Tuesday, December 30, 2014

Facebook and unprofessional behavior among surgical residents

Have you ever wondered about the behavior of surgical residents on Facebook? I have. A study from the Journal of Surgical Education posted online in June 2014 looked at the issue.

The paper, "An Assessment of Unprofessional Behavior among Surgical Residents on Facebook: A Warning of the Dangers of Social Media," identified 996 surgical residents from 57 surgical residency programs in the Midwest and found that 319 (32%) had Facebook profiles.

Most (73.7%) displayed no unprofessional content, but 45 (14.1%) exhibited possibly unprofessional material. Clearly unprofessional behaviors were noted in 39 (12.2%) resident profiles. The paper said, "binge drinking, sexually suggestive photos, and Health Insurance Portability and Accountability Act (HIPAA) violations were the most commonly found variables."

There were no differences in the rates of unprofessional behavior between male and female residents or by postgraduate year.

I have blogged previously about the ill-defined nature of professionalism, and the papers' authors acknowledged that it can be subjective. Some of the behaviors they felt were potentially unprofessional such as photos of residents holding an alcoholic drink, holding a gun while hunting, or making political or religious comments are debatable.

They referenced another paper that found similar rates of unprofessional behavior (16%) on Facebook among applicants to an orthopedic surgery residency program.

A 2005 New England Journal of Medicine case-control study found that practicing physicians disciplined by state medical boards were significantly more likely to have had documentation of unprofessional behavior in medical school as well as lower Medical College Admission Test scores and poorer grades in the first two years of medical school.

Unprofessional behaviors listed in the New England Journal paper were irresponsibility, diminished capacity for self-improvement, immaturity, poor initiative, impaired relationships with students, residents, nurses, or faculty, impaired relationships with patients and families, and unprofessional behavior associated with anxiety, insecurity, or nervousness.

Some of those \ seem a bit vague. Are diminished capacity for self-improvement and poor initiative really unprofessional behaviors?

Facebook unprofessional behavior and the unprofessional behavior documented in the NEJM paper which pre-dated the widespread use of Facebook may not be comparable.

But I suppose one could say that some of the Facebook behaviors could be categorized as immature or irresponsible.

Until stories about residents being rejected for jobs after training start emerging, there probably won't be a change in the way they use Facebook or other social media.

Or maybe society will change.

In 1987, politician Gary Hart had to withdraw as a candidate for the Democratic Party's presidential nomination because he had an extramarital affair, and just a few years later, the president himself had a dalliance with an intern in the White House and survived.

Who thought marijuana use would ever be legalized?

Saturday, December 20, 2014

My top seven posts of 2014

I'm now in my fifth year of blogging. Thanks to everyone who has taken the time to read what I have written—especially those who have commented. I've learned a lot from you.

My seven most read posts of 2014 are listed below. Click on the title to read the post.

"That electric hand dryer study was bogus" was an analysis of a study that made outrageous claims about electric hand dryers and dispersal of bacteria.

"What are the residency prospects for graduates of offshore medical schools?" took a look at the realities associated with graduating from medical schools outside the 50 states and Puerto Rico.

"Preventing infection: The "bare below the elbows" rule for doctors doesn't go far enough" discussed the role of clothing in the transmission of disease and the ultimate solution to the problem.

"A medical student says to abandon the match" was my take on a proposal to do away with the residency matching program in the US. Spoiler alert: I didn't think it was a good idea.

"How to select surgical residents: The evidence" was a review of the limited evidence concerning how surgical program directors select candidates to interview and rank.

"A paper of mine was published. Did anyone read it?" spoke to the proliferation of medical journals, the likelihood that a single paper will be read, and what the future may hold.

"Health Care and the $20,000 Bruise: A different take" raised a lot of questions about a Wall Street Journal article written by a doctor who took his son to an emergency room for an 11-day-old bruise on his head.

And the all-time winner so far is this post, "Appendicitis: Diagnosis, CT Scans and Reality," which was the tenth post I ever wrote and is approaching 22,000 page views.

Best wishes to all.

Wednesday, December 17, 2014

More germs: Planes, desks, and even kisses

Airplanes are so permeated with bacteria that it is truly a wonder that anyone survives a flight. I'll bet you thought it was the air in the cabin, but a recent story in USA Today says otherwise. "The real problems lie on the chair upholstery, the tray table, the armrests and the toilet handle."

What should germophobic passengers do? "First, they should travel with and use an alcohol-based hand sanitizer. They should also travel with a small pack of disinfectant wipes," said the microbiologist who did the study. "The first thing I do when I sit down is to wipe down the armrest and tray table because that's where my arms will be. You need to decontaminate where you'll be spending your time and eating."

From MailOnline: "Millions of us spend our days slaving over a keyboard. But lurking between the keys, hidden on the mouse and nestled in your phone lies [sic] more than 10 million bacteria—400 times more than on the average toilet seat." [Despite what I reported in my last post, the toilet seat will remain the gold standard for comparing contamination levels until it is unseated.]

At least that is way fewer bacteria than the next study found.

"Every Kiss Begins With 80 Million Germs" headlines WebMD about a paper published in the journal Microbiome. WebMD story says, "In one experiment, the researchers gave 21 couples a probiotic drink containing bacteria before they kissed. Swab samples afterwards showed the transfer of those 80 million germs."

From the methods section of the paper: "One of the partners was invited to consume 50 ml of a probiotic yogurt drink containing L. rhamnosus GG, L. acidophilus LA5, and B. lactis BB12 [all non-pathogens]. After 10 seconds, saliva and tongue swabs were collected from this partner (donator) and after a second intimate ["full tongue contact and saliva exchange"] kiss of 10 seconds, saliva and tongue swabs were directly collected from the other partner (receiver)."

Saliva has some antibacterial properties. Maybe the researchers didn't wait long enough to test for bacteria after one of the partners drank the yogurt? People who have 80 million pathogenic bacteria in their mouths probably have bad breath and poor oral hygiene. I doubt they are indulging in 10 second tongue kissing.

And here's an excerpt from the conclusion. "This study indicates that a shared salivary microbiota requires a frequent and recent bacterial exchange and is most pronounced in couples with relatively high intimate kiss frequencies of at least nine intimate kisses per day [my emphasis] or in couples sampled no longer than 1.5 hours after the latest kiss."

Ten second kisses? Nine intimate kisses per day? Other than perhaps high school kids, who is kissing 9 times a day for 10 seconds at a time?

Bottom line? After eating yogurt, wait at least 90 minutes before tongue kissing someone.

Friday, December 12, 2014

Germs found on credit cards, but there's hope for civilization

Regular readers of my blog know that I am a connoisseur of studies about bacteria in the environment and on human tissue. If you click on the "Infection" label to your lower right, you can read my previous posts on the subject. Not surprisingly, I am skeptical of inflammatory headlines claiming that germs on various surfaces are dangerous.

