Friday, June 26, 2009

Former Wide Receiver Sues Cleveland Clinic and the Browns

Joe Jurevicius has filed a medical malpractice lawsuit against the Cleveland Clinic and the Browns' team doctors. Jurevicius was one of seven former Browns to have contracted a serious MRSA (methicillin resistant staphyloccocus aureus) infection while playing for the team over the past three years. Last January, Jurevicius underwent what was supposed to be a routine arthroscopic knee surgery to clean out some loose cartilage. He developed fevers/chills and redness of the knee. A joint infection was diagnosed and he had to undergo six subsequent "washout" operations to clear up the problem. He ended up missing the entire 2008 season. This past March the new Browns management terminated his contract (saving the club $2.4 million).

In the suit, Jurevicius alleges that he contracted the infection because "the Browns did not sterilize their Berea training facility properly and that the medical personnel, including the Clinic doctors, failed to warn him they weren't taking proper precautions" (from Mary Kay Cabot of the Plain Dealer). I'm not sure how one is supposed to "sterilize" a weight room and other training facilities used by sweaty, gargantuan professional football players, but that's the beside the point.

This lawsuit isn't necessarily about negligence. What it represents is the known discordance between poor medical outcomes and the likelihood of the doctor being sued. (Malcolm Gladwell wrote about this in Blink.) The overwhelming majority of patients who sustain injury from medical malpractice or negligence do not sue their doctors. The mitigating factor in whether a lawsuit is brought often ends up being the status of the patient/physician relationship. If the patient feels her doctor is lying or withholding information or otherwise betraying the trust that serves as the foundation of the relationship, then she is more apt to seek justice in a courtroom.

The past couple of years have been a public relations nightmare for the Browns, problems that go beyond their pitiful performance on the field. And they haven't done much to rectify the perception that player welfare and safety is not a major team concern. Seven major staph infections is certainly worrisome in and of itself. But there's more. Kellen Winslow alleges that doctors told him that his first staph infection was his own fault (for putting too much vitamin E ointment on the wound). He was then told by management to keep his second staph infection quiet. When he went off the reservation and ranted to the media about it, he was subsequently suspended and fined by the team (only to have the punishments rescinded once all the details came out). LeCharles Bentley almost had his leg amputated from a severe MRSA infection. He ended going to a different facility for his final operation (a fact that did not sit well with the organization).

Given this apparent antagonistic and secretive stance the team has adopted over the years, is it any wonder that we're finally seeing litigation brought by a Browns player? Joe Jurevicius is a local boy from Mentor, Ohio. He's wanted to play for the Browns since he was a kid. He's made millions of dollars during a long, successful career as a professional football player. He isn't doing this for the money. (The lawsuit is only for 25 grand and lawyers fees, plus punitive damages.) After missing all of last year, the team decides to cut him in the offseason to save themselves two and half million bucks. This is akin to a general surgeon deciding that he won't take the insurance of a patient who has sustained a major common duct injury after a laparoscopic cholecystectomy and is now demanding to be remunerated in cash. You can't treat people like animals, even megamillionaire professional athletes. Perception is everything in malpractice. Hopefully the Mangini regime will use this controversy as a lesson....

Thursday, June 25, 2009

Gawande Redux

Dr Gawande responds to criticisms of his McAllen piece here. What he's responding to is criticism that McAllen's overutilization is perhaps justifiable, or at least explainable (medical malpractice, patient population, etc). He easily parries these objections with some charts and numbers and then he writes this:
The biggest changes? A dramatic rate of overutilization during a period that saw a marked expansion in physician-owned imaging centers, surgery centers, hospital facilities, and physician-revenue-sharing by home-health agencies. Home-health agencies there, for example, spent more than $3,500 per Medicare beneficiary—not only five times more than in El Paso, but also more than half what many communities spend on all patient care. In the end, none of the criticisms address either the pattern of overtreatment found in multiple studies of high-cost communities or the specific instances I found of revenue-driven care among doctors and executives in McAllen.

In other words: doctors have been poisoned by the "Culture of Money" (CoM).

And this is where I diverge. No one involved in the practice of medicine would deny that overutilization occurs to a sickening degree. My grievance with Gawande has to do with how he perceives the cause of the overutilization. He avers that it is all driven by the financial incentivization of physicians, exemplified by surgicenters and physician-owned radiology suites.

There may be some element of that in McAllen and elsewhere. But I see wasteful medicine everyday, and a great deal of it doesn't financially benefit the doctors who are most profligate. The problem of overutilization is, in reality, far more complex than the McAllen article would have us believe. Sure it would be a lot easier to use the tenets of the "Cost Conundrum" as a blueprint for repairing our broken health care system, but physician greed represents but a small piece of puzzle. Complex solutions make DC policy wonks uncomfortable. It can't be packaged into an intelligible sound byte. Physician greed, on the other hand, gives Peter Orszag et al a definable target, a "problem" to redress. In medicine and mathematics, often the simplest solutions are the most elegant. In this case however, we need to wade deeper into the morass if we hope to equitably solve our inefficient health care woes.

Wednesday, June 24, 2009

Krugman Catches Gawande Fever

Even the eminent Big Gov economist is referencing Atul Gawande's New Yorker article. Now it's official; every health policy wonk in America is now on record lauding the gloriousness and insight of the McAllen piece, as if it were a modern Revelation from above. God help us.

Let me be clear. Fundamentally I agree with Dr Gawande that physicians play a large role in running up health care costs. My issue is not with the "how" but rather the "why". Gawande very conspicuously attributes the exorbitant spending of McAllen to a "culture of money" that has infected its physicians. He rules out malpractice fears, defensive medicine, and the possibility of the higher quality/higher cost correlation. He then concludes that this leaves no other alternative but that doctors are ordering more and doing more just to line their own pockets. Then he extrapolates this to a national Either/Or paradigm of the Mayo model (collectivist, salaried, collaborationist physicians only doing what is right for the Patients, praise be their name) versus the McAllen model (greedy, self-referring, strip mall owning bastards). Read the article again. I urge all physicians.

