Diagnosis: Fail

This poor older guy had been going to urgent care centers and ER's over and over for 6 weeks complaining of "back pain". He was diagnosed with shingles. Valtrex was prescribed. One day he passed out at work and was brought into the ER hypotensive and septic. I drained about a gallon of pus from his fluctuant, erythematous, tender back. General surgeons get all the glory....

SurgeXperiences

Welcome to another tardy edition of SurgeXperiences! It's been a killer week for me so this is probably going to be a little substandard. Apologies will be forthcoming. Operating three nights in a row after 2AM while your partner is out of town will do that to you. So excuse the spelling errors, the fractured syntax, the incoherence, the lack of any semblance of organization. Which seems to fit perfectly in the context of the former Alaskan governor's rambling resignation speech....So here it goes, just follow the damn links.

We'll start with the heavyweights.

Ramona Bates has a nice post on "Sausage Fingers", aka macrodactyly. Here's another on the prevention and treatment of skin tears. I love how she includes a bibliography at the end of all her posts. Such meticulousness is the sign of someone who knows how to close a wound beautifully. The idea of doing that myself, however, causes acute psychic pain.

Bongi had an excellent week of blogging. Grab a Castle Lager, kick back, and enjoy reading this, this, and this.

Old man Sid Schwab re-joined the fray (at least for the time being) with a couple of new posts. He reflects on trauma here and geriatric surgery here. Nice to see him dabbling in the medical blogosphere again.

Bard-Parker gives us his thoughts on Atul Gawande's New Yorker piece here on his blog Cut to Cure.

Over at Make Mine Trauma, our favorite first surgical assistant gives us her thoughts on calling doctors by their first names. I get called Jeff and Dr. Parks. I haven't ever requested one or the other. I respond to both. Whatever you're comfortable with I say...

Dr. Alice is now a big shot thrid year resident! Read her well written diary-style blog here.

Via Kevin MD, a video on robotic surgery. The cost effectiveness gurus are going to love this robot business! Here's more on robots here from Ducknet.

From Medgadget---- a story about the largest kidney swap, involving 16 patients. Pamela Paulk blogs about the experience (she's donating to a co-worker) here.

Here's a link to a new nursing blog about carpal tunnel syndrome.

Dr. Bruce Campbell has a beautiful post here. A must read.

And you know what? That's all I can do. To all those submissions that were basically glorified ads for nursing schools and fitness instructors..... in the words of the great Alaskan stateswoman, "thanks but no thanks". Which just means I'll probably link to the them in the next Surgexperiences.

I apologize for the half assed effort. It's my third time hosting and I promise the fourth will dazzle you. That's right, dazzle.

Have a great summer.

Profoundly Ignorant

Former Treasury Secretary Paul O'Neill (no, not the unlikable retired New York Yankee outfielder, although both have about the same credibility when it comes to health care reform opinions) has a curious op-ed in the NY Times today. According to Mr. O'Neill, we don't need more entitlements to fund health care reform. The financing solution is simple; just make those damned doctors eliminate all hospital related infections and errors, the bastards!

The president says he likes audacious goals. Here is one: ask medical providers to eliminate all hospital-acquired infections within two years. This is hardly pie in the sky: doctors and administrators already know how to do it. It requires scrupulous adherence to simple but profoundly important practices like hand-washing, proper preparation of surgical sites and assiduous care and maintenance of central lines and urinary catheters. With these small steps, we would no longer have the suffering and death associated with infections acquired in hospitals and we would save tens of billions of dollars every year — money we should have in hand before new health-care entitlements are enacted.

These are the shark-infested waters we swim in these days. We're either greedy or careless. Either way, kill all the doctors (in the revisionist, postmodern Shakespearean rewrite).

Excuse me?

Here's a good op-ed from Charlotte Allen in the LA Times.

In Barack Obama's June 24th town hall meeting on ABC he was asked by one Jane Sturm, whose 99 year old mother had received a pacemaker and is now thriving at age 105, if consideration ought to be given to a patient's "spirit" for life when making those hard cost effectiveness medical decisions. Here's what he said:

"I don't think that we can make judgments based on people's spirit," Obama said. "That would be a pretty subjective decision to be making. I think we have to have rules that we are going to provide good, quality care for all people."

Um, excuse me Mr. President but that's what doctors do. We make clinical decisions based on a multitude of factors: best evidence, cost, and suitability of the particular patient in question for the treatment strategy. Arguably the most important factor is that human being sitting across from us in the exam room. You cannot divorce the individual patient from the decision-making process. I'll choose to operate on the hale and hearty 85 year old WWII veteran who walks his dog three miles a day over the obese, diabetic 52 year old with a history of angina every single time. Subjectivity is of paramount importance when trying to determine the best course of action. We act on subjective hunches all the time (Mr. X looks "sick", Mrs. Y just "doesn't look right", etc). That subjective clinical judgment develops with experience and time. And those who ultimately acquire it are the ones who make the best doctors; or at least the sort of doctor I want taking care of my family.

Once again, we see the Obama administration trying to railroad through an overintellectuallized, hyperrational alternative to healthcare reform as policy. It's like Obama/Orszag are an elite consulting firm doling out advice on how to streamline operations of an inefficient business enterprise. This isn't a fortune 500 company though. These are real people we treat, gentlemen. Save your models and bureaucratically designed algorithms for the banks and auto industry...