Money has been the subject of many studies, most of them showing it is covered with bacteria. A recent video from the Cleveland Clinic discussed a study from England which found bacteria on the hands of 11% of people tested, on 8% of the credit cards tested, and either 14% or 6% of paper money [the accompanying story was contradictory].

This is old news. A 2012 study from the European Cleaning Journal [not a peer-reviewed journal] found that 26% of paper money, and 47% of credit cards showed "high levels of bacteria including E.coli and Staphylococcus aureus," and "around 80% of banknotes and 78% of credit cards tested showed traces of bacteria, and some carried more germs than [wait for it…] the average toilet seat."

For those of you new to the field of culturing everything in sight, the toilet seat has been the gold standard for comparison of contamination as I noted in a 2013 post.

Tuesday, December 9, 2014

Should radiologists tell patients their test results?

Radiologists discussing test results with patients, a subject that has been lurking under the radar for a while, recently came to light because of an article in the New York Times. The idea is that patient anxiety while waiting to find out a test result could be alleviated by an immediate discussion with a radiologist.

That would be very nice, but there are potential problems, some of which are detailed in a post that appeared on the website of The Advisory Board and others in an editorial by radiologist Saurabh Jha accompanying a paper on the subject..

In the Times, Dr. Christopher Beaulieu, chief of musculoskeletal imaging at Stanford, said, “[T]he radiologist may be capable of transmitting the information but the obvious next question for the patient is, ‘What do I do now?’ which, as nontreating physicians, radiologists are not trained to answer.”

Thursday, December 4, 2014

Antibiotics vs. surgery for appendicitis: It's time for a randomized trial

Maybe you've heard that there is a growing debate about whether antibiotics are as good or better than surgery for treating appendicitis.

So far there have been several studies from Europe showing that antibiotics may be safely used to treat appendicitis in many cases. However, the studies have involved small numbers of patients and have exhibited some flaws in their methods. A few studies from the US have been published, but they were not randomized or prospective.

I have blogged about some of these studies on three occasions. If you would like to read these posts, click on their titles.

Antibiotics instead of surgery for appendicitis? I'm still not convinced

Antibiotics instead of surgery for appendicitis? No way

Antibiotics instead of surgery for appendicitis? I don’t think so.

A group of surgeons in Washington State are putting together what will be the first randomized prospective trial of antibiotics vs. surgery for appendicitis in the United States. In order to obtain a grant from the Patient-Centered Outcomes Research Institute to help fund the project, the investigators must demonstrate that people in this country would be willing to participate in such a study.

To help determine the level of interest, they have written a brief explanation of why this study is being proposed. It parallels my thinking on the subject.

At the end of their post is a link to survey involving one question:

If you had appendicitis, would you be willing to join a study that would randomize you (a 50% chance, or flip of a coin) to “surgery ” or “antibiotics?”

You don't have to read the Washington researchers' post to take the survey.

You may click here to answer that question. Thanks.

Tuesday, December 2, 2014

Patients can chew gum immediately before surgery. I guess

A study presented at the American Society of Anesthesiologists (ASA) meeting in October of this year found that patients who chew gum in the immediate preoperative period may safely undergo surgery.

The authors, based at the University of Pennsylvania, found that gum chewing increases saliva production and the volume of fluid in the stomach, but stomach acidity was equivalent to that of non-gum chewers. An article about the study said The mean gastric volume, or total amount of liquid in the stomach, was statistically higher in patients who chewed gum before their procedure (13ml) versus those who did not (6ml). A 7 mL difference might be statistically significant, but surely is not clinically important.

The research differed from previous studies because it involved patients who underwent upper gastrointestinal endoscopy, which enabled the investigators to recover all of the fluid in the stomach for testing. Prior studies had been done using nasogastric tubes, and it was impossible to determine whether all gastric fluid was recovered when the tubes were suctioned.

The study involved 34 gum chewers who were allowed to chew any type or any amount of gum compared to 33 patients who did not chew gum.

Friday, November 28, 2014

Work hours limits in Sweden: It's complicated

A physician in training from Sweden emailed me some questions, and the topic of work hours came up. To protect his identity, I have slightly altered a some of his responses, but I have not altered his message.

It´s quite interesting as physician work hours, or rather productivity, are debated a lot in Sweden right now.

The work hour restriction
[50 hours/week in Sweden] is not enforced at all. This summer I was working as a junior house officer in a surgical specialty at a county hospital, and I can´t say I noticed anyone trying to cap my work hours, on my first day I was encouraged to work as much as I could.

On the other hand I was not put on the on call schedule, as that involved covering the ED (outside of academia EM-physicians are scarce) and all surgical services. It is hard to get to work 50 hours a week covering only a 12-bed service, when the nurses do all the blood tests (except blood gases), urinary catheters, do all patient transporting, and such. I did get some OR time though.

I think there is no enforcement of the 50 hours/week restriction because doctors here don´t get paid as fee-for-service. There is zero difference if you do 5 or 10 cases during your shift. There is no incentive to work more than 50 hours/week, and doctors don´t.

A problem that is more particular for surgery is the limited capacity of operating theaters, in many hospitals productivity is low, case turnover time is long, and you can only do elective cases between 8:30-16:00 (and God forbid you operate past 16:00). In the hospital I worked, we were not allowed to start elective cases after 14:30, and we only had 2.5 days/week when we could operate.

If you want to make money, you take a leave, go to Norway, work 80-100 hours/week in some rural hospital there for a few months, and earn three times as much.
[I was also told about this by some Swedish surgical residents I met while attending a conference there last year.]

We do a lot of administration. A study published in a Swedish medical journal, in Swedish sadly, found that Swedish surgical residents spend 40% of their time on administration and 40% of their time taking care of patients. Their British counterparts did 15% admin and 66% patient care. An average work day was 8.2 hours in Sweden and 12.2 hours in England.

Because of this, few physician hours are "productive" and Swedish doctors see very few patients compared to most Organization for Economic Co-operation and Development (OECD) countries. Queues build up and the hospitals don´t want that. So I guess they want us to work.

There was however a government crackdown on a rural hospital in northern Sweden where the county (which is the governmental body running hospitals in Sweden) was fined for imposing too long work hours. So there may be change, but rural northern hospitals are not in an ideal position to recruit more doctors.

Right now work hours are restricted formally but in practice it is hard to get that amount of meaningful work done. It has some perks however, as residents can pick up their children from day care.
[Emphasis added]

Is this where we are heading in the United States?

Sunday, November 23, 2014

That electric hand dryer study was bogus: Here's why

Just about everyone I follow on Twitter commented and/or linked to an article about a study claiming that electric hand dryers spew bacteria all over people using restrooms.

The paper, which appeared online in The Journal of Hospital Infection, said that airborne germ counts near jet air dryers were 27 times higher than counts near paper towel dispensers, and counts near warm air dryers were 4.5 times higher. The authors also coated subjects hands with black paint and measured spatter patterns on surrounding walls and persons dressed in disposable coveralls. And a photo from the study shows the dispersal pattern from a warm air dryer.

