A Chance to Cut is a Chance to Cure

Somewhere, wherever unaired videotape goes to die, there's a rare artifact: a Sanjay Gupta goof.

As TV bloopers go, this one was tiny. But you had to smile, if only at the irony, when CNN's unflappable Gupta misspoke recently while taping an "AccentHealth" segment.

"No good for Sanjay," somebody yelled after Gupta, 34, who had just nimbly negotiated "interstitial cystitis," flubbed an easy, nonmedical word. "It's supposed to be 'unsuccessfully.' He said 'successfully.' "

War and the outside world seemed far away on a recent Monday, when Gupta and two Emory residents spent about eight hours doing complex spinal operations at Grady. Geeky, black Buddy Holly-esque magnifying eyeglasses covered the TV doc's famous face, and nurses hovered over hundreds of exotic-looking instruments. Yet it felt almost calm amid the beeping machines and occasional murmured "Irrigation, please."

"There's always a sense of urgency, but not chaos," Gupta says. "I always tell my residents, 'It's OK to have butterflies. Just make sure they're flying in formation.' "

Gupta became part of the story temporarily when the neurosurgeon-less Devil Docs asked him to perform brain surgery on a gravely injured Iraqi child. Ultimately, Gupta operated on five seriously wounded people, leading some journalism observers to wonder if he'd blurred the lines.

"How does Gupta the reporter and Gupta the doctor reconcile his competing roles and competing obligations?" the Poynter Institute's journalism ethics specialist Bob Steele wrote at the time. "Does the Hippocratic oath duty always trump the journalistic responsibility to gather information and report stories?"

The criticism took Gupta somewhat aback, because he always knew who he was.

"I had a very clear moral compass out there," Gupta says. "You never stop being a doctor, and you never stop being a human being."

His biggest fan might be Jesus Vidana, a 26-year-old Marine Reserve sergeant so seriously wounded by a sniper's bullet in Baghdad that medics initially declared him dead. Gupta operated on him, and Vidana, now back home in Los Angeles, keeps in touch with the man he credits with saving his life.

Surgeons in Washington County will begin turning away patients whose conditions are not life-threatening in hopes of forcing insurers to lower their malpractice premiums.

The work stoppage is scheduled to begin Nov. 15 with a majority of the county's general surgeons, who handle a variety of procedures from appendectomies to vascular repairs.

But dozens of surgeons and physicians in other specialties are expected to announce soon that they also will begin turning down non-emergency work in November, said Dr. Karl P. Riggle, a spokesman for the Washington County Surgical Association.

The move could be the most drastic yet taken by medical doctors in Maryland, most of whom face a 33 percent increase in their insurance premiums. Doctors claim the rising rates are caused by large malpractice award payouts and threaten to drive them out of business, but their call for tort reform has been opposed by trial lawyers.

a large group of northern panhandle surgical specialists stopped all their elective cases. Hospitals in the area, which were already struggling under inadequate reimbursement, began to suffer mounting losses in income. The hospital association’s involvement in the lobbying effort intensified dramatically.

Critical portions of the tort reform bill include a $250,000 cap on noneconomic damages and a $500,000 cap on all damages for treatment of emergency conditions for patients who receive care at a designated trauma center. Joint liability has been eliminated, and each individual defendant bears liability equal to his or her percentage of fault. Collateral payments, which had not been allowed in court before, may now be presented. The “ostensible agency theory” of liability was abolished. Additionally, a committee was established to develop a patient injury compensation fund to provide for economic damages that exceed financial limits set in the bill.

Requiring doctors and hospitals to report publicly on their performance and tying their pay to the results would dramatically reduce avoidable deaths and costs attributable to poor medical care, says a new report from an organization that works to improve health care quality.
Wild variations in medical care led to 79,000 avoidable deaths and $1.8 billion in additional medical costs last year, the private National Committee for Quality Assurance said in its annual report released Wednesday.

