and Healthcare Association, questioned Forbes' motivation in a telephone interview. ''He needs to be confronted,'' she said.
``His goal does not appear to be to help people get insurance, but to get them free care, or cheap care. That's not working to solve the problem.''
She said evidence indicated Forbes is using a Hispanic-sounding group as a front to help health insurers get lower prices. Forbes denies the charge.
Quick said hospitals locally and nationally are working to find ways to deal with the uninsured, which she dubbed ''a national crisis.'' Her group has ``a number of committees that continue to study this complex issue.''

The hospital in question Kendall Regional Medical Center , according to Mr. Forbes, is not shy about taking their patients to court.

In a press conference, Forbes said that, of all the hospitals in Miami-Dade, Kendall Regional had the greatest tendency to sue patients to recover unpaid sums. His survey showed that Kendall had filed 248 lawsuits in 2003 -- a seven-fold increase from the 34 lawsuits it filed in 2000.

But apparently they don't go so far as to throw their patients in jail. The CEO makes his point as plainly as possible:

Everyone gets charged the same at Kendall Regional, Sirvent said, though health plans negotiate smaller charges for their members.
''We don't have a contractual relationship with the uninsured,'' he said, adding that the hospital had to write off $275 million worth of care to the uninsured over the past three years.

As I have posted earlier (here, here, and here), hospitals and physicians are somewhat limited in any discounting that can be offered to uninsured patients due to potential conflicts with Medicare. Hospitals are taking notice:

Forbes' report on Miami-Dade did not include Tenet hospitals, he said, because Consejo and Tenet reached an agreement a year ago that uninsured persons who entered through emergency rooms would be charged managed-care rates.
That agreement has yet to be implemented, because Tenet is seeking clarification from the federal government whether it would affect its Medicare charges......

Meanwhile, closer to home, Grady Memorial Hospital tells us, if you're uninsured but not from Fulton or DeKalb counties, bring your wallet.

Grady Health System will stop providing primary care services at no cost to uninsured people who live outside Fulton and DeKalb counties.
Instead, patients will be expected to pay up front for standard clinic and office visits, beginning April 1, said Dr. Andrew Agwunobi, Grady's chief executive....."We have become the hospital for the uninsured without any boundaries on where patients live," said Agwunobi, a pediatrician-turned-budget-surgeon who previously pulled South Fulton Medical Center from the edge of bankruptcy. "Grady Health System is not a dumping ground for other counties or other hospitals."

According to the administration, Grady cannot continue to support uninsured residents from other counties who have been content to allow their uninsured to receive their medical care at Grady.

"I've been watching the bills pile up for 16 years, attending the Hospital Authority meetings," said state Rep. Doug Teper, a Democrat who represents parts of DeKalb and Fulton counties. "There's really never been a good mechanism in place to pay for out-of-county people. It's a challenge just to make sure the [address] information is correct, that patients really are from where they say they're from, let alone figure out who's going to cover costs."

A new system of identifying patients should help quickly determine an individual's address and insurance coverage. On Jan. 1, Grady began issuing silver "Grady Care" cards that resemble credit cards. Only DeKalb and Fulton residents who are uninsured and who have a proven place of residence are eligible for the cards. Medicaid, Medicare and privately insured patients don't need the card.

Some are concerned that by closing out the outpatient clinics could shift those patients to the emergency department. According to the article, they have a plan...

All emergency patients must pass through the triage process, which sorts out the severity of medical attention required and assesses eligibility for care, she said.

"Should out-of-county uninsured individuals show up in the emergency room with ailments deemed minor by triage nurses, such as a cold or heartburn, they'll be referred back to the clinic," Simpson said.

Hopefully the people at Grady will know the difference between a triage evaluation and the EMTALA mandated "medical screening exam".

Thanks to Ross for the Miami link.
While the Georgia General Assembly passes bills designating an official state amphibian, does their best to de-rail tort reform and the Department of Education wants to eliminate the word "evolution" from the curriculum, but still teaching the concept. The West Virginia House of Delegates is tackling that perennial bugaboo, ATV regulation.

West Virginia leads the nation in ATV deaths, and 26 percent of those killed since 2000 were juveniles, according to figures supplied by the West Virginia University Center for Rural Emergency Medicine......
WVU statistics show that since 2000, 16 percent of those killed on ATVs were passengers, only 5 percent of those killed were wearing helmets, 30 percent were killed on public paved roads, 34 percent were riding on private property, and 22 percent were riding on an unpaved road or trail.

The data from the WVU Center for Rural Emergency Medicine may be found here.

Of course, many more are injured, sometimes severely on ATVs. ATVs are extremely popular in West Virginia with the number one per capita sales volume in the U.S. (and number two overall). They are sometimes used as a family's "second car". Efforts to regulate them not only meet opposition from those of a more libertarian bent, but legislators that represent poorer, more rural districts (the same crowd that fights efforts to keep passengers out of the beds of pickup trucks)

The dueling proposals are described as:

The House passed legislation early in the session, basically the same compromise bill that failed last year. It prohibits riders under 16 from hauling passengers on public property, requires helmets for riders under 18 on public property, and limits to 25 the number of miles on paved roads an operator can drive.

The Senate version under consideration goes further. Senators included making helmets mandatory for those under 18 on public and private property; restricts the distance that can be traveled on paved roads to 10 miles, bans those under 16 from hauling passengers on public and private lands, and allows municipalities and homeowner organizations to make additional restrictions.