So case closed—paper towels are better, right?

I'm not so sure. Instead of reading an article about the paper or just the abstract, I obtained a copy of the whole paper. I also found some comments about it from a spokesperson for a hand dryer manufacturer.

What are the flaws in the study?

Monday, November 17, 2014

Should resident promotion decisions be based on a written exam?

A few days ago, some surgeons on Twitter discussed the role of the American Board of Surgery In-Training Examination, a test which is given every year in January.

The test was designed to assess residents' knowledge and give them an idea of where their studying should be focused. However, many general surgery program directors (PDs) use the test results in other ways. Some impose remediation programs on residents with low scores and even base resident promotion or retention on them. Some even demand that all residents in their programs maintain scores above the 50th percentile.

The Residency Review Committee (RRC) for Surgery frowns upon these practices and states in its program requirements (Section V.A.2.e) that residents' knowledge should be monitored "by use of a formal exam such as the American Board of Surgery In Training Examination (ABSITE) or other cognitive exams. Test results should not be the sole criterion of resident knowledge, and should not be used as the sole criterion for promotion to a subsequent PG [postgraduate year] level."

The problem for program directors is that the RRC also mandates (Section V.C.2.c) that "as one measure of evaluating program effectiveness" 65% of a residency program's graduates must pass both the American Board of Surgery's Qualifying Examination (written) and Certifying Examination (oral) on their first attempts. I have said before that the "65% on the first attempt rule" does not seem evidence-based.

Wednesday, November 12, 2014

Can cholecystectomies safely be done at night?

A new study from surgeons at UCLA found that laparoscopic cholecystectomies done at night for acute cholecystitis have a significantly higher rate of conversion to open than those done during daylight hours.

Nighttime cholecystectomies were converted 11% of the time vs. only 6% for daytime operations, p = 0.008, but there was no difference in the rates of complications or hospital lengths of stay.

The study, published online in the American Journal of Surgery, was a retrospective review of 1140 acute cholecystitis patients, 223 of whom underwent surgery at night.

The authors advocate delaying surgery until it can be done in the daytime, but this conclusion needs to be examined.

Although the percentage of gangrenous gallbladders was similar in both groups, it wasn't clear from the data how many patients were semi-elective and how many were true emergencies.

Operative procedure durations were 110.5 minutes for nighttime and 92.4 minutes for daytime cases, and 1.5 and 2.0 days elapsed respectively before the patients were taken to the operating room, both p < 0.0001. The hospital lengths of stay were similar at 3.7 days for the night group and 3.8 days for the day patients. The causes for these lengthy operations, delays in operating, and long hospital stays were not explained in the manuscript.

Wednesday, November 5, 2014

Proctoring, supervising, and coaching

Any surgeon who acts as a proctor for another surgeon or supervises residents or mid-level providers should be aware of the potential legal pitfalls.

An informative discussion of proctoring and supervision called "Is There a Proctor in the House?" appeared in 2012 on a website called Law Journal Newsletters.

Proctoring has always been an issue. For many years, surgeons have been assigned to proctor newly appointed staff in order to confirm that they were properly trained. Proctoring has been extended to those learning new techniques in minimally invasive and robotic surgery.

The usual scenario is that a proctor is assigned by a hospital's department chair or credentials committee with the expectation that the proctor will observe and report on the new individual's skills.

According to the article, "a surgical proctor who acts only as an observer should not have any medical malpractice liability if a procedure is performed below the standard of care." This holds true as long as the proctor has no physician-patient relationship and does not participate in any medical decision-making or scrub in on the procedure.

Thursday, October 30, 2014

How to rank surgical residency programs

In September, Doximity, a closed online community of over 300,000 physicians, released its ratings of residency programs in nearly every specialty. Many, including me, took issue with the methodology. Emergency medicine societies met with Doximity's co-founder over the issue and echoed some of the comments I had made about the lack of objectivity and emphasis on reputation.

I wonder if it is even possible to develop a set of valid criteria to rate residency programs. Every one I can think of is open to question. Let's take a look at some of them.

Reputation is an unavoidable component in any rating system. Unfortunately, it is rarely based on personal knowledge of any program because there is no way for anyone not directly involved with a program to assess its quality. Reputation is built on history, but all programs have turnover of chairs and faculty. Just as in sports, maintaining a dynasty over many years can sometimes be difficult. Deciding how much weight should be given to reputation is also problematic.

The schools that residents come from might be indicative of a program's quality, but university-based residencies tend to attract applicants from better medical schools. The other issue is who is to say which schools are the best?

Faculty and resident research is easy to measure but may be irrelevant when trying to answer the question of which programs produce the best clinical surgeons. Since professors tend to move from place to place, the current faculty may not be around for the entire 5 years of a surgery resident's training.

The number of residents who obtain subspecialty fellowships and where those fellowships are might be worthwhile, but would penalize programs that attract candidates who may be exceptional but are happy to become mere general surgeons.

Resident case loads including volume and breadth of experience would be very useful. However, these numbers have to be self-reported by programs. Self-reported data are often unreliable. Here are some examples why.

For several years, M.D. Anderson has been number one on the list of cancer hospitals as compiled by US News. It turns out that for 7 of those years, the hospital was counting all patients who were admitted through its emergency department as transfers and therefore not included in mortality figures. This resulted in the exclusion of 40% of M.D. Anderson's admissions, many of whom were likely the sickest patients.

The number and types of cases done by residents in a program have always been self-reported. The Residency Review Committee for Surgery and The American Board of Surgery have no way of independently verifying the number of cases done by residents, the level of resident participation in any specific case, or whether the minimum numbers for certain complex cases have truly been met.

So where does that leave us?

I'm not sure. I am interested in hearing what you have to say about how residency programs can be ranked.

Friday, October 24, 2014

Please stop this: "There are more ___ than Ebola victims in the US"

I get it. Can we please stop comparing the number of Ebola victims in the United States to all sorts of irrelevant things? PS: It's not that funny either.

The following are directly copied from recent tweets. Links have been removed for your protection.

There are more Saudi Princes than Ebola victims

Kim Kardashian has had more husbands than Ebola victims in the US

More Americans have been dumped by Taylor Swift than have died from Ebola

Fun Fact: More #kids die annually due to #faith healing than #Ebola.

FACT: Katie Price has claimed more victims than Ebola.

NYC traffic. another thing that's much more dangerous than #Ebola, courtesy of @bobkolker via @intelligencer

There are more people in this tram than ebola victims in America.

I've lost more followers than US Ebola victims [I didn't tweet this or any of these other tweets.]

@lbftaylor fewer #ebola victims in US than drunk Palins in a #PalinBrawl.

@pbolt @robertjbennett Also, there are more ex-wives of Larry King than there are ebola victims int he US.

Rush Limbaugh has more ex-wives than USA has Ebola victims!

@xeni Menudo has had more members than 3x the number of American Ebola victims...