There is another explanation. We certainly overutilize. We cut we radiate we probe we inject. There's this pressure to do something in American medicine that comes from a lot of different angles (patient pressures, the culture of modern medicine, the disconnect between the actual cost of medicine and those who prescribe/benefit from it). What I see in my everyday practice is overutilization, not from greed, generally, but from a lack of thinking. A lack of thought and clinical judgment. This is the heart of the trouble.

Last week I wrote about a 90 yo guy with metastatic pancreatic cancer who received a million dollar workup in the 2 days that he spent in the hospital. This week we were re-consulted on an older guy with CVA-induced dementia who keeps getting sent to the ER from his nursing home because of recurrent urinary tract infections. I reviewed his chart. Since April he has had two CT scans of his chest, two abdominal ultrasounds, two HIDA scans, three CT scan of his abdomen, an MRI of his brain, a PEG feeding tube, and a cystoscopy. In addition, he's been seen by general surgery, GI, ID, and neurology on each of his admissions. (We keep getting called because of fevers/sludge in gallbladder even though the guy has never complained of abdominal pain, nor is he tender, nor have any of the HIDA scans been positive.) Every time, he gets treated for his UTI and is sent back to the nursing home. The internist ordering all these exams/tests isn't making any money of it (although the radiology department loves her no doubt). She thinks she's simply being thorough, the patient's advocate.

Maybe there's a smaller role also being played by the threat of malpractice/defensive medicine, but mainly this is an ontologic failure of our profession. What does it mean to be a good physician? Is it ever enough to tell a patient that there's nothing more to be done? These are not easy questions. The culture of medicine has become poisoned by low reimbursements, malpractice litigation, high med school costs, less time available for individual patients. Doctors feel the need to do do do, to intervene, to prescribe, to operate. All this scrambling around and following up on tests and procedures leaves little time for actual thought. We've stopped thinking. And that's the essence of what is wrong in places like McAllen. Fixing it won't be easy. The causes are multifactorial and complex. But we have to start by re-assessing the way doctors are trained and the ethics that are inculcated in them. There isn't always a solution to a patient's sufferings and we need to stop interpreting this unfortunate reality as a source of failure.

Dr Gawande's article, interesting in the investigative, gotcha! sense, has been seized upon by our intellectual elites in Washington DC as a diagnosis and remedy for what ails American healthcare. It oversimplifies the problem (the way physicians process disease, patient expectations, and ever changing medical knowledge/technology) as one of pure and simple physician greed. Every practicing physician in America ought to be both offended and horrified by such an insinuation. We can certainly do better. We need to work harder and think more about what we are doing, especially with respect to how small decisions made on the local level affect the big picture. But let us not cede the terms of debate to people like Peter Orszag and Atul Gawande. Our profession has been characterized by selflessness, integrity, and intellectual curiosity for over a hundred years. Let us not allow allegations of physician greed in a southwestern Texas town be the cause celebre that defines us professionally as we head into the 21st century...

Sunday, June 21, 2009

Steve Jobs get a new liver

Steven Jobs apparently underwent an orthotopic liver transplant two months ago in Tennessee. In 2004, Mr Jobs was diagnosed with a pancreatic islet cell tumor (specialized neuroendocrine cells in the pancreas responsible for hormonal production) and subsequently had the defintive pancreatic resection. Over the past year or so rumors have abounded about his health given his rather skeletal, almost insectile, appearance. Turns out, his islet cell tumor recurred with liver metastases. Orac does a great job reviewing the literature and the treatment options for metastatic pancreatic neuroendocrine tumors so I'll just link to it here.

It seems that some in the media and the blogosphere have tried to tiptoe around the suggestion that something unsavory occured in this case. Two facts are often cited: 1) Steven Jobs received the transplant in a state where he doesn't reside. 2) The indications for a liver transplant for metastatic neuroendocrine cancers are a little controversial. The unstated implication then is that he used his power and influence as a famous bazillionaire to get priority on a new liver.

I don't buy it.

Number one, it isn't illegal or even difficult to get on several wait lists for transplant organs. Liver transplants are allocated according to a scoring system whereby the sickest patients have priority. The MELD (Model for Endstage Liver Disease) is a pretty straight forward and mathematical system. Higher scores get you a higher priority. Special points are awarded for the presence of malignancy (usually hepatocellular cancers, but obviously can include other histologic types). You can't game the system. UNOS, one of the most ethical medical organizations in the world, isn't the sort of organization that can be bribed with an offer of a thousand free MacBooks.

Livers are further doled out based on blood types. If you have a rare blood type (for your state) then even if you are very sick, your chances of getting a liver are low. So putting yourself on a transplant list in a state where your blood type is less uncommon is not only not unethical, but it's a rational move. A surgical colleague of mine's father had a liver transplant twenty years ago in Alabam even though he was living in northeast Ohio. He had a weird blood type and his wait time if he stayed in Ohio might have been over a year longer. And the guy wasn't some rich computer mogul. He just did what he thought he needed to do.

As to whether it is appropriate to transplant a liver for a metastatic neuroendocrine tumor, I would have to defer to the oncologists and transplant surgeons involved in Mr. Jobs' case. You won't ever find a randomized controlled trial proving "comparative effectiveness" of such a strategy. But liver transplant in such a clinical scenario isn't unprecedented. Islet cell tumors are a strange breed. Their behavior can be very aggressive or indolent. If this was an insulinoma then I would assume that his symptoms were potentially incapacitating. The procedure may improve his survival and will certainly attenuate his symptoms. Assuredly, he would not have been considered for a transplant unless imaging confirmed that the tumor was restricted to his liver. It's a tough call, either way. But it certainly isn't any of our business; Monday morning quarterbacking just makes us look petty and small.

Thursday, June 18, 2009

Traumatic Cervical Spine Injury: Is CT now the preferred imaging modality?

Leafing through this month's Journal of Trauma, I noticed an article written by the good people at my old stomping ground, Cook County Hospital in Chicago (I refuse to call it Stroger Hospital), that prospectively compares the diagnostic efficacy of CT scan of the cervical spine with the standard of three plain radiographic views of the c-spine. I remember they had just started accumulating the data when I was a chief resident. Over 1500 patients were accrued. Radiographic evidence of cervical spine injury was detected in 78 of the patients, with 50 having clinically significant injuries.