I agree with the latter of the two proposals, as the vast majority of those killed or severely injured that I cared for were riding on their own property. The saddest was a six-year old girl who was riding on one during a friend's birthday party. She was on an ATV with five others when she was thrown into a tree, she died in ED from a high cervical fracture and head injuries.

The Gazette has an excellent series about ATV problems in the Mountain State here. (Free registration)

Friday, January 30, 2004

No surprise from another meta-analysis about mammograms and breast implants.

Scientists sifted through data from seven mammography registries across the country on women who had the tests between 1995 and 2000.

Of those, 137 women with implants and 685 women without implants developed breast cancer within one year of their test.

Mammograms missed 55 percent of breast cancers in women with implants compared with 33 percent among women without implants. Routine mammograms help detect small tumors and calcium deposits before other symptoms appear.

The conventional wisdom in the surgical community was that while breast implants did not increase the incidence of breast cancer, followup is more difficult. Once a breast cancer is found in a augmented breast, treatment becomes more difficult. Breast conservation a harder goal to achieve due to two main reasons:

The studies on breast conservation did not include patients with breast implants

Breast implants do not tolerate radiation well as they tend to contract and result in cosmesis that is less than desirable.

Implants also make biopsy more difficult, since one loses style points if the implant is violated. This is one area where I personally have found stereotactic biopsy to be advantageous as the machine tends to push the implant out of the field.

However, to researchers' surprise, tumors in women with implants were not discovered at a more advanced stage.

"That's the good news," said Diana Miglioretti, a biostatistician at Group Health Cooperative's Center for Health Studies and the lead author of the article in today's Journal of the American Medical Association.

"(Tumors) are being detected somehow even though they're being missed on mammograms," Miglioretti said.

As I don't have the full text of the JAMA article in front of me, I can't comment on how the tumors were found. Physical exam? Ultrasound? Or a later mammogram that had a more definitive lesion that was biopsied and had been missed on the initial study?

So what should the woman who is considering or has breast implants do?

If someone was trying to decide if they were going to get (implants), I would say this is a potential risk," said Dr. Karla Kerlikowske, a primary care physician at the University of California-San Francisco and one of the study's authors. "For those who already have implants, I would make sure they're going to a facility that has the capability of doing displacement views," Kerlikowske said

Of course the missed-cancer rate of 33 percent of the non-augmented breast is nothing to brag about.

Thursday, January 29, 2004

Hey Allen, try this!!!!


from The Onion
The Georgia Tech Sports Blog

I do like the "Buzz" graphic though...
A reader posted this comment on my January 24th entry.

Not all academic practices are the same. Many give a relatively small salary to the staff. The majority of their income is from the practice plan - i.e. from treating patients. Those of us in academic's are generally just as tied to our clinical practice as any other physician, and this includes paying for overhead as well as the "Dean's tax". It's not all milk and honey in an academic practice.

While the comment is, IMHO, more of a rebuttal to Dr. Smiths post than mine, I agree with what the author has written. The practice of medicine in the academic setting has changed greatly over the past few years. In the past an academic surgeon could expend a great deal of time and effort to research and teaching. They could do this because for the most part they left the mundane procedures and certain parts of the complex ones to the residents or fellows. An example would be on a CABG the fellow would open the chest, harvest the vein, cannulate the patient and call the attending when the patient was placed on bypass. The attending would come in and perform or assist with the anastomoses, and then leave. Barring complication the fellow would complete the case by themselves. If the program was large enough the attending could bounce from room to room when the "underlings" were ready for them. General surgery attendings would leave the hernias and breast biopsies (for example) almost exclusively to the housestaff.

With the rise of managed care, reimbursement has fallen and put pressure on academic health centers.

Cuts in Medicare reimbursement to hospitals made by the Balance Budget Act of 1997 threatened the financial viability of academic medical centers, with the AAMC projecting that half of its members would be losing money by 2002. The Medicare, Medicaid and SHIP Benefits Improvement and Protection Act of 2000, passed by Congress last December, will repair some of the damage, restoring $12 billion to all hospitals over five years. The Act also delayed implementation until 2003 a one percent reduction of a multiplier used to calculate GME payments, which Dickler estimates will yield $700 million to teaching hospitals over those two years.

The fiscal health of teaching hospitals and medical schools, however, remains at risk. One-quarter to one-third of AAMC's teaching hospital members still continue to show an operating loss every quarter, he adds.

Faculty were pressured into providing more clinical services to increase revenue. Departments of Surgery have not had much of a problem with this a they, for the most part, make money for their institutions. Surgeons have also been affected by lawsuits and audits that have required an increased presence of the attending surgeon in the OR. (A good thing, I might add). (More on the University of Washington problem may be found here, a situation where their chief of neurosurgery was convicted of felony fraud)

So while their clinical responsibilities increase they are still required to engage in teaching or research. But many are balking at it:

Harvard Medical School is struggling to persuade its physicians to teach its students, as doctors seeing more patients to stay afloat financially have less time to educate the next generation of doctors at one of the country's
most prestigious medical colleges.
The medical school dean, Dr. Joseph B. Martin, who was hired in 1997, appointed a task force to study the issue as part of a far broader curriculum overhaul, the first major rethinking of the school's curriculum in 20 years.
Earlier this year at a faculty meeting, Martin, who is generally soft-spoken, let faculty know he was upset about the teaching situation. ''Martin expressed deep and serious frustration at not being able to
convince more faculty that teaching responsibilities are the core of a faculty appointment and that faculty have an obligation to carry out their teaching responsibilities,'' according to the faculty report of the meeting
in February. ''He said efforts to convey this have been largely unsuccessful.'' Members of the Task Force on Faculty Teaching Responsibility said course directors are finding it increasingly difficult to recruit faculty to
teach -- despite the school having 9,000 physicians and researchers at its affiliated hospitals and institutions and a requirement that they teach 50 hours a year if asked. More faculty are saying no to requests, many
physicians in the hospitals will agree to teach students at patients' bedsides for only two weeks rather than a full month, and, in rare cases, course directors are hiring non-Harvard faculty to tutor small groups and oversee labs.