Put #ebola in the context of vaccination preventable dz: 118,000 children < 5 yrs old die from measles per year

@Tiffuhkneexoxo @LeeTRBL more dc team quarterbacks have played this year than there are US ebola victims

Rest assured, there will always be more American guns in Africa than Ebola victims. Everything is fine. Relax

As #Enterovirus spreads faster x country & kills more than #Ebola, sure victims' parents must b sad congress isn't demanding an ED68 czar.

We are all far more likely 2 be victims of identity theft than #Ebola. Obama has a plan to fix that

Americans spend more money on Halloween costumes for their pets than the UN spends on helping Ebola victims and fighting ISIS combined.

@mikebarnicle 9900 gunshot victims since Newtown, much scarier than Ebola.

So FYI... More people die from the #flu than #ebola .

Fear hospital infections not Ebola. 1 in 25 patients are infected. 75,000 die yearly.

Every day in America around 100 people lose their lives to mostly preventable car crashes. #Ebola

There are more experts on CNN right now talking about Ebola in America than people with ebola in America.

Wednesday, October 22, 2014

1 in 20 Americans are misdiagnosed every year


A paper published in April found that about 12 million Americans, or 5% of adults in this country, are being misdiagnosed every year. This news exploded all over Twitter. Anxious reports from media outlets such as NBC News, CBS News, the Boston Globe, and others fanned the flames.

The paper involves a fair amount of extrapolation and estimation reminiscent of the "440,000 deaths per year caused by medical error" study from last year.

Data from the authors' prior published works involving 81,000 patients and 212,000 doctor visits yielded about 1600 records for analysis.

A misdiagnosis was determined by either an unplanned hospitalization (trigger 1) or a primary care physician revisit within 14 days of an index visit (trigger 2).

A quote from the paper [Emphasis added] : For trigger 1, 141 errors were found in 674 visits reviewed, yielding an error rate of 20.9%. Extrapolating to all 1086 trigger 1 visits yielded an estimate of 227.2 errors. For trigger 2, 36 errors were found in 669 visits reviewed, yielding an error rate of 5.4%. Extrapolating to all 14,777 trigger 2 visits yielded an estimate of 795.2 errors. Finally, for the control visits, 13 errors were found in 614 visits reviewed, yielding an error rate of 2.1%. Extrapolating to all 193,810 control visits yielded an estimate of 4,103.5 errors. Thus, we estimated that 5126 errors would have occurred across the three groups. We then divided this figure by the number of unique primary care patients in the initial cohort (81,483) and arrived at an estimated error rate of 6.29%. Because approximately 80.5% of US adults seek outpatient care annually, the same rate when applied to all US adults gives an estimate of 5.06%.

Thursday, October 16, 2014

Lactated ringers and hyperkalemia: A blog post meriting academic credit

In a recent post, I suggested that physicians should receive academic recognition for certain social media activities. "Myth-busting: Lactated Ringers is safe in hyperkalemia, and is superior to NS," written by Dr. Josh Farkas (@PulmCrit), is a great example of why that is true.

Using only about 1250 words and 6 references, he explains that infusing lactated ringers not only does not cause harm, it is actually superior to normal saline in patients with hyperkalemia, metabolic acidosis, and renal failure.

I highly recommend reading the post which should take you only a few minutes. If you're too lazy to do that, here's a summary.

Dr. Farkas found no evidence that lactated ringers cause or worsens hyperkalemia. In fact, he presents some solid evidence to the contrary.

If the serum potassium is 6 mEq/L, a liter of lactated ringers, which contains 4 mEq/L of potassium, will actually lower the potassium level.

Because almost all potassium (~98%) in the body is intracellular, the infusion of any fluid with a normal potassium content will result in prompt redistribution of potassium into the cells negating any of the almost negligible effect of the potassium infusion.

A normal saline infusion is acidic, resulting in potassium shifting out of cells and increasing the serum potassium level. Lactated ringers, containing the equivalent of 28 mEq/L of bicarbonate, does not cause acidosis.

There's a lot more in the post. Read it.

This issue is arguably the most misunderstood fluid and electrolyte concept in all of medicine.

In my opinion, the post should be displayed on the bulletin boards of intensive care units, emergency departments, and inpatient floors of every hospital in the world and should be read by every resident or attending physician who writes orders for IV fluids.

Disclosure: I've never been a fan of normal saline. Two years ago I wrote a post that discussed two papers showing that because of its negative effects on renal function, normal saline was inferior to lactated ringers in critically ill patients.

Wednesday, October 15, 2014

Readmissions: Sometimes it's the patients

My Twitter friend Dan Diamond (@ddiamond) posted a picture of a slide that said a hospitalized patient was taught to inject insulin using an orange to practice on. When he was readmitted to the hospital with a very high blood sugar, it turned out that instead of injecting himself at home, the patient was injecting his insulin dose into an orange, and then eating it.

We've all heard stories about patients who took suppositories by mouth instead of the way they were intended.

Since doctors get blamed for just about everything, some would say that patients who take suppositories by mouth or eat an orange filled with insulin do so because they were not properly taught by their doctors (or nurses).

I have blogged before about the problem of who is at fault if patients do not follow up. Although I feel that much of the time it's the patient who decides not to return for follow-up, it seems prevailing sentiment and possibly even the courts say it's the physician who should be held responsible.

But how do you explain this? A study in Heart, a BMJ journal, found that of 208 hypertensive patients referred to a clinic for suboptimal blood pressure control, 52 (25%) were either completely or partially non-adherent [aka non-compliant] with their antihypertensive medications as determined by urine mass spectrometry.

The authors concluded that urine testing for medications or their metabolites would help doctors avoid ordering unnecessary investigations for patients whose blood pressures were not well-controlled.

The reasons for patient non-adherence were not mentioned. Could all 52 patients not have been told about the importance of taking their medications? I doubt it.

You might think the 15% who were partially non-adherent may have forgotten to take the drugs occasionally, but it turns out that most of those in this group took adequate doses of most of other their prescribed medications. This suggests that they selectively omitted some doses of one or more drugs.

The only explanation I can fathom for the 10% who had no traces of any BP meds in their urine is that they just said "to hell with it" and didn't take their meds at all.

I know someone with type 2 diabetes who doesn't watch her weight or what she eats and doesn't check her blood sugars. She says, "You've got to die of something. I'd rather live my life the way I want to."

Is it that doctors and nurses aren't educating the patients or are the patients at fault?

The answer to this question has important implications because of the newly established financial penalties for hospitals with high readmission rates.

Older methods that may improve adherence are tracking prescription refills and having pharmacists or nurses specifically assigned to explain medications to patients in detail.

Here's something that might help.

A recent meta-analysis showed that adherence to HIV/AIDS antiretroviral therapy was modestly improved when patients were sent reminders to take their medications by text message. Those who were more adherent had lower viral loads and better CD4 counts.

Of course, such an intervention assumes that patients have mobile phones or pagers capable of receiving texts, will check for messages, and will act upon the advice. Compared to patients with HIV/AIDS, those with hypertension might tend to be much older and possibly not as technologically savvy.