Here's where it gets good. CT scan of the cervical spine detected all 50 injuries (100% sensitivity) while the plain films only identified 18/50. Even in patients with clinically significant injuries, the plain films only had a sensitivity of 46%. The paper concludes by advocating that CT of the cervical spine replace plain c-spine radiographs as the preferred initial test to exclude blunt cervical injury.

This is a classic case of where the data has finally caught up to what actually happens in real life. (Got that, you CER disciples? Science isn't as accomodating or as quick as we would like. The proof of what is already apparent in clinical practice can lag years behind.) I cover trauma at a level II center and I'll be honest; I don't spend a lot of time looking at plain films of the neck. They're always sort of suboptimal and don't consistently show all the vertebrae you need and if there's a question, you're just going to get a CT cervical spine anyway. So I go straight to the CT films. Thanks to the County trauma team, we can now all feel better about doing what has, for years, seemed obvious and intuitive.

Wednesday, June 17, 2009


The Atul Gawande article from the New Yorker went viral not only in the esoteric world of the medical blogosphere, but it also grabbed the attention of our health care policy makers in Washington DC. Almost universally, Dr. Gawande's piece is being hailed as "hitting the nail on the head". President Obama has referenced it in several speeches. I actually invested a lot of time in the article. I pored over it like I was studying for an embryo exam in med school, underlying key passages like a tool. My impression is perhaps less flattering.

In the piece, he visits McAllen, Texas, notorious for being one of the most expensive places (per capita) for the delivery of health care in America. McAllen spends twice as much per patient as the national average. Gawande sought to understand why.

Now I've been reading Gawande's stuff in the New Yorker for ten years and I've always enjoyed his writing. He writes with a lucid effortlessness that makes me extremely jealous. You always get the sense that he pumps these pieces out between cases, writing on the back of his patient census. (As a side note: I've always enjoyed writing but for years I'd been painfully paralyzed by self-doubt and over-analysis. I was the kind of guy who would write paragraphs over and over, tinkering, changing a word or syntactical construction here and there to get it "just right". Incapacitating writer's block. I couldn't finish anything. I hated everything I wrote. Especially after writing the same sentences 6 or 8 times. It was blogging that gave me the release. In the blog format, you have to just "let it fly". It's almost like an on-line writing workshop. Straight from mind to paper to critical evaluation. There's no time for timorous apprehension. Anyway.) In addition to his adroit style, he has a way of focusing attention on the heretofore unnoticed details that actually play a larger role in how events play out. He's a lot like Malcolm Gladwell in that respect. In this article, instead of focusing on insurance companies or defensive medicine or the pharmaceutical industry, Gawande alights on the idea that the driving force behind escalating health care costs are doctors. After all, that useless MRI never gets done unless a physician orders it. The suspect heart cath doesn't get performed unless a cardiologist (the one who stands to profit) deems it necessary.

Ultimately, he concocts a theory of physician mindset. Doctors at the Mayo Clinic deliver premium health care at a much lower cost than the national average. Gawande's proposal is that we need to change the way we structure ourselves as physicians. At Mayo, collaboration is strongly encouraged. Everyone gets paid the same. There are no financial incentives to perform unnecessary medicine. This is his ideal. How such a collectivist commune translates to the rest of the country where the overwhelming majority of medicine is private practice is unclear. In any event, he comes to focus on what he denotes the "culture of money" that is driving the extravagance seen in McAllen. To elucidate this, he goes on to note that many doctors in McAllen have alternative sources of income, such as partial ownership of strip malls and apartment complexes. (Another side note: What does it matter what a doctor does with his/her spare time? If a doc is making money off real estate deals on the side, how in god's name would that effect his clinical decision making as a physician? If anything, I would think it would tend to make him/her less apt to order/perform unnecessary procedures. As a matter of fact, maybe I ought to stop wasting so much time blogging and look to capitalize on the depressed Cleveland real estate market in my spare time. Then I could kick back and do "casual" general surgery.)

But it is this phrase---culture of money---- which has seized the attention of our DC policy wonks. And it's not surprising. Solutions to compex social problems tend to get oversimplified, in the "Aha! I never realized that!", Gladwellian fashion. It's much more reassuring to attribute something like exponentially rising health care costs to a single factor like doctors succumbing to the "culture of money" than to acknowledge that the real etiology is extraordinarily nuanced and multifactorial. Targeting physician motivations as the primary culprit makes it much easier to construct a feasible reform strategy. Eliminate incentives that drive physicians to overutilize and voila', health care crisis solved! Then you can package a reform bill that includes features like bundling of payments with extended global periods, disallowing physician ownership of surgicenters/hospitals, restructuring reimbursement such that graduating doctors are less inclined to subspecialize, and encouraging the creation of collaborative physician groupings a la the Mayo Clinic. Assuming that your underlying premise (greedy doctors) is correct, then the legislation makes perfect sense; it's a no brainer.

I obviously think Dr Gawande has gone off the tracks just a bit with his analysis. In the beginning of the article, he chats with a family practice physician who says "...young doctors don't think anymore". But that line of thought is truncated. Instead, we wander off down the pathway of physician greed and intransigence and we never return. I'd like to revisit the idea of physician thinking.

Let's first address the idea that monetary considerations are driving physician decision making. In the article, Gawande admits that the physician-owned hospital in McAllen barely gets a sixth of the patients in the region. So that means that the overwhelming majority of physicians in McAllen do not derive any economic benefit from self-referral to a physician owned facility. So what about procedure-based incentives? Certainly, we need to do a better job of clarifying the indications for specific interventions. The cardiologists and orthopedists who are overutilizing healthcare resources are doing so to line their own pockets. This is undeniable. But I truly believe that this sort of unprincipled practice represents the exception rather than the rule. (Remember, McAllen itself is an outlier; most hospital systems hover around the mean in terms of health care expenditures.) Also, these proceduralists don't materialize out of thin air. Someone has to consult them. And this gets me to my point.