DB has an excellent post about this from June 2003. Be sure to read Dr. Henry's thoughtful comments.

The surgical journals are filled with academic job postings, since physicians are realizing they can earn much more money for the work they are doing in private practice. Although some at the Medical College of Georgia aren't doing too badly:

1. Mark R. Lee, department head, Medical College of Georgia, $439,482 (neurosurgery)
2. Julian J. Nussbaum, department head, Medical College of Georgia, $415,000 (ophthalmology)
3. Dennis M. Marcus, associate professor, Medical College of Georgia, $404,167 (ophthalmology)
4. Thomas R. Gadacz, department head, Medical College of Georgia, $374,958
(general surgery)

Nice work if you can get it.
As I was leaving the house early this mornig for my 6:30 meeting there was a segment on ABC's World News Now about how Howard Dean's wireless microphone was responsible for the outrageousness of this post-Iowa caucus speech.
So the reason that he has hired a new campaign manager and is asking his staffers to go without pay for two weeks is because of Mister Microphone?
Apparently, according to Diane Sawyer, the microphone Dr. Dean was using has some sort of device to screen out crowd noise so the speaker may be heard. Other clips were shown with microphones that were in the audience and Gov. Dean could barely be heard over the crowd noise.
While there may be a legitimate concerns over the coverage of the speech, there is a grain of truth to the underlying concern.

According to Jonathan Alter in Newsweek:

Political gaffes hurt only if they express something the media already want to convey. If brainy Bill Clinton, not Dan Quayle, had misspelled "potato," no one would have blinked. If mild Joe Lieberman had yelled on election night, it would not have been played ad nauseam. Not one of the words Dean used in his caucus-night screech was at all inflammatory; the power of the videotape was that it seemed to show the rage everyone had been told lay below.

How does the Mr. Microphone Theory explain this?

Tuesday, January 27, 2004

The University of Georgia



Wolfgang Amadeus Mozart


Saturday, January 24, 2004

I must have said that a dozen times yesterday as I tested for the ATLS course. Teaching ATLS is one of those thins that is a great deal of fun for the first day, but at the end of the second day you are glad you only teach twice a year.

Thanks to Dr. Smith in posting my email about poor Dr. Dean. Dr. Smith brings up a good argument for Dr. Steinberg's absence from the campaign trail...

Well, after that Monday night scream you've got to think his personality might have something to do with her decision, but it's still not such an easy thing to abandon a medical practice - at least not one that you own. The difference between Dr. Steinburg and the academic is that the academic's salary is paid by the university. If he chooses to practice part time, he doesn't have to worry about covering the cost of over-head, the university will. A doctor in private practice has to keep earning the money to pay for her rent, malpractice, staff, utilities, etc. The profit margin in medicine is very small. Cutting down by one or two days a week can erase a doctor's income. It also means two days when you're not available to your patients. And that means that a certain percentage of patients will leave and go to someone who is more accessible. (emphasis mine)

Another one being that it is no one's business why Dr. Steinberg chooses not to campaign.

One of the first bits of advice of a non-medical nature related to surgery that I received as a resident was the "Three "A"'s of private practice"

Availability, Affability, and Ability...IN THAT ORDER

Meaning if you are not available to your referring physicians and get along with them you can have the hands of a DeBakey and still have to struggle for business.

Wednesday, January 21, 2004

Reported today in multiple outlets a synopsis of a study to be presented in the Journal of the National Cancer Institute. The full text may be found here (PDF). The authors conducted a meta-analysis of 15 randomized trials comparing results in patients who had received radiotherapy after breast conservation, versus surgery alone.

Two doctors evaluated the results of 15 international studies and found that women who omitted radiation therapy after surgery were dying at a rate 8.6 percent higher than women who had the radiation.

This with a three-fold increase of same-breast recurrence in the non-radiated group. This was independent of any systemic therapy given (previous studies had shown a decrease of same-breast recurrence in patients receiving systemic therapy). Relapse rates occurred 1.4-5.7 percent per year in the non-radiation group and 0.4 to 2.1 percent per year in the radiation arm. Patients with clear margins had increased survival with radiation.
As with any meta-analysis, the data should be takes with a grain of salt. The authors themselves point out that:

Although the effect of radiotherapy in reducing the risk of recurrence is undisputed, no statistically significant differences in overall survival in any individual trial.(emphasis mine)

The rationale for breast conservation over mastectomy has been that while the rate of in breast recurrence has been higher with breast conservation, the rate of overall survival is the same. This was examined in the NASBP B-06 trial in 1973. This data has held true for twenty years with results examined in the October 17, 2002 New England Journal of Medicine

The cumulative incidence of recurrent tumor in the ipsilateral breast was 14.3 percent in the women who underwent lumpectomy and breast irradiation, as compared with 39.2 percent in the women who underwent lumpectomy without irradiation (P<0.001). No significant differences were observed among the three groups of women with respect to disease-free survival, distant-disease–free survival, or overall survival.