So what is the solution? I don't know, but sometimes the problem is the patients.

Saturday, October 11, 2014

Is student test performance impaired by distracting electronic devices?

After listening to a lecture, third-year students at the Harvard School of Dental Medicine were surveyed about distractions by electronic devices and given a 12-question quiz. Although 65% of the students admitted to having been distracted by emails, Facebook, and/or texting during the lecture, distracted students had an average score of 9.85 correct compared to 10.444 students who said they weren't distracted. The difference was not significant, p = 0.652.

In their conclusion they authors said, "Those who were distracted during the lecture performed similarly in the post-lecture test to the non-distracted group."

The full text of the paper is available online. As an exercise, you may want to take a look at the paper and critique it yourself before reading my review. It will only take you a few minutes.

As you consider any research paper, you should ask yourself a number of questions such as are the journal and authors credible, were the methods appropriate, were there enough subjects, were the conclusions supported by the data, and do I believe the study?

Tuesday, October 7, 2014

Reaction to post on academia and social media

"Should social media accomplishments be recognized by academia?" a post of mine from October 4th, generated some lively discussion on Twitter.

Here are a few of the more interesting responses:

@ashishkjha Important question from @Skepticscalpel Should academia value impact on social media? Yes. And it's coming. Slowly.

@MartinSGaynor Science comes 1st, 2nd, 3rd.. MT @ashishkjha Important Q: @Skepticscalpel Shld academia value impact on social media?

@ashishkjha agree how to measure impact a key question. Eye balls can't be enough. But too important a question to ignore.

‏@DoctorTennyson Yes-I think social media has a role for #publichealth, #education, and fosters collaboration. More than obscure journals

@NirajGusani still you add value to your dept -how do/should they measure it?

‏@gorskon Heck, at @ScienceBasedMed, we get 1M page views a month, but I get no credit.

@gorskon I agree though. For the most part, social media harms, not helps, academic career.

Saturday, October 4, 2014

Should social media accomplishments be recognized by academia?

In August, I posted this: "A paper of mine was published. Did anyone read it?"

A recent comment on it raised an interesting point. Dr. Christian Sinclair [@ctsinclair] said that a website he is helping to run called "Pallimed" has received almost 2 million views since 2005.

He then made the following calculation:

Two million views with an average of 1:30 minutes on a page = 3 million minutes = 50,000 hours = 2,083 days = 5.7 years of 24/7/365 informal learning on hospice and palliative care topics.

He said that this type of communication counts for nothing regarding academic advancement and added that writing another paper and having it published in a journal no one reads or a chapter in an expensive book no one will buy is considered worthwhile.

This reminded me of something I have talked about in recent presentations. The first laparoscopic cholecystectomy done in the United States took place in 1988. The procedure rapidly became popular due to its obvious benefits over traditional open surgery—smaller scars, shorter hospitalizations, quicker returns to normal activity.

Tuesday, September 30, 2014

More about offshore med schools and residency prospects

Back in April, I blogged about the prospects for graduates of Caribbean medical schools matching in categorical surgical positions and estimated that graduates of two of the more prominent Caribbean schools, St. George's and Ross, had a 2.5 to 3% chance.

What about some of the other Caribbean schools? Hard data are difficult to obtain since most of the schools do not publish match statistics, and in particular, the number of graduates who don't match in any specialty.

Here is what one recent commenter on that April post had to say:

My girlfriend studied at University of Medicine and Health Sciences (UMHS)-St.Kitts in the Caribbean. She is a very hard worker and studied well. All of my savings are gone and extra bank loans add up. No match, no residency, and no more hope. Applied for medical lab tech and waiting. In my opinion, IMG is not an option, try local medical schools and if not try something else.

The UMHS website says 59 of its graduates matched in a specialty in 2014, 2 in preliminary surgery and 2 in general surgery, presumably categorical. The number of graduates of UMHS is not listed although the school apparently has three graduations per year reflecting its three different starting dates for students per year.

Another school, Medical University of the Americas on the island of Nevis, had about 90 matched graduates for 2014, 2 of whom obtained positions in surgery—both preliminary.

An additional commenter on my April post, who turned out to be the owner of a different Caribbean school, said this:

Caribbean medical school is best platform and nice and informative….. Successful communication is key in every successful business…. Understanding your subject and having good knowledge on your blog topic is always essential for a successful blog… Thanks for this post…..

Normally I would have blocked this comment as spam, but before I did so, I googled his school, the American Global University School of Medicine, located in the Central American country of Belize. The International Medical Education Directory lists its total enrollment as 100 students. The school's website does not provide any details about match results for its graduates or much of anything else, such as names of faculty or specific hospitals where students do clinical rotations in the US.

I found some other interesting links—too many to list here—about the school, its officials, and its standing in Belize. You would be wise to google it too, or you can see some links in my comment to the school's owner on my April post.

If you have any interest in attending this or any other school not accredited by the Liaison Committee on Medical Education (LCME), you should do a thorough Internet search before going ahead with an application. Do not send money unless you are certain that the school is legitimate and that most of its graduates are obtaining residency positions.

Keep in mind that the number of residency slots available for international graduates will decline even further over the next few years because several new US medical schools will be producing graduates, and many established schools have expanded their classes.

Friday, September 26, 2014

What is an acceptable rate of VTE prophylaxis?

According to the paper “Hospital Performance for Pharmacologic Venous Thromboembolism Prophylaxis and Rate of Venous Thromboembolism: A Cohort Study” that appeared online in JAMA Internal Medicine last month, a rate of 70% for all eligible patients is good enough.

The retrospective study looked at rates of prophylaxis for VTE at 35 Michigan hospitals.

Of the 20,794 eligible patients included in the analysis, 1,658 either died or were transferred to higher or lower levels of care leaving 19,136 evaluable patients, 226 (1.2%) of whom suffered a VTE during either the hospitalization or the 90-day follow-up period.

Tuesday, September 23, 2014

How to get the answers you want from a survey

This isn't about religion or politics, two subjects I tend to avoid. This is about surveys and how they can mislead.
I received this survey in the mail last week. It is from CatholicVote.org and is touted as the "largest survey of Catholics ever conducted on the issue of ObamaCare."

CatholicVote.org promises that the results will "send a strong and clear message to every politician running for election or reelection in the 2014 midterm congressional elections, that the overwhelming majority of Catholic voters demand ObamaCare be repealed."

Judging from the way the questions are framed, I think the message will be clear.

Here are a few examples:

From Section B "ObamaCare's War on Christianity and Morality"

Question #2: Do you think ObamaCare is violating the Constitution's First Amendment protections for freedom of religion and freedom of conscience by forcing pro-life Americans to purchase health coverage that includes abortion inducing drugs?