I think the family practice guy in McAllen who talks about young doctors who "don't think anymore" gets at the crux of the problem. A lot of physicians have stopped thinking about patient care, for a multitude of reasons. Reimbursements suck. You have to see a gazillion patients in the office keep your head above water. Internists cover several ER's and accumulate large censuses at hospitals all across town. There are only so many hours in the day. You can't possibly provide the amount of thought and time that each patient on your list requires. So you subcontract out a lot of the work of medicine to specialists. You don't make any less money either way. So you might as well "cover yourself" and get the specialists involved. And of course specialists will tend to recommended expensive radiographic tests and interventional procedures. That's what they do. And they don't necessarily benefit financially from all the orders they write. Think about the typical 44 yo female admitted with abdominal pain. GI gets consulted. The patient recently had a colonoscopy and an EGD which were normal. The CT is normal from the ER. How often will the GI consultant simply write: no further recommendations? How about never. He's a specialist for god's sake. There's this tendency to DO. To order something. So you get an ultrasound and a HIDA scan and maybe a CT angiogram of the mesenteric vessels and finally a small bowel follow through. It all comes back normal of course, but now you've covered all your bases. You've done something. And this happens all the time. Meanwhile, the internist cursorily swings by once a day, sees all the work being done by his consultants and rushes off to his next patient. Is it laziness? Or is it just a natural reaction to an increasingly difficult economic reality?

A slightly different scenario. I know an excellent internist at one of my hospitals who has a proclivity for shotgun consulting half the hospital on a lot of his admits. As a clinician, I think he's fantastic; detail-oriented, takes his time, cares about his patients. But he gets a lot of consults. Any fever gets an ID consult. Abdominal pain warrants consults from GI and general surgery. He tends to order a lot of needless X-ray studies. If a CT scan mentions a small incidental adrenal adenoma, he'll order an MRI and get an endocrine consult when all you need to do is get a follow up CT in 6 months or so. He isn't lazy. He works his ass off. He knows everything that goes on with his impatients. But in his mind he is providing a higher standard of care by involving multiple specialists and getting the maximum amount of work up done. He doesn't have any nefarious kickback schemes. He just truly believes that his patients are better served by having multiple sets of eyes looking after them. The issue of cost never crosses his mind.

So we have two paradigms: The primary care doc who has stretched himself out too thin and the one who thinks he is providing superior care by overconsulting. Neither of these two paradigms has anything to do with greed. One covers his benign neglect by getting specialists to do the dirty work. The other succumbs to the idea that more is better, that it isn't enough to just tell a patient to take a couple of Tums and call him in the morning.

These two models are what need to be addressed because they're much more prevalent than doctors self referring unnecessary cases to facilities that they have a financial stake in. The gatekeepers of medicine (internal medicine, family practice) control the flow of patients to specialists. Specialists will never change; they will always be procedurally oriented. On the other hand, changing the thinking of the gatekeepers (altering the way they practice medicine, how and when they order consults, incentivizing them financially to do more of the work on their patients themselves) will do a lot more to reduce health care spending in the long run than trying to attack this supposed "culture of money" afflicting American physicians in places like McAllen. We aren't in the position we are because of McAllen. McAllen is an outlier, it's atypical; but it certainly represents a faster way to fall further into the red. But places like McAllen are rare. We've tripled the amount of health care spending in America since 1985 even without the McAllen model being common. There's obviously more to it than strip mall owning, fast car driving, overly-prolific orthopedists in south Texas.

So let's ease up on the Gawande/McAllen fawning for just a bit. It's an interesting, well written article but the conclusions in it are highly suspect and certainly don't represent a panacea solution to the extremely complex healthcare dilemma....

Tuesday, June 16, 2009

Presidential Surgery

James Wiedeman MD, FACS has a cool piece in this week's JACS (not free to the public, sorry) on seven American presidents who underwent surgical procedures during their lifetime. He does a little Monday morning quarterbacking, retrospectively reviewing the cases and discussing how the management would have been different today. Some highlights:

George Washington contracted acute epiglottitis after a horse ride in the cold rain. The doctors treated this by bleeding him (to "decrease congestion") of 2.5 liters of blood. One doctor eventually recommended an emergency tracheotomy, but Washington refused. He died 12 hours later.

Grover Cleveland had a hard palate verrucous tumor removed (along with a chunk of his maxilla) while secretly drifting up the East River in NYC on a yacht.

Dwight Eisenhower was a train wreck. I had no idea. He apparently sustained 7 heart attacks over the course of his life. In 1956, he presented with a high grade bowel obstruction secondary to severe ileocolic Crohn's disease. The surgeons, for some reason, elected to simply bypass the problem area rather than resect it. That's certainly not what we'd do nowadays. Ten years later, he had another operation for recurrent SBO and died from a post op MI.

FDR likely died of metastatic melanoma (brain mets).

Ronald Reagan deferred a colonoscopy for 16 months, despite the insistence of his personal physician. When the scope was finally done, they found a large tumor in the cecum. He underwent a right hemicolectomy and did well.

Lyndon Johnson had an open cholecystectomy. (see picture above)

My favorite. James K. Polk suffered from recurrent kidney infections as a teenager. His surgeon diagnosed cystolithiasis (bladder stones) as the underlying etiology and recommended surgical intervention. This was in the early 19th century, remember. So they strapped him to a table and suspended his legs in the air with restraints. They gave him some brandy to sip and then the surgeon made an incision in his perineum and used a gorget (most terrifying name of a surgical instrument of all time) to burrow through his prostate, into the bladder, and scoop out the bladder stones. OH MY GOD. That may have pinched a bit. Strangely enough, President Polk never fathered any children.

I was a bit surprised that Dr Wiedeman neglected to write about the frontal lobe lobotomy performed on our 43rd President. Apparently the details are still classified....