Using the data above as a baseline and comparing it to the 90th percentile care offered by the best health plans, we can calculate the expected avoidable mortality and morbidity for a number of the nation's most common, costly and deadly diseases if everyone received care through one of the top plans.

Under the lights of his operating room at New York Presbyterian Hospital, heart surgeon Dr. Craig Smith looks like a futurist, using high-tech robotic techniques on elderly patients once deemed too fragile for major surgery. Outside the OR, he's pure old school, with a deadpan wit and a schedule of 16-hour days. A college running back, he says he copes with stress by "keeping my emotions canned up and focusing on the job." To perform a "relatively routine" quadruple bypass on former president Bill Clinton last week, Smith postponed his 34th-wedding-anniversary vacation. He's just what Americans picture when they think of a surgeon: brilliant, stoic, workaholic and male.

In the near future, surgeons like Smith may be the exception, not the rule. Since 1999 surgery has attracted about 5 percent of medical graduates—down dramatically from the 12 percent it pulled in the '80s and '90s, when the best and brightest students saw it as both intellectually enriching and, well, enriching. Surgical insurance premiums began to climb in the late '90s, making the field look a lot less lucrative. In some areas of the country, premiums have doubled or more since 2000, with surgeons paying well over $100,000 annually just to stay in business. Meanwhile, in an effort to boost enrollment and create a generation of doctors (particularly surgeons) who were more than technically proficient geeks, medical schools started recruiting a new kind of student—someone more laid back, with interests outside work. And they've succeeded: lifestyle-friendly specialties like radiology, orthopedics and dermatology are thriving. Anand Rughani, a third-year student at McGill, was toying with surgery but will probably choose neurology instead. Surgery "is so demanding," he says. "It can change your values. With lawsuits, you treat things fairly aggressively for fear of not doing something. Maybe surgery isn't the best thing for the patient, but that's what you end up having to do."

Medical schools are struggling mightily to bring students back to the OR with promises of a kinder, gentler professional future. New rules established last year dictate that medical residents can work a maximum of 80 hours a week—far fewer than the 120 hours traditionally demanded by surgery residencies—and courses in bedside manner are now mandatory in many curricula. The old guard isn't necessarily happy. "It's difficult to explain to my generation, who worked 120 hours a week, how people with two thirds as much training are going to get the same experience," Smith says. Duke University's surgery program was put on probation in June, partially for a citation related to lax enforcement of the 80-hour workweek.

As the boomers age, demand is likely to increase—just as today's young surgeons, accustomed to lighter schedules, start taking senior positions. Smith, at 55, toils as many hours as residents do. "If you like the work, it's tolerable," he says. But if you want your anniversary off, maybe you should go into neurology.

"They've got some good players. They've got to score more than 13 points to win a national championship."

My advice to the wealthy and paranoid; Change over to magnetic resonance whole-body scanning. It may be more harmful to your wallet but it has no proven cancer risk and is just as useless as a screening exam. Have fun!

In recent years, there has been considerable interest in direct patient referral for imaging studies to screen the whole body for disease detection. In general, the majority of the facilities that have been performing whole-body screening have done it with new, fast, multidetector computed tomography (CT) systems. Speed of data acquisition, in the order of a few minutes for the entire body, has made it a compelling method of investigation. There are some limitations and concerns with CT, described briefly below, but the major focus of this Clinical Update is whole-body screening with magnetic resonance imaging (MRI). Within the last few months, this has become a feasible approach, the most important advances being a dramatic increase in data acquisition speed concurrent with maintenance of high image quality.