A) Yes, this is certainly a violation of the Constitution's First Amendment protections.
B) No, this is not a violation of the Constitution
C) Not Sure
D) Other

Question #4: As a state lawmaker in Illinois, Barack Obama voted twice to deny lifesaving medical care to babies born in botched abortions. What is your reaction to this fact?

A) I support President Obama on this.
B) I am horrified and angered by this.
C) Not Sure
D) Other

From Section C "ObamaCare's War on Freedom"

Question #5: Do you think President Obama knew about the crushing cost of ObamaCare for families across America, and was just lying about the cost to get ObamaCare passed into law? Or do you think he shares our shock and dismay at the staggering cost of ObamaCare?

A) I believe President Obama knew about the crushing cost of ObamaCare for families across America, and was just lying about the cost to get ObamaCare passed into law.
B) I think he shares our shock at the staggering cost of ObamaCare and was just unaware of it.
C) Not Sure
D) Other

Question #6: How do you think the mass exodus of doctors from medicine will impact your ability to see a doctor and get the medical treatments you need?

A) A doctor shortage on this scale will certainly drive healthcare costs up dramatically and make it far more difficult for me to see a doctor and get the medical care I need.
B) I don't think we'll see much impact from this doctor shortage.
C) Not Sure
D) Other

Had enough?

I look forward to seeing the results.

Monday, September 22, 2014

The $117,000 surgical assistant's fee

In a post a few months ago, I wondered why Medicare could not control its costs using the investigative power of the federal government instead of releasing physician payment data and relying on journalists to do the work.

Two stories that appeared within days of each other raise a similar question about the private insurance industry's methods.

An article in Modern Healthcare described the impending closure of the proton-beam therapy center at Indiana University, one of only 13 such facilities in the country. Proton-beam therapy, which is very expensive, has never been proven better than other types of treatment for prostate cancer.

Here's what Modern Healthcare had to say:

Blue Shield of California and Aetna last year said they would no longer cover proton therapy as a treatment for localized prostate cancer. Cigna Corp. does not cover proton-beam therapy in the treatment of prostate cancer either.

“I look at this closure as a sign that insurers are finally empowered to say this is a dubious medical technology” in the treatment of patients with prostate cancer, said Amitabh Chandra, director of health policy research at the Harvard Kennedy School of Government.

A couple of days later in the New York Times, a piece by Elisabeth Rosenthal related several anecdotes about patients who were saddled with large and unexpected bills from out-of-network physicians who were involved in their care.

A particularly egregious example was a $117,000 bill from the surgeon who assisted at a 3-hour cervical spine fusion operation. Just to put it in perspective, that's $39,000 per hour or $650 per minute—numbers a professional athlete might envy.

Although the procedure took place at a teaching hospital where residents are usually available to assist, the operative record apparently documented that no qualified resident was available.

The surgeon billed $133,000, but since he was in-network, he received only about $6,200.

Despite some pushback by the patient, the insurance company eventually paid the surgical assistant's $117,000 fee. If he's worth 19 times more than the operating surgeon, maybe he should be doing the operation instead of merely assisting.

Apparently this is not an isolated event. Quoting the Times, "J. Edward Neugebauer, chief litigation officer at Aetna, said the company had ... sued an in-network neurosurgeon on Long Island who always called in an out-of-network partner to assist, resulting in huge charges. The surgeons shared a business address."

The story in the Times related several other instances of insurance companies acquiescing and paying extremely high out-of-network charges.

If insurance companies can decide not to pay for proton-beam therapy, why do they agree to pay an assistant surgeon $650 per minute? I realize they didn't want to leave the patient holding the bag, but have they no recourse other than to pay?

On the home page of the Medical Society of the State of New York, its president responded to the Times piece by pointing out that New York's legislature just passed a law addressing surprise bills, and he correctly noted that some insurance companies do not pay in-network physicians enough to cover their expenses.

But he failed to acknowledge that many of the fees noted in the article are outrageous. Why not at least mention that issue? Doesn't he realize those fees make all doctors look bad?

Wednesday, September 17, 2014

Can Google Glass make you a better surgeon?

Advocates of Google Glass in surgery are apparently desperate to find some use for the device.

An article headlined "Google Glass makes doctors better surgeons, Stanford study shows" concluded that the study offered "compelling preliminary evidence that the head-mounted display can be used in a clinical setting to enhance situational awareness and patient safety."

Using an app capable of displaying vital signs on Google Glass in real time, 7 surgical residents recognized critical desaturation in simulated patients having procedures under conscious sedation 8.8 seconds faster than a control group of 7 residents relying on standard monitors. Glass-wearing residents also became aware of hypotension 10.5 seconds before the control group.

Not mentioned in the article but present in a linked abstract of the paper not yet submitted for peer review was this pearlneither difference was statistically significant.

This evidence is not that convincing. Even if the difference had been statistically significant, it is surely not clinically important.

How seeing vital signs on Google Glass is better than relying on the simple alarms that are built in to every monitor is not clear. Either way, you must stop the operation and look up to see the vital signs.

In a brief video accompanying the article, a surgeon can be seen rather clumsily activating and resetting the app on his Google Glass. The time required to perform these maneuvers apparently was not discussed.

The article, probably written directly from a press release, took a comedic turn with this sentence, "One test demanded that the resident perform a bronchoscopy, in which the surgeon makes an incision in the patient’s throat to access a blocked airway." But bronchoscopy does not involve making an incision in the throat or anywhere else.

If you would like to hear a different side of the Google Glass story, check out this video review from GeekBeatTV entitled "Google Glass is the worst product of all time." You can forward to the 3:45 mark to get past the woes of wearing prescription glasses with Google Glass and hear about the poor battery life, the balky commands, the system crashes, and more.

Tuesday, September 16, 2014

Aortic dissection leads to man's death in the ED: His wife's perspective

A woman wrote to me about the day her husband died. I have edited her email for length and clarity and changed some insignificant details to protect her anonymity as she requested.

Joe passed away outside in the parking lot while they were getting on a helicopter for transport to a hospital equipped to do his surgery.

He had presented to the ED in terrible pain with lots of thrashing and writhing. His right hand was very cold. His right arm tingled to the point of hurting bad. The vision in his right eye was cloudy, and his hearing was muffled on the right. This was in addition to being very pale and diaphoretic upon admission. This is when I felt a dissecting aorta should have been suspected.

I don’t recall the vitals in the beginning, but they were changing and his blood pressure was dropping very fast. As soon as they finished the EKG-in the first 5 minutes of the visit, I asked the doctor about John Ritter's death [the actor died of a dissecting thoracic aneurysm in 2003]. First I asked if he could check for the condition that caused John Ritter's death. I called it an abdominal aortic aneurysm. The doc corrected me and said that it wasn’t an AAA it was a dissected aorta. I said OK, then check for that. This was 1 hour before the CT scan that led to his diagnosis.

Thursday, September 11, 2014

More ratings—this time it's residency programs

Can you really decide which surgical residency program is right for you using Doximity's Residency Navigator?

I don't think so, and here's why.