The B-06 trial was restricted to tumors <4cm in diameter. In clinical practice that limit is expanded in women with larger breasts. Subareolar location of tumor is a relative contraindication as well. Because of their poor tolerance to radiation, women with vasculitis are not good candidates for conservation.

Radiation treatments require a large commitment on the part of the patient. Treatments last for six weeks, five days a week. Some patients have difficulty arranging reliable transportation to radiotherapy.

Hopefully with wider use of local radiation delivery systems such as the Mammosite or the Intrabeam can reduce the time and effort required to obtain good adjuvant therapy. Trials are ongoing.

My routine is to give the patient the option between the treatment modalities. I make the patients promise to undergo radiotherapy. I never make a patient commit to a choice their first visit, but have them come back with a family member to discuss things.

Despite the overwhelming evidence, many patients are not given the option of breast conservation.

Tuesday, January 20, 2004

Does Dr. Howard Dean talk to his patients this way when they are non-compliant?

Monday, January 19, 2004

CDC: Injuries cost billions every year from CNN

Injuries caused by falling down, car wrecks and other accidents cost the U.S. economy $117 billion every year, the U.S. Centers for Disease Control and Prevention reported Thursday.
This represents 10 percent of all medical spending and much of it could be prevented, the CDC said.

"In the United States, injuries are the leading cause of death among persons aged under 35 years and the fourth leading cause of death among persons of all ages," the report reads.

So not only are the numbers of injured very high, injuries affects the most productive segment of society. My fellow medbloggers debate the effectiveness of prevention in other diseases. Injury prevention could reduce those numbers greatly.

We know that seat belts and child safety seats and smoke alarms are effective. And we can prevent falls among older adults through exercise programs that include balance training, vision correction, and reduction of medications to the fewest number and doses, and environmental changes

To this list I add:
Wear helmets when riding a motorcycle, or bicycle.
Practice firearm safety.
Use alcohol responsibly, this is much more than "don't drink and drive". Alcohol consumption plays a large role in the assaults that come through the ED

I'll be watching the coverage of the Iowa Caucuses while on call.....may post some more later.
Why PETA will hand out lurid comic books to children, but hasn't raised a fuss over this ad for asthma prevention?

While the website has this disclaimer:

No fish were harmed during the making of this public service announcement. Fish handlers were present at all times during the shoot to manage the care and well being of the fish on hand.

That goldfish sure does look uncomfortable.

Saturday, January 17, 2004

Paying more for your liability insurance? If so, you're not alone as seen in this story in Medical Economics.

Malpractice premiums continued their dramatic rise last year, with no relief in sight for 2004. Rates in many states jumped more than 25 percent in 2003, and most carriers expect double-digit increases again this year. Even in states that showed no increase for 2003, many carriers have rate increases approved or pending for 2004, according to the latest survey conducted by Medical Liability Monitor, a newsletter that covers the malpractice insurance industry.

Not surprisingly, doctors in some of the biggest cities pay the highest premiums, with those practicing in the Miami area coping with the worst prices. Top rates for coverage there run more than $65,000 for internists, $227,000 for general surgeons, and nearly $250,000 for ob/gyns. Elsewhere, internists are paying as much as $50,000 in Detroit, $41,000 in Chicago (up 30 percent), $34,000 in Houston, and nearly $30,000 in Philadelphia (also up about 30 percent).

Even if liability insurance was fairly reasonable in your neighborhood, that may soon change:

Even in states with relatively modest premiums (like Connecticut, Missouri, New Jersey, New Mexico, and Tennessee) some insurers hiked rates for internists more than 50 percent. In the Virginia suburbs surrounding Washington, DC, one carrier raised rates for internists nearly 140 percent.

And you are going to probably get less for your premium, if you can get coverage at all:

Not only are doctors paying higher rates, many are getting less coverage for their money, or having trouble finding any coverage at all...... Faced with increased claims frequency and higher payouts, some companies are tightening eligibility requirements, eliminating discounts and dividends, restricting coverage, dropping physicians who have spotty records, or simply withdrawing entirely from certain states.

The story has several tables, one which gives high and low premiums in each state. So far with increases of 17-18 percent in Florida, and 15 percent in Texas for internists, tort reform is not providing relief yet. What concerns me is that the state held out as the example of award caps, California, had increases of 7 to 19 percent.

While some point out that payouts in medical liability claims are a small percentage of health care spending, the figure does not take into account the costs of defending cases that are dropped or found for the defendant. Whatever payouts are doing the increases in premiums, which cannot be passed on to the patient, are affecting the bottom line of many physicians.

Friday, January 16, 2004

The medblog community has gotten quite agitated (and rightly so) over this column by Maureen Dowd about Howard Dean and his wife, Dr. Judith Steinberg. This comes right on the heels of a Jodi Wilgoren article in the New York Times.
Rants concerning have been posted by Dr. Centor, Dr. Smith, Dr. Rangel, and Ms. Williams who describes Ms. Dowd, as we do down south, as "catty".