Thanks to Bianca Castafiore for the reminder. One hundred and five years ago today, Stephen Daedalus and Leo Bloom wandered the streets and alleys of Dublin (fictionally speaking, of course) in the epic James Joyce novel Ulysses. It's one of my top three favorite books. If you haven't read it yet--- take three months, suck it up, fight through it, gnash your teeth, get frustrated, don't give up, enjoy it, and just read the damn thing.
"...I was a Flower of the mountain yes when I put the rose in my hair like the Andalusian girls used or shall I wear a red yes and how he kissed me under the Moorish wall and I thought well as well him as another and then I asked him with my eyes to ask again yes and then he asked me would I yes to say yes my mountain flower and first I put my arms around him yes and drew him down to me so he could feel my breasts all perfume yes and his heart was going like mad and yes I said yes I will Yes. "

Monday, June 15, 2009

The flip side of the coin

An old guy rolled into the ER with severe abdominal pain. He was hemodynamically stable but he looked like hell. He was sweating and pale and trying to joke around with his family sitting bedside, but it came off forced and hollow. He had peritonitis on exam. His WBC count was over 20k with an extreme left shift. His lactate was 4.8. The ER had already obtained the CT scan prior to my arrival. The images above show extensive hepatic portal venous gas and pneumotosis of the right colon. He needed an operation.

The appearance of portal venous gas is historically an ominous prognostic variable. Liebman et al's Annals of Surgery paper on the topic from 1978 quoted a 75% mortality rate. Recent literature studies suggest slightly better outcomes (40-80% mortality) but it's still not what you want to see on a CT scan. This guy was upper seventies, had a history of CAD and PVD and he had undergone an open AAA repair five years ago.

The surgery was a nightmare. It was 1 in the morning and it seemed the entire length of his small bowel was fused to his anterior abdominal wall. It took me almost an hour just to open up the length of the incision. There was no space in the peritoneal cavity. Everything was adherent and fused. It was as if someone poured a gallon of Elmer's glue over all his intestines and allowed it to congeal. The minutes kept ticking by. I could smell the gangrenous bowel, hidden somewhere in the depths of his distorted anatomy. But I couldn't see it. It was akin to efforts of a rescue squad trying to dig out survivors buried in the rubble following an earthquake. You go too fast and you can cause more damage. Conversely, allowing too much time to elapse similarly compromises your goals. It ended up being a three and a half hour case. The cecum was a marbled blackish green, and I did a quick right hemicolectomy with an end ileostomy/mucus fistula combo. In the family waiting room, I was very honest. I told the family that his chances were probably less than 50%. We would see how the next 48 hours went.

He got better. He went to a rehab center on post operative day #8. It worked out. He isn't going to die from an infarcted cecum. He gets to enjoy his family for at least another few months or even years.

And this is the flip side to the argument of limiting the amount of care we provide to patients who are either very old, very sick, or a combination of both. The story I wrote earlier this week about the man with stage IV pancreatic cancer is entirely different. No amount of medicine, no specific procedure exists that would alter his final outcome. But this case with the infarcted colon is much more equivocal. This guy survived. But we expended a great deal of resources to enable this to occur. He was in the ICU for four days. He was on a ventilator for 48 hours. We kept him on powerful, expensive broad spectrum antibiotics. I had him on parenteral nutrition for a few days. Multiple specialists followed him every day. Now he will have to be housed in a rehab facility for maybe a month or more. He will have to learn how to care for his ileostomy (not something he's too excited about). He certainly survived the catastrophic event. But will his life ever be the same?

So what do we do? We have the ability to truly save patients from insults that had previously killed human beings for thousands of years. How do we decide when it's justified to throw everything in our armamentarium against a disease afflicting a patient? If 50% of patients are going to die no matter what you do, is it still defensible to aggressively treat all of them?

Ultimately, I think, it becomes a very private and delicate conversation between doctor, patient, and family. That's all there is. It doesn't get much more complicated than that. But I think maybe that's the way it ought to be, the way it ought to remain. Delegating that decision to an algorithmic tree devised by some depersonalized entity (like MedPAC in D.C.) seems to be a betrayal of what it means to be a physician, a capitulation to expediency and economics....

Iranian Scandal

Take a few moments to skim through Andrew Sullivan's excellent round up of Friday's fraudulent Iranian presidential election and its aftermath. Polls leading up to the election suggested that the reformist candidate Mir Hussein Mousavi led Ahmedinejad comfortably. The final "tally" instead showed an Ahmedinejad landslide. The central government then shut down YouTube, cell phones and text messaging, kicked out foreign journalists, and put all the opposition candidates under house arrest. To their credit, the Iranian people have risen up, are demanding an end to the thuggery and deception of the current theocratic regime. Are they on the verge of revolution? Will the voice of the people be crushed?

It seems to me that this is a major news story. But you'd never know it by watching the MSM news or reading most American newspapers. (My local rag, the Plain Dealer, mentions the Iranian election on page A17 of the Sunday paper via an AP wire snippet.)

Saturday, June 13, 2009

The Voice of the GOP

The moronic Rush Limbaugh spouts off here on how "exercise freaks" are driving up healthcare costs with all their "knee injuries and sprains". Portly souls like himself, who keep in reasonable shape on their own, don't even need to see a doctor. It's the joggers and bikers and treadmillers and swimmers and the Haagen Daz-lite crowd who are the true villains. That socialist Obama is waging war on his obese brethren!

Mm-hmm, strong work from the current Leader of America's only opposition Party. Next week he'll be blaming the financial crisis on all those solvent homeowners with their "miserly saving and fiscal prudence".

Friday, June 12, 2009


In the doctor's parking lot I saw a car (BMW or Lexus or something of that ilk) with license plates reading "DMII". I figured it belonged to one of the endocrinologists. You know, DMII, diabetes mellitus type II? Clever, eh?

But then I started thinking. Isn't diabetes a chronic, debilitating disease that deleteriously affects the lives of millions of Americans? Are you really sure you want to be using "DMII" as a vanity plate on your fancy, ultra expensive luxury vehicle? Nothing says "compassionate doctor" like letting everyone know that at least someone, i.e YOU, is happy that diabetes happens to be so prevalent.

What if other specialists drove around with similar plates? You'd have the Urologist with "REDPEE". The surgeon with "ANALWART". The cardiologist with "HARTATAK". The dentist with "CAVITY". And of course, the oncologist with "CANCER!".

Wednesday, June 10, 2009

Twitter! It's so Cool!!!!