The rankings of residency programs were obtained by surveying surgeon members of Doximity. They were asked name the five top programs for clinical surgery training. When the survey was announced in June, I predicted that most respondents would probably overlook the word "clinical" and focus on the usual famous academic institutions.

I also pointed out that anyone not intimately familiar with a program would be unable to judge whether it is good or not and suggested that reputation would be the main driver of results.

In fact, that is exactly what happened. Of the top 40 programs listed, all are based at university hospitals, as are 66 of the top 70. Back in June, I speculated about the top five programs and got the first two correct but in the wrong order.

A 2012 survey of surgical residents with over 4200 responders (an 80% response rate) found that community hospital trainees were significantly more satisfied with their operative experience and less likely to worry about practicing independently after graduation. Wouldn't you then expect a few community hospital programs to be among the top 40 hospitals for clinical surgery training?

Proof that the survey's findings are not reliable is that every one of the 253 surgical residency programs in the country was mentioned by one or more of those who responded. This included one program that has been terminated by the Residency Review Committee for Surgery. At least it appears near the bottom of the list.

The number of voters who cited the lower ranking programs must have been very few, meaning the difference between the 200th and 240th program ranks is probably not statistically significant.

Some programs that were rated are so new that very few or no residents have graduated yet. How could anyone know if they are turning out competent clinical surgeons?

Board passage rates for programs, which are available online, were omitted for some and were not clearly identified as the percentage of residents who passed both parts of the boards on the first attempt only.

The percentile rankings of alumni peer-reviewed articles, grants, and clinical trials are displayed prominently. What do those data have to do with the research question—which residency programs "offer the best clinical training"?

So what's the bottom line?

You can put the Doximity Resident Navigator in with the other misleading ratings of hospitals and doctors. Applicants considering surgical residencies should not rely on it for guidance.

It has warmed the hearts of faculty and residents at highly rated programs, but I wonder how the OR lounge discussions are going at places where programs ranked lower than expected.

Tuesday, September 9, 2014

From the trenches: More about grit

The following was compiled from two comments on my recent post about grit written by a doctor who calls himself "Geronimo." It is reproduced with permission.

Grit cannot be assessed by a survey. I wholly agree. As a military physician, my firmly founded opinion is that grit is essential to the practice of medicine. Grit is the elusive characteristic that carries the clinician through the challenges that exceed ordinary capabilities. You cite a paper that argues for surgical training to borrow aspects of SEAL training. I applaud any measure that would allow senior faculty and program directors to unilaterally shape their residents’ training, whether or not it bears any resemblance to the rigors of BUD/S [Basic Underwater Demolition/SEAL training].

The 2011 loss of 30-hour call for medical students and interns was a fatal blow to residency training, in my estimation. I count myself fortunate for having a 30 hour call internship before embarking on my operational career. While downrange, it is not at all uncommon to be woken at inconvenient hours of the night to tend to the wounds of war. If you don’t know how you function cognitively, physically, psychologically, and emotionally while sleep deprived, exhausted, hungry, cold, and pissed off, you’re behind the curve. While it isn’t any fun to work in such a state, or to work with people so challenged, it is decidedly less fun to be a patient expiring for want of any medical provider, let alone a tired one. American medicine used to be in such a place in the not so recent past, to hear the story told by my forbearers.

Monday, September 8, 2014

Chance can turn a surgeon into a killer

Risk-adjusted 30- to 90-day outcome data for selected types of operations done by specific surgeons and hospitals are now being publicly posted online by England's National Health Service.

According to the site, "Any hospital or consultant [attending surgeon in the UK] identified as an outlier will be investigated and action taken to improve data quality and/or patient care."

After cardiac surgery outcomes data were made public in New York, some interesting unexpected consequences were noted.

Surgeons and hospitals resorted to "gaming the system" by declining to operate on patients who were high-risk and tinkering with patient charts to make those they did operate on seem sicker. This can be done by scouring the charts for all co-morbidities and making sure none are overlooked when they are coded. An article from New York Magazine explains it in more detail.

Interpreting outcomes data can be tricky.

In a post three years ago about a report that nine Maryland hospitals had higher-than-average complication rates, I pointed out that whenever you have averages, some hospitals are going to be worse than average unless all hospitals perform exactly the same way or, like medical students, are all above average.

A much more sophisticated way of looking at this subject appeared in a fascinating 2010 BBC News piece by Michael Blastland, who is the Nate Silver of England [or maybe Nate Silver is the Michael Blastland of the US], called "Can chance make you a killer?"

Blastland set up a statistical chance calculator for a hypothetical set of 100 hospitals or 100 surgeons performing 100 operations each. The model assumes that every patient has the same chance of dying and that every surgeon is equally competent. The standard is that a mortality rate 60% worse than the norm set by the government for any hospital or surgeon is not acceptable.

You are assigned one hospital. Using a slider, you may choose an operative mortality rate anywhere from 1% to 15%. After you do this a number of times and recalculate for each mortality rate, you will notice that the number of unacceptably performing hospitals or surgeons changes randomly for each percent mortality and your hospital may appear in the underperforming group strictly by chance alone.

The whole concept is explained in more detail on the site. I encourage you to try it for yourself. The link is here.

So it may be difficult for the NHS to separate the true outliers from the unlucky surgeons who happened to fall outside the established norms.

What do you think about this?

Wednesday, September 3, 2014

Health Care and the $20,000 Bruise: A different take

Twitter is buzzing about yet another medical billing horror story. This one appeared in the Wall Street Journal and was written by Eric Michael David who is an MD PhD JD and an officer at a biotech company.

He saw a large, swollen bruise on his three-year-old son's head several days after falling off his scooter. Other than the bruise, no other abnormalities were mentioned. He took the boy to "one of the top pediatric emergency rooms in the country" to have a CT scan done. It showed "a small, 11-day-old bleed inside his head, which was healing, and insignificant."

Dr. David received a bill for $20,000, $17,000 of which had been paid by his insurance company. He was responsible for the remaining $3000.

He noted a $10,000 charge for a trauma team activation which he said never happened. After a lengthy series of exchanges with the hospital's billing department and Dr. David having to prove that a trauma team activation was unwarranted and not permitted by certain regulations, he was able to have the charge rescinded.

The essay went on for some 1200 words listing the steps that he went through. He correctly described what a mess American healthcare delivery is and why as long as overuse and upcoding are rewarded, the Affordable Care Act will not fix it.

Dr. David was right to contest the $10,000 charge for a trauma team activation that wasn't indicated and didn't even occur.

What he didn't address was this.

Why would a doctor who said that he had "served on trauma teams in two of the busiest hospitals in New York City" feel the need to take his apparently asymptomatic son with an 11-day-old injury to an emergency room for a CT scan?

Doesn't this imply overuse of a different type?

Secondary questions:

Did anyone bring up the issue of radiation from the CT scan?
Did the docs in the ED think a CT scan was necessary?
"Inside his head" is a rather odd phrase. Does it mean intracranial? Intracerebral?
Was "one of the top pediatric emergency rooms in the country" the only option or could this asymptomatic boy have been seen in a doctor's office?
Why is the charge for a trauma team activation $10,000?