Optimal investigation for many diseases requires using dynamic administration of gadolinium chelate (a type of intravenously administered contrast agent that is in routine use in MRI), and because MRI can image only about 40 cm in vertical length of a person in 1 data acquisition (essentially 1 of 4 major regions: head and neck, chest, abdomen, or pelvis), this would involve too many separate injections of contrast (eg, separate injections for the liver, heart, and breast [in women])......
Presently a confounding variable exists with protocols for whole-body screening. It is widely recognized that several organ systems are currently imaged by MRI with an extremely high level of diagnostic accuracy and reproducible image quality (eg, liver, pancreas, kidneys, brain, spine, musculoskeletal system, gynecologic organs, and major blood vessels) that exceeds the abilities of CT.[4-11] However, despite recent technical advances, described at the beginning of this Clinical Update, the diagnostic accuracy is not high for prostate, coronary vessels, colon, or breast, secondary to such factors as decreased sensitivity, decreased specificity, or inconsistent display of small and/or moving structures.

1.Ionizing radiation is bad if you don't need it. No such problem with MRI
2. Non-contrasted CT is fast and avoids potential reaction problems, but they are lousy as screening studies, not such a problem with MRI.
3. The use of contrast improves sensitivity, but problems abound. Gadolinium is fairly safe.
4. The rate of injection is slower with MRI which causes less side effects

The Los Angeles County Board of Supervisors on Monday unexpectedly moved to shut down the trauma unit at Martin Luther King Jr./Drew Medical Center, immediately drawing the ire of physicians, politicians and community activists.

The only public hospital serving a large swath of South Los Angeles, King/Drew treats more trauma patients than any other hospital in the region except County-USC Medical Center.

The proposed trauma closure, expected to take effect in about 90 days, amounts to a last-ditch scramble to save a foundering hospital that repeatedly has been cited by regulators for harming patients and in some cases contributing to their deaths.

County officials said they would make every effort to persuade other hospitals to open trauma centers. But health experts said the loss of King/Drew could further jeopardize a beleaguered system that has lost about 10 trauma units in the last two decades. The county now has 13, including King/Drew.

Just two of the county's trauma centers are within 11 miles of King/Drew: Harbor-UCLA and St. Francis medical centers.

King/Drew serves one of the most violent areas of the county, with the highest rate of homicides.

"Closing down a [trauma unit] within a couple miles of the most violent parts of the city? South Los Angeles? Compton? Lynwood?" asked Sal La Barbera, homicide supervisor in the Los Angeles Police Department's Southeast Division station, which covers Watts. "This will definitely have an impact on how many lives are saved…. Harbor [UCLA] is an extra 10 or 15 minutes."

King Hospital and its affiliated medical school, the Charles R. Drew University of Medicine and Science, have been rocked by accusations of needless deaths, racial tension, poorly trained medical students and incompetent nurses and tens of millions of dollars in malpractice settlements.

King/Drew consistently ranks at the bottom of American teaching hospitals. A report in January by federal health officials said that at least five of the hospital's patients died needlessly last year, and the county authorities are investigating accusations that hospital officials ordered nurses to lie about the abysmal state of things.

''The hospital is run like a tribal fiefdom, and it's appalling,'' said Connie Rice, a civil rights lawyer here who is African-American. ''You can't ask questions because it's a black institution. If you ask questions, they scream racism. But it's not a question of race, it's a question of competence.''....
According to the January federal audit, three people died last year in ward 4B, where the nurses did not know how the heart monitoring machines worked.

A man who was suffering from gangrene of the intestines was brought to the emergency room last March and was found 18 hours later lying in his vomit, having received no medical care. He later died. Another man suffering from gangrene was neglected for the better part of a day and died, the audit said......

A national accreditation board last year rescinded the private medical school's authority to train surgeons and radiologists. The county has temporarily severed the hospital's relationship with the medical school, because of the quality of education.

A woman with respiratory failure and ovarian cancer received the wrong dosage of an antibiotic on Feb. 28; did not receive an ordered dose of a blood thinner on March 1; and was given only three of 12 ordered doses of respiratory drugs from Feb. 28 to March 2.