When I see such an uproar about a MoDo column I think about something that appeared in The Weekly Standard in October 2002. Written by OxBlog's Josh Chafetz. They are:
The Immutable Laws of Maureen Dowd
(earlier permutations may be found here and here). Some of them apply here:

THE FIRST IMMUTABLE LAW OF DOWD: The first and most important rule is what might be termed the People magazine principle: All political phenomena can be reduced to caricatures of the personalities involved. Any reference to policy concerns or even to old-fashioned politicking is, like, so passé. And, of course, with every caricature goes a nickname.

In worn jeans and old sneakers, the shy and retiring Dr. Judith Steinberg Dean looked like a crunchy Vermont hippie, blithely uncoiffed, unadorned, unstyled and unconcerned about not being at her husband's side — the anti-Laura. You could easily imagine the din of Rush Limbaugh and Co. demonizing her as a counterculture fem-lib role model for the blue states.

While Elizabeth Edwards gazes up at John from the front row of his events here, while Jane Gephardt cheerfully endures her husband's "Dick and Jane" jokes, while Teresa Heinz Kerry jets around for "conversations" with caucusgoers — yesterday she was at the Moo Moo Cafe in Keokuk at the southernmost tip of the state — Judith Steinberg has shunned the role of helpmeet.

THE THIRD IMMUTABLE LAW OF DOWD: It is better to be cute than coherent. Along these lines, Dowd's favorite rhetorical device is parallelism.

As Robert Pear and David Kirkpatrick wrote in The Times, administration officials are planning an extensive election-year initiative to please conservatives in a swivet over gay marriage; their social engineering scheme will try to shore up traditional marriage, offering training to couples in the interpersonal skills needed to achieve and sustain "healthy marriages."

Before Mr. Bush ventures into the inner cities to practice his conjugal noblesse oblige, perhaps he should beeline to a more rural spot — a split-level ranch house with green shag carpeting and Grateful Dead albums in Burlington, Vt.

The doctors Dean seem to be in need of some tips on togetherness and building a healthy political marriage, if that's not an oxymoron.

While the above may be a reach, I thought it was worth posting, due to the chord Ms. Dowd's column struck with many of my fellow travelers.

There is a cottage industry of Dowd-bashing in the blogpsphere, and they are all thinking:

She takes a month off and this is the best she can do!?!
While researching my appendectomy post a few days ago I found this.

It was night call in the big training hospital. A professor, a surgical resident and a rotating intern were operating on young woman with appendicitis.

At one point, the professor noted a disturbing presence of bowel gas about the wound. He became concerned about a possible perforation of the colon, the large intestine to which the appendix is attached.

The professor enlarged the incision, pulled the intestines out and inspected them. He found no defects, so they closed. The patient recovered uneventfully.

The entire case might have been forgotten by all if a certain member of the surgical team had been more prudent. Little did the professor know that, while looking for the source of bowel gas leakage, they were searching the wrong abdomen.

It came from the intern! He remained silent throughout the procedure, then later thought it was funny that the surgeons busied themselves fooling with the intestines on account of his deed......

The first things I learned about scrubbing a case as a medical student were 1. Don't argue with someone who says your gown or gloves are contaminated, and 2.If you break wind in the OR on an abdominal case, fess up.

Read the whole thing....

Wednesday, January 14, 2004

An orthopedic surgeon, BloggingDoc, jumps into the medical blogosphere with Complications, an orthopaedic surgeon's notes.
Thanks to Doc Shazam for the link.
I know quite a few orthopedic surgeon jokes, if anyone would like to read them!! ;)

Tuesday, January 13, 2004


Pollack spurns NFL, stays at UGA
Good day to be in Bulldog Country!!!!
Dr. Alice gets Instalanched, watch the fun!!!

Monday, January 12, 2004


Young Doctors Working Too Many Hours

Apparently the intern who reported Johns Hopkins to the ACGME has been having a rough go of it.....

Madsen, meanwhile, suffered a common whistle-blower's fate. "People I worked with, people I knew very well, would not look at me, would not talk to me," he said. He left the program and eventually wound up at Ohio State University Medical Center where he says he is happy.

What made him angriest, he said, was Johns Hopkins' "blatant disregard" for the new regulations. He said the hospital made no schedule changes even as the new rules deadline loomed last summer. "They said, 'Hey, we're Hopkins. We're going to do anything we want.'"

And apparently other programs are attempting to "cook the books":

Justine Wood, a spokesman for the union Committee for Residents and Interns, said a common story he hears is residents are told "more or less explicitly" to falsify time sheets.........A resident in Philadelphia, who asked not to be identified for fear of the retaliation, said she worked a 34-hour shift last week because she didn't want to dump work on her colleagues.

Some are less than impressed with the ability of the ACGME to straighten things out, as seen in this
testimony before the Massachusetts legislature last month:

Why is the ACGME ill-equipped to enforce work hour regulations?

First, the ACGME can only enforce its regulations by withdrawing a program's accreditation. Residents, in order to qualify for licensing exams and continue their professional development, must graduate from an accredited training program. Few residents are willing to report work hour violations to the ACGME if it means that their program might lose its accreditation as a result.

Second, the ACGME does not provide adequate whistleblower protections for those who report violations. The ACGME will not accept anonymous complaints. Instances where residents' names have been disclosed, leading to hostile work environments for those individuals, have led many residents to believe that the ACGME is not able to guarantee confidentiality.