Improving the M&M conference

"Surgical pathology works more than 80 hours per week, has no regard for your gender or your life situation, and can be devious and sneaky in its presentation."

The following is a guest post by Dr. Leo Gordon, a surgeon from Los Angeles.

A recent paper in Annals of Surgery found that 24% of graduating surgical residents "were unable to recognize early signs of complications." One possible solution is a redesign of the morbidity and mortality (M&M) conference .

I have spent a significant part of my professional life in an effort—at this point it is a crusade—to change the nature of the M&M conference. For 11 years, I moderated 495 conferences, 1485 presentations, and 30 written examinations based on the error and complication-reducing points raised during the discussions.

If properly implemented, a redesigned M&M conference can satisfy the ACGME core competencies, the suggestions of the Institute of Medicine, and the public's demand for a reduction in medical errors.

What I have dubbed the "M&M Matrix" converts the weekly conference into a vibrant educational effort and creates a constantly updated patient safety curriculum for the resident and attending staff.

If the M&M Matrix is such a valuable idea, why hasn’t it been widely adopted?

Here are the reasons:

Friday, August 29, 2014

Pain is not the "5th vital sign"

No, contrary to what you may  have heard, pain is not the 5th vital sign. It's not a sign at all.

Vital signs are the following: heart rate; blood pressure; respiratory rate; temperature.

What do those four signs have in common?

They can be measured.

A sign is defined as something that can be measured. On the other hand, pain is subjective. It can be felt by a patient. Despite efforts to quantify it with numbers and scales using smiley and frown faces, it is highly subjective. Pain is a symptom. Pain is not a vital sign, nor is it a disease.

How did pain come to be known as the 5th vital sign?

The concept originated in the VA hospital system in the late 1990s and became a Joint Commission standard in 2001 because pain was allegedly being undertreated. Hospitals were forced to emphasize the assessment of pain for all patients on every shift with the (mistaken) idea that all pain must be closely monitored and treated .

This is based on the (mistaken) idea that pain medication is capable of rendering patients completely pain free. This has now become an expectation of many patients who are incredulous and disappointed when that expectation is not met.

Talk about unintended consequences. The emphasis on pain, pain, pain has resulted in the following.

Diseases have been discovered that have no signs with pain as the only symptom.

Pain management clinics have sprung up all over the place.

People are dying. In 2010, 16,665 people died from opioid-related overdoses, a four-fold increase from 1999 when only 4,030 such deaths occurred. And the number of opioid prescriptions written has doubled from 109 million in 1998 to 219 million in 2011.

Meanwhile in the 10 years from 2000 to 2010, the population of the US increased by less than 10% from 281 million to 308 million.

Doctors are caught in the middle. If we don't alleviate pain, we are criticized. If we believe what patients tell us—that they are having uncontrolled severe pain—and we prescribe opioids, we can be sanctioned by a state medical board or even arrested and tried.

Some states now have websites where a doctor can search to see if a patient has been "doctor shopping." I once saw a patient with abdominal pain in an emergency room. After looking up her history on the prescription drug website, I noted that she had received 240 Vicodin tablets from various doctors in the four weeks preceding her visit.

That's a lot of Vicodin, not to mention a toxic amount of acetaminophen if she had taken them all herself during that month.

What is the solution to this problem?

I don't know, but as long as pain is touted as the fifth vital sign, I do not see it getting any better.

Thursday, August 28, 2014

The solo general surgeon is a dying breed. What is next?

This is a guest post by Dr. Paul A. Ruggieri, a general surgeon in Fall River, MA and author of a new book “The Cost of Cutting: A Surgeon Reveals the Truth Behind a Multibillion-Dollar Industry.”

A potential casualty of employment in a hospital system may be the ability to openly disagree with the organization. Will surgeons, as highly paid employees, be confident enough to speak up against hospital policies affecting patient care without worrying about corporate retaliation? Will employed surgeons be able to speak out against hospital cost-cutting measures that infringe on patient care without being labeled whistleblowers or troublemakers? Can they voice their displeasure without worrying about the security of their job? If you are branded “not a team player,” referrals may dry up. Or, you may suddenly be “asked” to take more emergency room call. You may also be asked to travel farther to see patients and generate surgical business in another town. You may be replaced. You could end up as a surgeon without a practice. If let go, you may discover that the clause in your contract prohibiting you from practicing within the area drives you out of town.

Will employed surgeons be able to openly highlight waste and fraud without fear of losing their jobs? As highly paid employees, surgeons risk much if they criticize the organization that employs them, even when the intent is improved patient care. Knowing the economic stakes of speaking against the corporate team, I suspect many may choose to be silent.

Tuesday, August 26, 2014


Back in May, I posed this question, "Does anyone really read anything online?" Based on some data from various sources, I concluded that not many do. I also noted that many links I tweeted were passed along by others who could not possibly have read them in the elapsed time between my tweet and their tweet.

The problem may not be limited to online readers.

Have you ever heard of "tsundoku"? It's an informal Japanese word defined as "the act of leaving a book unread after buying it, typically piled up together with other such unread books."

This reminds me of a phenomenon which I observed among medical students and surgical residents over the course of many years.

Whenever a subject arose that they were not too familiar with, they would go off to the library and copy some articles about it and carry the articles around in their pockets for weeks. The papers would curl up at the edges and become as soiled as their white coats. But most of the time they were never read.

I would point out to them that photocopying an article, even though it can take a few minutes, was not a substitute for actually reading it.

I thought I might have been the only one to have noticed this, but recently a Twitter follower of mine, Terry Murray [‏@terromur], tweeted, "In the 1980s, the librarian at Hosp for Sick Children in Toronto urged 'neuroxing' (i.e., reading) instead of photocopying."

The Internet version of this phenomenon is facilitated by programs like Evernote, which make it easy to save links or PDFs for reading later. And you don't even have to go to the library.

I suppose some people eventually do read them. But I'll bet the majority don't.

Maybe the definition of tsundoku should be expanded to include the act of leaving a link unread after tweeting it, typically piled up together with other such unread links.

Friday, August 22, 2014

Should healthcare workers stop shaking hands and "fist bump" instead?

Some well-intentioned researchers from West Virginia University published a small study claiming that substituting a fist bump for a handshake might reduce the transmission of bacteria.

Since many illnesses can be transmitted by contaminated hands, the idea is plausible, but it's a good example of the media misinterpreting a study and misleading naïve readers..

They measured the surface area of open hands and fists in 10 subjects. Not surprisingly surface area of an open hand was significantly greater than that of the fist—30.206 vs. 7.867 sq. in. respectively, p < 0.00001.

They also measured the contact time of handshakes and fist bumps. The handshake took 2.7 times longer than that of the fist bump (0.75 vs 0.28 seconds). [No statistical analysis provided]