A stroke patient had to wait nearly five hours for a drug to help prevent heart attacks and recurrent stroke. At one point, pharmacists wouldn't fill the order because a doctor had spelled the drug's name wrong. Later an inspector watched as two pharmacists within half an hour picked up the pill bag and looked at it but did not approve its use.

In the case of a tuberculosis patient, an inspector found a missing dose of intravenous antibiotics on a pharmacy counter more than two hours after it had been ordered, with a sticker that read "missing dose." The inspector noted errors in three of six medications given to the patient.

A paraplegic with a pressure sore and bone infection was not given a laxative suppository that had been ordered and reordered by a physician over at least five days.

The hospital's supporters are not sitting still. A rally co-sponsored by the Congress of Racial Equality in late January showed just how deep the racial tensions are. Representative Maxine Waters, Democrat of California, warned county officials that if the neonatal unit was closed, ''we will be on top of your desk.''

In a telephone interview, Ms. Waters elaborated. ''What we're saying is we're going to watch you,'' she said. ''The county only reacts when the spotlight is on them. They're not going to close that hospital. They can't close that hospital. They need to supervise it, and shuffling a few people around isn't going to do it.''

Dr. Ernest Smith, an instructor in the Drew University department of internal medicine who is African-American, is outspoken in his criticism of the county health department, which he sees as unfairly laying blame at the feet of the black administration.

''When things go wrong, why do they point the fingers at administrators and not the master down there at 313 North Figueroa Street,'' Dr. Smith said, referring to white officials at the county health department. ''Maybe the place would operate better if we received our fair share of money.''

Health department officials say, however, that King/Drew receives more money per patient from the county than any other hospital in the system. ''The quality of the administrators isn't there that a hospital needs,'' said John Wallace, spokesman for the county health department. ''It's been allowed to go on for years.''

Yvonne Brathwaite Burke, a black county supervisor whose district includes the hospital, admits there are some problems at King/Drew. But she said the problems had been blown out of proportion. ''It's not a matter that you go there and you die,'' she said, ''it's that the press picks up on every little mistake.''

The closure of the trauma unit, officials said, does not stem from failings in the unit, which has long been a source of great pride and prestige to the community. At one point, the U.S. military trained surgeons in the unit because it so closely simulated wartime medicine

Rather, the proposed closure is intended to relieve pressure on the rest of the hospital. Running a trauma unit is costly because the patients are so sick, many are uninsured and the hospital is required to have a host of specialist doctors on standby 24 hours a day to respond immediately when an emergency arises.

Teresa Heinz Kerry says "only an idiot" would fail to support her husband's health care plan.

But Heinz Kerry, the wife of Democratic presidential candidate John Kerry, told the (Lancaster) Intelligencer Journal that "of course, there are idiots.".....

If Kerry is elected, Heinz Kerry predicts that opponents of his health care plan will be voted out of office. She says, "Only an idiot wouldn't like this."

"When the time comes for your colectomy...make sure your surgeon uses the Ajax Mark II linear stapler...The Mark II has the lowest rate of fecal leak of any stapler on the market"

In the last twenty years there has been a steady growth in the share of surgery carried out by daysurgery in many countries, thanks mainly to technological and medical innovations, such as less invasive surgery and better anaesthetics. Day-surgery is beneficial because it reduces the unit cost of treatment, which is driven by the length of stay. For a given endowment of beds, the availability of less invasive surgery can increase the volume of treatments performed and free up hospital beds. However, if the increase in day-surgery utilisation is accompanied by a contemporaneous reduction in the number of hospitals beds (as in most OECD countries), then the net impact on activity may be lessened. Moreover, less invasive and safer treatments raise the net benefits for the patient, making the procedures more desirable. That is likely to lead an increase in demand, especially for groups such as the very elderly, for whom there would otherwise be counter-indications for invasive surgery. The final effect on waiting times is then indeterminate.