Third, the ACGME conducts pre-arranged site visits approximately every 3.7 years, allowing programs to maintain an appearance of compliance. Residents have been asked to lie to ACGME investigators regarding the number of hours they work. One resident reported anonymously that he was not even able to see his time sheet to ensure that his hours were logged appropriately. By contrast, New York State enforces its separate work hour limits by contracting with an independent peer-review organization that conducts repeated, unannounced site visits.

Finally, although graduate medical education is funded through the Medicare program, the ACGME is not accountable to the public. They do not disclose the details of why a program has had their accreditation withheld. Patients who receive their medical care from residents have no way to know if they have been placed at risk of medical error by an institution that forces its residents to work to the point of fatigue.
Overall, the ACGME is not able to provide adequate enforcement of work hour regulations because, as stated by the New York Times, the ACGME "faces an inherent conflict of interest. Its board is dominated by the trade associations for hospitals, doctors, and medical schools, all of which benefit from the cheap labor provided by medical residents."

The much reported violations of Hopkins and Yale have been resolved without much pain, so a whistleblower may ask "Why bother?"

My thoughts on the issue may be found on7/2/03, 7/3/03, and 8/23/03.

For more insight check out HoursWatch.
Last week Mr. Holt at The Health Care Blog had a post summarizing this article from The Boston Globe about the error rate in pediatric appendectomies, that is the removal of a normal appendix due to the presumed diagnosis of appendicitis. (The abstract, from the January issue of Pediatrics may be found here).

Overall, at least 8.4 percent of appendectomies -- one of the most common pediatric surgical procedures -- are performed on children who turn out to have a normal appendix, researchers at Children's Hospital in Boston found. That's largely because appendicitis can be difficult to diagnose, since the sharp abdominal pain and nausea of an intestinal virus, gynecological problems in girls, and other conditions produce similar symptoms, and no test for the disease is 100 percent accurate.

The risk of misdiagnosis is much lower -- 4.8 percent -- at hospitals that do many pediatric appendectomies, perhaps because doctors are more skilled at interpreting children's symptoms and more likely to confirm the diagnosis with a CT scan or ultrasound. But appendectomies are so common that the Children's Hospital researchers say it would be impractical to perform most appendectomies in a few major medical centers, a practice common with complex surgeries like coronary bypass operations.

Impractical indeed since the 4.8 percent negative appendectomy (NA) rate was only achieved in 13 hospitals of the 2521 that contributed their 1997 appendectomy statistics (accounting for 5.6 percent of procedures studied). These were done in hospitals that had >3 pediatric appendectomies per week. If your local hospital does 2-3 per week, your error rate jumps to 7.6 percent. Only 21 of the 2521 participating hospitals reach this level. These hospitals accounted for 5.7 percent of appendectomies. The great majority of the recorded appendectomies (75.7%) were performed in hospitals (1023 of 2125) doing anywhere from 4 to 8 a month with a NA rate of 8.9-7.9 percent. Most of the hospitals studied (1060 of 2125) performed less than one pediatric appendectomy per month, accounting for 12.9 percent of procedures and a NA rate of 8.8 percent.

Given its' age the data probably have less to do with practice today than first meets the eye because of one important thing: the increasing use of CT scanning as a tool in the exclusion of appendicitis over the past several years. Before the widespread use of CT, patients with equivocal evaluations for appendicitis were observed and underwent serial exams. If no improvement was noted after 12 hours or so, they were often taken to the operating room for appendectomy. With a negative CT a patient may be managed as an outpatient, or if admitted, the threshold for operation is higher.

While some may not agree with the increased use of imagery to evaluate for appendicitis, if the goal is to reduce the NA rate and the financial and medical complications thereof, why not?

But recent research has questioned that tolerance of error, showing that unnecessary appendectomies are both risky and expensive. A University of Washington study found that, among adults, unnecessary appendectomies typically resulted in a six-day hospital stay, while one patient in 40 develops serious complications and 1.5 percent of the patients die.

Dr. David R. Flum, an assistant professor of surgery at the University of Washington in Seattle who led the 2002 study, estimates that Americans paid $741.5 million for unnecessary appendectomies on adults in 1997, the year on which his study focused.

The basis for the above numbers is this paper published in the July 2002 Archives of Surgery. In the second paragraph the authors describe appendicitis as a "straightforward diagnosis by clinicians" and later in the conclusion as "a common diagnosis, it is by no means a simple one to establish." The paper then presents the increased LOS, hospital charges, case-fatality rate, and infectious complication rate of NA. The rates for NA were higher for women and those <5 and >60 years of age. The authors themselves point out that the higher costs and LOS may be due to further evaluation to determine the cause of the abdominal pain, and the case-fatality rate due to other causes (since it was higher in the very young and very old).

With lifetime risk of 12 percent for men and 25 percent for women, the building of a better mousetrap to diagnose appendicitis is always going to be a goal of surgery. My personal experience is that I have performed about 50 appendectomies over the past 2 years and CT has not been wrong yet. My error was taking the young 20'ish man with guarding and rebound on exam to the OR for an appendectomy despite a negative CT. A generous pathologist called it "early" appendicitis, but it looked normal to me.

Friday, January 09, 2004


LANE RANGER: Georgia deficient in trauma centers

Lurking under Georgia's radar screen is a public health care crisis that costs hundreds of people their lives each year.