Republican Senator Charles Grassley has discovered the wonderful world of Twitter. Here's a sampling:
Pres Obama you got nerve while u sightseeing in Paris to tell us”time to deliver” on health care. We still on skedul/even workinWKEND.

Pres Obama while u sightseeing in Paris u said ‘time to delivr on healthcare’ When you are a “hammer” u think evrything is NAIL I’m no NAIL

Excellent tweeting, Senator! Intellectually speaking, I haven't come across anything so nuanced and stimulating since intercepting some tweets from a couple of teenaged girls at the mall last weekend. Indeed, you cannot stop Twitter; you can only hope to contain it....

Monday, June 8, 2009

Field of Dreams?

I saw the above commercial this past weekend. It's sponsored by the Prostate Cancer Foundation and it basically shows a montage of little kids (ages 6-10) who have to resort to having a game of catch with disembodied gloves attached to garage doors and mannequins and mattresses, because ol' Dad isn't around anymore. The implication, you see, is that he died of prostate cancer. The message is simple: get screened for prostate cancer and support research in the field because maybe some day that will be your kid out there in some lonely field, having a catch with a scarecrow or a sycamore tree.

I certainly won't argue the point that prostate cancer is a serious health threat (#5 leading cause of cancer death in men). But the presentation in the commercial is laughably disingenuous. The commercial would have us believe that prostate cancer is striking down men across the country in their prime, leaving fatherless young children in its remorseless wake. But the reality is that the median age of diagnosis of prostate cancer is 68! And most of these cancers are slow growing and indolent, anyway. The ad is sensationalistic and irresponsibly misleading. It would be like the National Breast Cancer Foundation producing an advertisement where you had Prom Kings showing up at high school dances without dates because the Prom Queens had all died of breast cancer. Sure, it would be a powerful ad; but at what cost? Cancer is too serious a health issue to risk compromising the credibility of research organizations with dishonest advertising campaigns like the one above....

Sunday, June 7, 2009

Quality Assurance--- A combination of clinical excellence and cost effectiveness

Every hospital has QA (quality assurance) committees. There's one for general surgery, radiology, trauma, internal medicine. Every department has a cadre of doctors assigned to do chart reviews, flag those cases with complications, and then meet once a week/month to discuss the case in question with the physicians involved. It's a way to keep track of the errors that inevitably occur in medicine, monitor their frequency, and identify ways of reducing their occurence in the future. You can argue about how well QA committee's work, but it certainly provides a mechanism for ensuring personal accountability to your peers. There's nothing worse than getting a letter from the QA chairman telling you that you need to present Patient X the following Tuesday. No one expects perfection in medicine (right?), and most of these meetings are more educational rather than punitive, but it's still a powerful negative feedback mechanism. You don't want to look bad. You want to be better.

I had an idea the other night. Why don't we also have Cost Effectiveness (CE) committees? Isn't this the logical progression, given the reform-minded environment we currently practice in?

Here's what I mean. How about if we start flagging those charts that stand out for the inordinate amount of cost incurred during the hospitalization. Most of the time, I think you'll find that everything done was entirely justified. But what if we start to identify certain physicians who tend to overutilize resources? The gastroenterologist who seemingly performs more inpatient endoscopies as a percentage of his total number of consults, compared with his peers. The general surgeon who tends to order more HIDA scans and MRCP's than his colleagues. The radiologist who consistently recommends a breast MRI after a large proportion of her mammogram interpretations. The internist who seems to always get 4 or 5 specialist consults, ordering many of them even before seeing the patient himself. What we'd be looking for are trends, not one time transgressions. Peer pressure is a powerful force. Who knows, maybe physicians called to explain their choices before the committee will be prompted to re-evaluate the way they practice medicine in the future.

Listen, change is coming. It would be far better for physicians to proactively implement reform mechanisms (like a CE committee) than to passively wait for mandates from Washington.

Reality sets in...

From the NY Times, it seems that the architects of Obamacare are starting to realize that revamping American healthcare is going to be expensive. Who would have thought it? And now it's starting to dawn on Orszag et al that just soaking the "rich" isn't going to provide nearly enough cash flow.

Eliminating the tax exclusion on the value of health coverage provided by your employer (i.e. redefining health benefits as taxable earned income, thereby bumping many Americans into higher tax brackets) is probably too politically unpalatable to be implemented. But I like some of the other ideas. Why not institute a national sales tax on products that tend to negatively impact health? Raise taxes on snacks, sodas, and high fat content foods. Make alcohol more expensive. (You can buy a case of Busch Light for 12.99---less than 60 cents a brewski!) Legalize marijuana and tax the hell out of it. And what about this: make people submit their documented BMI (body mass index) on their W2 forms every April. If you fall into the category of obese or morbidly obese then you pay a corresponding penalty fee, to be applied toward the healthcare kitty. If we're going to undertake such a massive public investment, the individuals need to be held accountable...

Thursday, June 4, 2009

The Microcosm

I received a consult one morning on an old guy, ostensibly for "abdominal pain". It was early, before 7:30 and no one had seen him yet. The internist had admitted him over the phone from the ER. I walked into the room and I saw a ninety year old, 100 pound guy who glowed yellow. He looked skeletal. His skin was paper thin, like cellophane wrapped around a chicken breast. He was affable enough. He knew where he was. He said his stomach had been hurting him for months. He'd lost close to fifty pounds since Christmas. He lived alone in an assisted living facility. He had a son in Alabama, but that was it.

I read through the chart. His bilirubin was 8 and the rest of his liver function tests were wildly abnormal. His Ca19-9 was over 20,000. A CT scan had been done at 3AM but there wasn't a read on it yet. I looked at it myself and easily identified a giant mid body pancreatic mass with multiple liver mets. I wrote a note about the findings and recommended a hospice consult.

The next day, I didn't make rounds on him until late, close to 7pm. In the interval, an astounding amount of medicine had been practiced. Consults had gone out to GI, oncology, and nephrology (creatinine 1.9). The GI guy had ordered an MRCP and, based on some mild distal narrowing of the common bile duct, had scheduled the patient for a possible ERCP in the morning. A stat CT guided biopsy of the liver lesions had also been done. The oncologist had written a long note about palliative chemotherapy options and indicated he would contact the son about starting as soon as possible. The nephrologist had sent off a barrage of blood and urinary tests.