Waiting lists are a common tool for managing access to elective surgery. However, little evidence is available on the health impact of delaying surgery for various conditions. Other than mortality, adverse events experienced by patients while on a waiting list have not been systematically examined. Without these data, appropriate access time for surgery must be determined on the basis of expert opinion.
When treatment is delayed, the condition of a patient on a surgical waiting list may deteriorate and require urgent medical attention. In this case, emergency admission for the awaited procedure may be regarded as an adverse effect of waiting. Also, routine operating room activity may be seriously disrupted by unexpected nonelective admissions of patients on waiting lists.

In patients with biliary colic caused by cholelithiasis, extended treatment delays may increase the probability that the patient will be admitted for delayed cholecystectomy as an emergency case. Emergency admission may be associated with more frequent or more severe attacks of biliary colic or other biliary complications such as acute cholecystitis, obstructive jaundice, cholangitis or pancreatitis. However, little is known about the relationship between time spent on a waiting list and the risk of emergency admission in these patients....

The median length of stay on the list was 6 weeks. However, there was considerable variation in individual waiting times. The probability of undergoing elective surgery increased rapidly from 25% within 3 weeks of the last clinic visit to 50% at 6 weeks and 75% at 10 weeks, and then gradually reached a plateau. Although 90% of patients underwent surgery by 17 weeks, the remaining 10% waited another 1 to 3 weeks (total 18–52 weeks) for their operation.....

the weekly emergency admission rate increased from 0.8 to 5.7 per 100 patients from the first 4 weeks to the interval of 40-52 weeks. When adjusted for sex, age, enrolment period and surgeon volume, the emergency admission rate was more than 1.5 times higher after 20 weeks, 2 times higher after 28 weeks and 7 times higher after 40 weeks relative to the first 4 weeks of waiting-list time.

Surgeons with a low volume of cholecystectomies (less than 20 per year) operated on the majority of patients with extended delays. In general, low-volume surgeons had a primary interest in surgical oncology. This may explain the order in which their patients accessed cholecystectomy during the waiting period.

When the talk turns to waiting lists -- as it does often in political circles these days -- there is an assumption that waits for surgery are caused by inadequate resources.

If we only had more surgeons, more operating rooms and more money, the thinking goes, we could clear up this pesky problem.

If only it were so simple....

A team of researchers from the University of Alberta and the University of Calgary showed that almost half of carotid endarterectomies (an operation to clear blocked arteries in the neck) are of questionable value, and that 10 per cent of these surgeries are entirely inappropriate and probably dangerous to patients.

A second study, conducted by Health Canada, found that the mastectomy rate varies dramatically from one province to the next, which likely means that hundreds, maybe even thousands, of women are having their breasts removed unnecessarily.

These are but two examples, but there are many more. The vast majority of tonsillectomies were dubious; lower back surgery, once the rage, provided little pain relief in the long term; medically unjustified hysterectomies, gall bladder removals, cesarean sections and cataract operations are legion. More recently, some solid studies have shown that surgery for arthritic knees is of no value, and that "active surveillance" of some cancerous tumours is more effective than surgically removing them.

Background We determined the effect of breast irradiation plus tamoxifen on disease-free survival and local relapse in women 50 years of age or older who had T1 or T2 node-negative breast cancer.

Methods Between December 1992 and June 2000, 769 women with early breast cancer (tumor diameter, 5 cm or less) were randomly assigned to receive breast irradiation plus tamoxifen (386 women) or tamoxifen alone (383 women). The median follow-up was 5.6 years.

Results The rate of local relapse at five years was 7.7 percent in the tamoxifen group and 0.6 percent in the group given tamoxifen plus irradiation (hazard ratio, 8.3; 95 percent confidence interval, 3.3 to 21.2; P<0.001), p="0.004)." p="0.049),"

Background In women 70 years of age or older who have early breast cancer, it is unclear whether lumpectomy plus tamoxifen is as effective as lumpectomy followed by tamoxifen plus radiation therapy.