"If Georgia did nothing but become average, we'd save more than 600 lives a year," said Dr. James Patrick O'Neal, state Emergency Medical Services medical director. "If we had a statewide trauma network, we'd save more lives than that."

Vast chunks of Georgia remain unserved by a trauma center, hospitals qualified, equipped and staffed to treat people severely injured in car crashes or other mishaps. Only 14 of the state's hospitals meet the criteria to be designated as trauma centers, and only four, including Atlanta's Grady Memorial Hospital, are designated as Level 1, qualified to give the most extensive level of care.

South of Macon, there is only one Level 1 center, Savannah's Memorial Health University Medical Center.

A large group of Georgia lawmakers heard a heartfelt plea from health care professionals and safety advocates at a Thursday breakfast gathering to do more to address the lack of quality trauma care.

"It is costing more and more to provide this service," said Dr. M. Gage Ochsner, the Savannah facililty's director of trauma services. "Most of our trauma centers have provided it as a community service, but when it starts driving them into the ground, they have to look at [eliminating] it."

O'Neal said two-thirds of Georgia's hospitals are operating in the red, making it more difficult to justify providing expensive trauma coverage.

Complicating the issue even further, said Ken Beverly, chairman of the board for the Georgia Hospital Association, is Georgia's lack of a Good Samaritan law shielding physicians from many of the liabilities involved in emergency room work.

"Doctors don't want to go into emergency rooms," he said.

Injury is the leading cause of death for all Georgians aged 1 to 45, and ranks fourth among Georgians of all ages. It costs us 4,500 lives a year, hundreds of which could be saved if they could be reached, taken to a trauma center and treated within the famous "golden hour."

Yet many Georgians are critically injured on roads hundreds of miles from a trauma center.

"If you are in some of these areas, you can expect to get the same care you got 40 years ago if you're in a motor vehicle crash," said Ochsner.

Lives that can be saved are only part of the story, said Dr. Arthur Kellermann, chairman of Emory University's Department of Emergency Medicine.

"Disabilities can be averted if we do the right things on the front end," he said.

Political leaders who addressed the gathering could do little more than express concern as the state battles a budgetary crisis. "We know there's a problem there, and we're looking for solutions," said House Speaker Terry Coleman (D-Eastman).

Senate President Pro Tempore Eric Johnson (R-Savannah) urged health care officials to "bring your legislators into your emergency rooms and show them how many physicians are needed."

"This is a basic quality-of-life issue," said Lt. Gov. Mark Taylor. "This is a life-and-death situation for our citizens."

Not only is south Georgia lacking in level one trauma centers, few hospitals south of Macon are level two centers. The state also lacks an infrastructure in the southern region to provide rapid transport to a trauma center.

Saturday, January 03, 2004


The basketball Dogs topple formerly undefeated and #3 Jackets in Athens today. A good start in 2004 for Georgia athetics, especially given the trouble the basketball team has been in the past year.
Ah the wintertime, when fourth-year medical students around the country travel form coast to coast interviewing for residency positions. Almost as fun as interviewing for a real job. I had lunch the other day with a medical student who wanted to go into surgery (poor soul) and asked me about the interview process and that got me thinking about my own interview experiences. Luckily for me the fourth-year requirements at my medical school were pretty lax (only six months of rotations were required) so I was able to take a good deal of time off to interview. I was pretty much on the road for December and January of my fourth year.
At that time surgery resident interviews were held on Saturdays. The reasons for this were twofold: Grand Rounds could be a part of the interview, and since there were no elective cases over the weekend the faculty could give full attention to the applicants. That may be different now with the eighty-hour workweek limits are making Saturday conferences passe'.

Some of the highlights of my interview trek:

University of Tennessee, Memphis
Very good program, and at the time,very large. One of the highlights was touring the Elvis Aaron Presley Trauma Center. We were proudly shown the room were Elvis died. Quite the tourist attraction during"Dead Elvis Week"

University of Louisville
This was an interesting interview for two reasons: One was the opportunity to meet the chairman, Dr. Hiram Polk. Dr. Polk had (has) the reputation of running a very tight program and firing residents on the spot if they displeased him. A part of the interview day was rounds with Dr. Polk and the residents, quite a show. The other was having the chance to read our Dean's letters and recommendations, as we carried our application files from session to session. During this trip I paid a very fun visit to the National Corvette Museum in Bowling Green, KY.

Georgetown University
My first interview. The mission of this program is to generate academic surgeons (a point not well made when I applied). The highlights were observing the Russian Embassy through my hotel window and touring the National Cathedral.

University of Arkansas
Hillary Clinton was in Little Rock during the time of my interview. The ED had a trauma room taped off for her in case something happened.

University of Texas Southwestern Medical Center
A large program, taking thirteen residents a year. Spent a few days in Dallas and toured the Sixth Floor Museum. Historical tour of the ED where Kennedy died.

Interviewing is a tiring and expensive process, and like many applicants, I canceled many interviews because I became tired and ran out of money.

The American College of Surgeons has an excellent resource for those applying for or considering a surgical residency here.

Friday, January 02, 2004


Despite a 24-0 lead in the second quarter of the Capital One Bowl Georgia almost lost it to Perdue and the World's Largest Drum. With a 11-3 record, a young team, and hopefully David Pollack returning, next year should be a good one for the Bulldogs.
ED NOTE: I actually began this post on 12/31 but I could not access Blogger for the most part yesterday. Unfortunately I am on call today and have been unable to get to my computer to get it posted until now. Enjoy!!!