I stared at the chart for a while. I was a little tired and foggy brained. But I couldn't believe it. The poor guy was zonked out in his bed, exhausted from all the tests and procedures that had been administered that day. I wrote in the chart something along the lines of "further invasive procedures/chemotherapy would be ill-advised" and I strongly encouraged a hospice consult. (I may or may not have capitalized and triple underlined the word hospice.)

The next day, the dogs were called off. The son arrived from Alabama. They had decided to forego any further treatment. He would take his Dad home....


Jon Stewart on Dickie C.

Wednesday, June 3, 2009


The Medicare Payment Advisory Commission (MedPAC) is about to get a promotion. MedPAC is the independent congressional agency that advises Congress on Medicare payments/reimbursements. Up till now, MedPAC's suggestions were just that; suggestions to be implemented or ignored by Congress. According to the Washington Post, President Obama is considering two options that would grant MedPAC more power. The first is a resolution from Jay Rockefeller which would move MedPAC into the executive branch. This would make MedPAC a de facto autonomous agency that could unilaterally set Medicare payment schedules and fund policy initiatives. (This is the vaunted "Federal Reserve" of healthcare envisioned by Tom Daschle.) The second would simply allow MedPAC to fast track their recommendations through Congress without the possibility of filibuster or amendment.

Either way, we're looking at a small agency that is about to assume the command post of how we determine reimbursement for physicians and other health care providers. Taken alongside rhetoric of "health care reform is entitlement reform", this sort of development ought to be frightening for any practicing physician. Here's $150 for that gallbladder you did at 2am, Dr. Parks. Nice doing business with you. Thanks for helping America get back into the black!

That explains it....

Lebron James underwent what sounds like a superficial parotidectomy yesterday at the Cleveland Clinic (see, I don't always call it the evil empire). The parotid glands are the largest salivary glands in the body, located anterior to the ears. Most parotid tumors are benign but they tend to grow and can cause unsightly cheek bulges (and rarely can devolve into malignant tumors over time). So surgical intervention is generally recommended.

It's a dicey case, however. I don't do parotidectomies. The gland is bisected by the diaphonous fibers of the branching facial nerve. A superficial parotidectomy involves meticulously dissecting half the gland off all five branches of the nerve. You bag even one branch and the patient ends up with a saggy eyelid or she can't smile properly. I remember as a resident operating on a woman who was literally a professional clown. She and her husband did kid's birthday parties. Nobody likes a frowny, squinty clown, right?

Anyway, rather than lumping our latest collective failure into the Cleveland Sports Jinx, I'm going to go ahead and attribute our ouster at the hands of the Orlando Magic to Lebron's swollen parotid. Better that than give props to the likes of Dwight Howard or the ghastly Hedu Turkoglu.

Rationing? Or intelligent use of resources?

We keep hearing a lot about how any health care reform will necessarily involve some form of "rationing". The Whigs, I mean Republican Party, would have us believe that Obamacare will lead to Soviet bread line-style rationing of health care. Just you wait; you'll be standing in serpentine Disneyland-type lines jagging back and forth with a bunch of other people with appendicitis waiting to get surgery, so they imply.

I hate this kind of garbage. "Rationing" is such a loaded word that carries collectivist connotations of delayed care and loss of autonomy. We hear about rationed health care and everyone wants to march against the tsar. But we have a disturbing tendency nowadays to overuse and/or misuse terminology in our political/cultural discourses. Sotomayor is a racist. Obama is a socialist. Iran is evil. It's ridiculous. These are important words with very specific meanings and contexts. Throwing them around while ad libbing on a Fox News pundit panel is just irresponsible and intellectually dishonest.

There's a difference between rationing and intelligent use of healthcare resources. No one is talking about making patients wait 6 months for a heart bypass. Obama isn't going to deny your laparoscopic cholecystectomy if you come into the ER with acute cholecystitis. At issue is the overutilization of expensive, limited resources. Should a 90 year old demented patient be kept on a vent in the ICU with every other day dialysis? Does every morbidly obese 55 year old with cranky knees (but is still ambulatory and able to work) need bilateral titanium knee replacements? Does every woman with breast cancer need a breast MRI? Do we need $5 million DaVinci robots in every hospital?

We're not talking about rationing the staples of health care provision (preventative care, emergency/oncologic surgery, etc). What needs to be trimmed are the extraneous goodies that coincidentally tend to make the most money for hospitals and providers. Not everyone admitted to the hospital with indigestion needs upper and lower endoscopy. Not every chest pain needs a heart catheterization. Not everyone with aymptomatic gallstones needs a lap chole.

There's a difference between trimming excess fat and limiting basic necessities. True rationing (food in wartime, gasoline in an oil shock) forces us to cut back on the basic stock we depend on for subsistence. Cutting back on luxury items is not rationing; it's just smart economic behavior. We need to do an honest accounting of what is truly necessary in medicine. It won't be easy. Tough decisions lay ahead. But calling any form of healthcare cost containment "rationing" or "social medicine" is just ridiculous political grandstanding.

Monday, June 1, 2009

Malpractice or Criminal?

The Cleveland Plain Dealer reports on the story of Eric Cropp, a local ex-pharmacist, who was recently convicted of involuntary manslaughter in the tragic death of a 2 year old girl under his care. The child, Emily Jerry, was being treated for cancer at Cleveland's Rainbow Babies and Children's Hospital. A pharmacy technician had mistakenly prepared Emily's chemotherapy medicine in a hypertonic solution of saline. Eric Cropp, the supervising pharmacist on duty that day, had signed off on the preparation. Emily Jarry slipped into a coma and subsequently died.

As a result of the incident, the Ohio legislature passed what is now known as "Emily's Law", which provided quality control guidelines for pharmacy technicians. Prior to the law, people could obtain employment in a pharmacy lab with barely a high school diploma. Reassuring, no? The pharmacy technician in this case, Katie Dudash, was granted immunity in return for testifying against her boss, Eric Cropp. Mr. Cropp now faces sentencing (maximum 5 years in prison) on July 17th.