Methods Between July 1994 and February 1999, we randomly assigned 636 women who were 70 years of age or older and who had clinical stage I (T1N0M0 according to the tumor–node–metastasis classification), estrogen-receptor–positive breast carcinoma treated by lumpectomy to receive tamoxifen plus radiation therapy (317 women) or tamoxifen alone (319 women). Primary end points were the time to local or regional recurrence, the frequency of mastectomy for recurrence, breast-cancer–specific survival, the time to distant metastasis, and overall survival.

Results The only significant difference between the two groups was in the rate of local or regional recurrence at five years (1 percent in the group given tamoxifen plus irradiation and 4 percent in the group given tamoxifen alone, P<0.001). p="0.94)."

Again, radiation rules the day with a three percent reduction (96% to 99%) of local recurrence after Tamoxifen+XRT. While the XRT group had more adverse effects such as retraction or hyperpigmentation when compared to the Tamoxifen only group, most of those resolved within 1 year and all within four years. Both studies had about 700 patients. One problem I had with the second study was this statement:

All women underwent lumpectomy (i.e., partial mastectomy or a wide local excision) with a clear margin, defined by the absence of tumor on the inked pathological margins. Axillary-node dissection was allowed but was discouraged

So some of these women may have been understaged. Now for some tidbits from the editorial:Breast Radiotherapy after Lumpectomy - No Longer Always Necessary:

Does this absolute difference in the rate of local recurrence of 3 percent matter clinically, when weighed against the cost of the use of additional resources and treatment-related adverse effects? An overview of 40 trials in this field has confirmed that local radiotherapy is associated with an increase in deaths from cardiac and other causes, which nullifies a long-term reduction in deaths from breast cancer Modern radiotherapy techniques, including three-dimensional treatment planning and intensity-modulated radiotherapy, with cardiac shielding, can minimize the risk of cardiac irradiation in most patients Some side effects persist, and the CALGB investigators reported an increased incidence of breast pain, fibrosis, breast edema, and poor cosmetic results in the group that received radiotherapy. In addition, breast radiotherapy is resource-intensive and time-consuming for the patient and may decrease the quality of life There is, of course, the counterargument that not having radiotherapy may increase a woman's anxiety about the possibility of recurrence and could require more frequent follow-up. On balance, nevertheless, there are clear advantages in identifying subgroups in a large population of elderly women who do not require radiotherapy after lumpectomy and tamoxifen......

Against this background, what course should we recommend to older women with small, hormone-receptor–positive breast tumors who have undergone lumpectomy? The Canadian trial indicates that women under the age of 70 years should still receive radiotherapy in addition to tamoxifen. This is frustrating advice, because although it is clear that the majority of women treated with lumpectomy and tamoxifen alone would not have a relapse, we still cannot confidently predict which women will be in the majority. We are entering an era in which the use of molecular markers, gene-expression profiles, and other molecular prognostic indicators is being investigated as a means of individualizing adjuvant medical therapies,15 and there is no reason why the same approach should not be applied to radiotherapy. Future trials of radiotherapy should be required to include tissue biopsy for prospective molecular analyses and informed consent for this type of research.

As our understanding of breast cancer has evolved, so has our ability to treat it in the most effective, minimally invasive way possible. We have gone from the morbid Halstead radical mastectomy to local resections and perioperative radiation. Clear margins are becoming recognized as a more important risk factor than absolute tumor size. We are witnessing the evolution of the axillary dissection from a requirement to an operation of historical interest.

So the take-home is: for a small, selected group of patients (older than 70, small tumors, receptor positive) then benefit of radiation may not outweigh the morbidity, given the less aggressive course of breast cancer in the older population. This may prove to be a hard sell, given the fact that 899 of the 1572 patients eligible to enroll in the first trial declined.

Cross-posted at Galen's Log

link posted by Bard-Parker : 8:50 AM

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