This article from SF gate (originally printed in The Wall Street Journal). The story describes efforts to have the American Board of Medical Specialists to create a separate board of vascular surgery. To excerpt:

The overall mortality rate from abdominal aortic aneurysm surgeries averages about 5 percent. But when general surgeons perform the surgery, the mortality rate is 76 percent higher than when vascular surgeons do it, according to a recent University of Michigan/Johns Hopkins study of 3,912 cases. Other studies have reached similar findings.

I cannot argue with the statistics presented in the story demonstrating that fellowship-trained vascular surgeons have a lower mortality rate performing aortic aneurysm repair. (The abstract of the source material may be found here). I do question how much advantage a fellowship-trained low-volume surgeon would compare with a high-volume general surgeon. My partner (who is a fellowship-trained high-volume surgeon) subscribes to the Journal of Vascular Surgery and I will review the statistics and report back. As I have posted before on 12/2 and 11/28 one does better with a high volume surgeon and/or hospital with certain complex procedures.
But some feel that other steps are required:

Vascular specialists want the American Board of Medical Specialties, an influential professional group, to make vascular surgery a separate specialty, with its own certificate of expertise. Doctors say this would lead most hospitals to decide that only vascular surgeons should perform nonemergency vascular procedures, just as only neurosurgeons can do surgery on brain aneurysms, and only cardiac surgeons can operate on the heart.

However, I do not think that the creation of a separate vascular surgery board will help with the problem as presented.
First of all there is no national body which determines what procedures a surgeon may or may not perform. Each individual hospital sets their own standards for privileges. Some hospitals require fellowship training and/or certification, while others may not (the same may be said for managed care organizations). Smaller or rural hospitals may not initiate a requirement for board certification.
Secondly, any changes, after they were initiated, would take several years to show the effects desired. That is because the "grandfathering" that would occur. Even the most vocal proponents of the creation of a new board agree that would have to occur:

Many general surgeons, of course, are highly competent, and some have done extensive aneurysm repair operations, gaining significant expertise in the process. Dr. Veith and others say such surgeons should be eligible to qualify for a full vascular certificate if one is created

What Dr. Veith and others in the story do not point out is that a mechanism to insure a level of expertise is in place at the American Board of Surgery. The ABS offers a special certification in vascular surgery, which requires the completion of a fellowship. So the certification issue has already been addressed.
Is it economics? Not according to the story:

A change in policy, of course, would also be a business windfall to the vascular surgeons, but they insist the motivation is successful medical outcomes, not profit

In addition:

Speaking about the broader debate, David H. Nahrwold, president of the ABMS, declined to discuss the vascular surgeons' campaign. But he says that, generally speaking, one downside of limiting certain medical therapies to specialists is doctors' availability for patients.

Leading vascular surgeons argue that there are enough vascular specialists to do the necessary operations. Currently, there are about 2,100 vascular surgeons in the U.S. Moreover, they say, if vascular surgery becomes an independent specialty, it could lure more medical residents into the field.

The conditions mentioned in the recent New England Journal of Medicine (esophageal and pancreatic cancer) that were studied to measure volume-related outcome are not common and rarely present as emergencies. Aortic aneurysms are becoming more common along with other forms of peripheral vascular disease. By limiting the number of providers, access may be limited, especially for patients in rural areas, or even medium-to-small cities. Given the current difficulties in filling general surgical residency slots, I think the expectation that creation of an independent board will "lure" more residents into the specialty is optimistic at best.

The desire of vascular surgeons to have their own board is nothing new, as I have heard the arguments since I was a medical student. I think that two of the motivating factors behind the drive to have a "board of their own" are a desire for respect and a desire for control.

The respect factor comes from the fact that plastic surgery, thoracic surgery, and colo-rectal surgery all have their own boards represented at the ABMS. The vascular surgeons would like to be on a level playing field.

As far as control goes, vascular surgery is a specialty undergoing a great deal of change. The advent of endovascular techniques has opened the treatment of all types of vascular disease, aneurysms, carotid disease, and peripheral vascular disease. Many of these procedures are being done by cardiologists and radiologists and not by vascular surgeons. This is a source of great concern to vascular surgeons. (One of my attendings went to a meeting where a speaker began his talk on this issue with the statement that the specialty of vascular surgery would "cease to exist in ten years"). As non-invasive means for treating coronary artery disease have become more effective, cardiothoracic surgeons have increased the amount of non-cardiac vascular surgery they perform. Then there is the amount of vascular procedures done by general surgeons. The vascular surgeons are taking from all sides and wish to try to get some control of the wild ride they are on.

As this rant comes to a close, two more points:
One problem with centralization of procedures is that the treatment of the emergent patient may suffer. A surgeon does not learn how to handle aortic aneurysms by only operating on ruptured ones, they build experience with elective cases during daylight hours. A patient with a ruptured AAA is not likely to tolerate a trip to the vascular referral center. As I have posted before:

.....If the mortality rates are bad for low-volume surgeons doing elective cases, just you wait for the figures for no-volume surgeons doing emergency cases.....

Anyway, patients should inquire as to their surgeon's experience in performing procedures, especially complex ones. Primary care physicians should be roughly familiar with the experience of the surgeons they refer to, in case the patient is too intimidated to ask.


Thursday, January 01, 2004

Glad to see that Blogger is working again!!!
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