A case like this is obviously tragic and unnecessary. This Cropp character was undeniably negligent and unprofessional to the extent that he was the one ultimately responsible for making sure that that little girl got the correct medicine. But I have to admit, I was initially taken aback when I read that he was being prosecuted as a criminal. He wasn't drunk or impaired. He wasn't even the one who prepared the mixture. He was inattentive and lazy and careless, and now he faces the real possibility of serving jailtime as a consequence. He's a pharmacist, not a doctor, but the implication and precedent is clear-- health care professionals are not immune to the prospect of a criminal trial .

Generally, medical malpractice is litigated as a civil tort. In civil cases, as opposed to criminal suits, the alleged victim brings the lawsuit for the purpose of remedying perceived damages sustained via monetary compensation. In criminal cases, the State is the plaintiff. The core elements of a successful medical malpractice suit include: an owed duty (physician/patient relationship), breach of duty (the act of malpractice), injury sustained (the negligence leads to a complication), and damages suffered. The plaintiff must prove all four elements in order to win the case. For example, let's say your surgeon nicks your bile duct during a routine lap chole, but is able to successfully identify and repair it at the same operation. That's a lawsuit you won't win because you've only really proven 1 of the 4 elements (injury sustained). The sole purpose of medical malpractice (as trial lawyers will gladly tell you) is to reimburse an injured patient for negligence and to encourage health care professionals (via the negative feedback mechanism of a million dollar lawsuit) to better govern themselves, i.e physicians who have been successfully sued multiple times for medical malpractice presumably will then show up on the radar of the state licensing boards and face loss of practice privileges.

Doctors face potential criminal charges more commonly for procedural violations such as medicare fraud and selling narcotics prescriptions. Criminal prosecution for medical malpractice, on the other hand, is extremely rare in the United States, but maybe that's starting to change; more than half of the criminal cases since 1809 have been filed since 1984. When we talk about criminal conduct, there are two main components: actus reus (guilty act) and mens rea (guilty mind). Mens rea deals with the perpetrator's state of mind, specifically his intent. Criminal prosecution of medical malpractice includes mens rea as the fifth component that must be proven.

In California in 1996, Wolfgang Schug MD saw an 11 month old child in the ER, diagnosed an advanced inner ear infection and recommended that the parents drive the kid to a larger hospital 55 miles away. The child ended up dying of overwhelming sepsis. Five months later Dr Schug was handcuffed in his ER by detectives and brought to the County jail. He was charged with second degree murder. At trial, the judge listened to the prosecutor's presentation and threw out the case before Dr. Schug's attorneys could present any counter-evidence.

The frightening thing is that the decision to make a medical malpractice event a criminal case is entirely up to the discretion of the prosecutor. Vague, non-specific terms like "wanton disregard of patient well-being" and "willful recklessness" are used to guide the decision making process but ultimately it becomes an arbitrary judgment call. We can all imagine scenarios where a doctor could be justifiably criminally prosecuted. The recalcitrant drunk surgeon who skips out of town before formal disciplinary measures can be implemented and finally really hurts someone while impaired at some rural, unsuspecting hospital in another state. The depraved OB/Gyn who repeatedly refuses to follow standard of care guidelines such as fetal monitoring because he "knows what's best". The quack who forges a medical degree after losing his license in one state and ends up clear across the country in a doc-in-the-box where he kills someone by writing the wrong prescription. But rarely is the real world so incontrovertible. We will always have bad outcomes secondary to questionable decision making in medicine. We have safeguards in place (hospital QA committees, state licensing boards, national malpractice databases) to help ensure that "bad physicians" are identified and either reformed or removed from practice. But is it enough? Eric Cropp lost his license after a professional inquiry. He hasn't been able to find work since. He disgraced himself as a pharmacist. But now he will also go through the rest of his life stigmatized as a convicted felon who has done time in the clink. He's basically ruined. The tragic death of a toddler notwithstanding, I find such a predicament rather harsh.

Something is off in a case like this. Criminal prosecution of doctors will never be common, number one, because who the hell would ever go to medical school if there was a possibility you could not only get sued, but have to go to jail for an unintentional error (and btw defending a criminal lawsuit is NOT covered by malpractice insurance), and number two, the trial lawyers would never allow it (remember, in a criminal suit the State is the plaintiff and the purpose is punishment rather than compensation of the victim/trial lawyer). But a case like this one sets an ominous precedent for future emotionally charged situations where there are bad outcomes (like when a child dies). Can you imagine losing your child because some idiot technician mixed up the wrong medicine and the lazy-ass pharmacist didn't bother to properly inspect it? You'd want justice right? And exactly how does a $12 million or whatever malpractice judgment in your favor propitiate your rage when you've just buried your kid? You'd want those responsible punished somehow, beyond financial decimation, beyond professional disbarment, but truly, irrevocably punished. You'd give all that settlement money just to see them led off to jail in handcuffs. I understand that kind of pain. But let's make sure the full force of the law is reserved for those rare cases of "wanton negligence" and "willful neglect"....

Abortion doctor murdered in church...

Dr. George Tiller was murdered on Sunday while at his church services. His wife was sang in the choir. It was a beautiful June Sunday morning in Kansas when the alleged gunman, Scott Roeder, entered the holy sanctuary and fired a bullet into Dr. Tiller.

Now, I'm not going to get into the whole abortion debate. I would never presume to judge a woman who chose to end a pregnancy. It isn't an act that I could support personally but, again, I've never been in that situation. Dr. Tiller was notorious for being one of the few abortion doctors in the United States who performed abortions on viable fetuses (20-24 weeks). He avered that he did it only in situations where the mother's life was in danger or in cases where prenatal diagnostic tests revealed a severe fetal defect (anencephaly, hypoplastic left ventricle syndrome, etc) often associated with early infant death. Whatever the case may be, whatever your own moral inclination, this is a despicable crime; made more despicable by the fact that it was committed under the false banner of righteousness. No Christian ought to be proud of Scott Roeder. The death of George Tiller was an act of pure evil. I would even go as far as calling it an act of domestic terrorism.