Gawande Responds

Atul Gawande paid a visit to this humble blog the other day to respond to some recent posts I've done regarding his notorious expose' piece in the New Yorker on McAllen, Texas. Here's what he wrote:

As a Buckeye surgeon myself (I grew up in Athens OH), I felt I should respond. I don't actually disagree that the story of what causes overutilization is multifactorial, complicated, and bound to vary from community to community. McAllen's has a strong revenue-driven component. Besides payment incentives, habit and fragmentation of care play a role in almost every community, as well. I agree the malpractice system is a mess too and have written and researched at length on this (although it is a much smaller factor -- nowhere with caps or other restrictions have seen lower cost growth).

But I don't think we in medicine acknowledge the revenue-driven component nearly as much as we should. This is a powerful factor. It reinforces leadership that treats medicine as a business. It also discourages leadership to organize care with greater collaboration and time for patients to produce less overtreatment and undertreatment when such work reduces revenues. Reform needs to reward and protect communities that nonetheless achieve success with lower cost and high quality. I gave a lecture recently at greater length on the value of studying and emulating communities that do this differently: http://www.newyorker.com/online/blogs/newsdesk/2009/06/atul-gawande-university-of-chicago-medical-school-commencement-address.html. I don't think we disagree on the fundamentals here.

See, isn't nice to be able to collegially exchange ideas and thoughts? The internet sure is neato! Atul, as I suspected, realizes that health care reform is an extraordinarily complex endeavour. The McAllen piece highlights one aspect of the problem; i.e. when physicians have too much financial benefit at stake. In that regard, his piece was a masterful strike, a call to arms to look at ourselves, as physicians, in the mirror. The problem is that our Washington DC health care gurus have desperately latched on to this as the be-all end-all of health reform tactics: go after the greedy doctors! Hence my incessant (annoying?) ranting the past few weeks....

Happy 4th!!!

Best Star Spangled Banner ever....

Gawande Rebuked?

For a while there I thought I was the lone voice of dissent on the Atul Gawande New Yorker article which determined that the profligate spending patterns seen in McAllen, Texas was almost entirely due to the "culture of money" that had infected its physicians. In three posts over the past two weeks I have countered Dr. Gawande's deductive leap of faith with an alternative interpretation--- that the etiology of overutilization is instead multifactorial (defensive medicine, patient expectations, lack of thinking, laziness, overemphasis on testing/algorithms in medical training etc.). In response to those posts I basically heard crickets. The viral spread of Gawande's article through the blogosphere and up to the steps of the White House had ingrained the tenets of the article into the national consciousness as the conventional wisdom. I can't tell you how many respected bloggers/columnists I've read over the past month who have called the article "the best piece of health care policy I've ever read". The medical community had apparently already made up its collective mind.

But then I stumbled across a post in the Health Care Blog. The author, Daniel Gilden, does some actual number crunching (rather than make generalized conclusions based on anecdotal evidence) and what he finds is that the patient population of McAllen is the biggest factor in driving up costs. When one accounts for the fact that people in McAllen are fatter and have higher rates of diabetes and heart disease, the difference in spending between McAllen and El Paso or Grand Junction disappears.

McAllen is different from many areas of the United States: it is sicker and poorer. The observed differences in the rates of chronic disease are highest for those conditions rampant in low income American populations: diabetes and heart disease. Further, Medicare beneficiaries in McAllen have significantly higher rates of co-occurring chronic conditions. As a result the costs of caring for McAllen Medicare population appears high in comparison to other areas but not abnormally so. McAllen suffers from a tremendous burden, but it not caused by its physicians: the care they provide leads to costs that are substantially comparable to the other counties in the article once adjustments are made for the magnitude of the health problems they face. The disturbing pattern of physician practices uncovered by Dr. Gawande sounds a warning not because it foretells a McAllen-like future but because it portrays the on-going crisis that affects both McAllen and Grand Junction and it is national in scope. Physician culture is only part of the McAllen story.


Patients with chronic disease, especially those with multiple conditions, are extremely costly to treat. Cost savings will not be realized by denouncing and penalizing medical systems because they treat patient populations with high rates of disease. Instead health care reform must develop policies that support streamlining and coordinating care for beneficiaries with multiple chronic conditions, wherever they reside. Policies that support lifetime continuity of coverage, disease prevention and early treatment, could reduce healthcare costs for populations who now reach Medicare eligibility with a history of under-service. Physician culture has a role to play: Accountable Care Entities are intended to reduce barriers to access by facilitating care coordination. The high costs of care in places like McAllen will not be dramatically reduced by transforming physician ethics and organization if the roots of the crisis are in the interaction between class, demographics and chronic disease.

Amen. Again, there's no doubt in my mind that the Gawande piece (however interesting, well written and provocative it may be) is one of the most dangerous acts of anti-physician propaganda to come down the pipeline in twenty years. We have our President waving it in front of reporters and Congress. Let's at least take 5 minutes and make sure the conclusions reached have a base in reality before we allow our national policy makers to use it as a blueprint for reform, shall we?