Monday, May 30, 2011

The Most Uninspiring Med School Graduation Speech Ever

Atul Gawande's recent commencement speech to Harvard Medical School is here. Read it if you like. It won't exactly send chills down your spine, to say the least.

His essential message is this: Healthcare is far too complex for any one doctor anymore. So gear up to be an interchangeable part, a faceless drone who performs menial tasks according to checklists and algorithms that Really Smart People will provide for you. Don't be a Cowboy (in the romanticized, individualistic sense of a bygone era) unless you want to be like a real live lower-case "c" cowboy in Wyoming who functions as part of a team and follows protocols (Dr Gawande talked to one himself, it's true!). All that debt you've taken on to be a physician? It's so you can be an anonymous member of an integrated Team. Like a Pit Crew. Who doesn't get jacked up to join a pit crew? I sure do!!!

Is it any wonder that Dr Gawande is the very Messiah of future healthcare delivery to people like Maggie Mahar and Ezra Klein? Not a word about being a better physician, about recapturing the old ethic of patient ownership. Nothing about the challenges individual doctors face to stay on top of new medical developments and how they can be surmounted. Nothing about personal accountability. Nothing about putting your heart and soul into this noble calling.

Friday, May 20, 2011

Weekend Surgery Puzzle

So a patient comes in with hypotension, tachycardia. His family found him down on the bathroom floor laying in a pool of dark maroon stool. In the ER he is immediately intubated and we resuscitate him with saline and PRBC's. An orogastric tube is placed and massive amounts of blood is evacuated from the stomach. The stomach is then copiously lavaged with saline until clear. An upper endoscopy is subsequently performed that morning which shows 4-5 large duodenal ulcers. But none of them are actively bleeding. No visible vessels are present.

He goes to the ICU on a protonix drip and stabilizes his hemoglobin for 48 hours. Then one Sunday he drops his pressure and starts passing large amounts of blackish-red stool. The GI doc and I are there simultaneously. His blood pressure is tenuous, despite aggressive resuscitation. It seems like he has re-bled from his duodenal ulcers and may need emergency surgery.

But the orogastric tube is putting out bilious contents. The GI guy quickly slips an endoscope into his stomach. And then there's no blood. The ulcers appear stable. Bile washes back from the duodenum.

What is the next step? What operation do you think the dude will need?

Thursday, May 19, 2011

Rules for Case Blogging

Last week Kevin Pho wrote about a physician in Boston, Alexandra Thran, who was disciplined by both her hospital and the state medical board for writing about a trauma patient she had seen. Although Dr. Thran hadn't divulged the patient's name, enough information was conveyed that allowed others in the community to identify the patient in question.

That story really freaked me out. Because, as you know, I sometimes write about my adventures in general surgery. Am I a dead man? Is the Ohio State Medical Board going to give me the Bradley Manning treatment? Am I destined to working the night shift at a CVS minute clinic in five years?

As with most ethical issues, there is a lot of gray and nuance. But in general, I think you are safe writing about personal cases from your practice if you exercise a certain degree of reasonable restraint. Write about your experiences, not as a form of personal aggrandizement, but as an attempt to share, educate, and converse with laymen and other professionals about disease processes and treatment options in the open forum that is the Internets.

Here of some general rules of thumb:

1) If someone famous comes under your care, just don't write about it. If the patient is famous enough, some aspects of his/her clinical condition will leak out. There may be understandable angst and resentment that Celebrity X's privacy isn't guarded as well as anyone else's. If you write about the celebrity's case, even if you conceal it, there's too great a risk that details will overlap with leaked information from other sources. Then a giant HIPAA target forms on your back. So don't write about how the back up center for the Bulls came into the ER at 3AM with a sex toy stuck in his rectum, thinking that simply using pseudonyms gets you off the hook.

2) Strive to present cases for educational purposes. Ramona Bates is the exemplar for medical blogging when it comes to case presentation (how she has the patience to type out full bibliographies just kills me). I'm not so regimented but I try to at least provide a little pathophysiology and surgical dogma background. Compare a write up of cecal bascule in a peer reviewed journal here with my post on the same topic. My post was certaintly a little less dry and stuffy, perhaps a little too irreverent, but that's why you won't be reading much of my work in renowned journals. Conversely, my cecal bascule post was read by a lot more people that the one in Applied Radiology.

3) When you post images/scans, make sure you have removed all identifying data. Duh.

4) Let the case marinate in your mind a bit. Don't rush immediately from the OR/ER to the laptop. I usually give the cases several weeks/months to mature.

5) Review the literature to make sure your management correlates with standard of care protocols. You don't want to write about that APR you did on an early stage squamous cell anal cancer, and then have someone point out on a public blog that you ought to have sent the patient for an oncology consult to discuss the efficacy of the Nigro protocol (chemo/radiotherapy) as sole treatment.

6) Don't be a jackass. Don't brag or write things like "the patient was in good hands that night.."

7) Make sure your operative consents contain a section about "using images for educational purposes".

8) For cases that involve detailed, individualized descriptions of the operation, post op events, and eventual recovery phase---- discuss your plans to blog about it with the actual patient. Even let them read the post before you publish it.

Wednesday, May 18, 2011

Andrew Sullivan Continues his Anti-Physician Drumbeat

The Cause Of Death: Greed?
Earlier this week, Michelle Andrews reported that "hospitals perform autopsies on only about 5 percent of patients who die, down from roughly 50 percent in the 1960s." She also dug up a 1998 report that found "autopsy results showed that clinicians misdiagnosed the cause of death up to 40 percent of the time." Robin Hanson has a theory:

A pretty obvious explanation for fewer autopsies: docs don’t like being proven wrong. Such dislike can lead to lawsuits, and generally make docs look bad. ... Could there be any clearer evidence that docs care more about getting paid than about healing patients, yet the public can’t bring itself to imagine docs are that selfish?

That was from one of his blog-link posts this morning. Let me first deconstruct the incoherence of the assertion of the title---> "The Cause of Death: Greed?" I mean seriously. What is being scrutinized here is the decrease in autopsies that are performed in American hospitals over the past 50 years. What on earth does that issue (worthy of investigation, certainly) have to do with greedy physicians being the cause of those patients' deaths? If the patient is already dead, then what does the relative generosity of a physician have to do with what caused his death, in the context of whether or not an autopsy is done? Let's say an autopsy would reveal that the physician made an error and he wants to conceal that fact by quashing an autopsy, then one could make the assertion that the physician is acting greedily by seeking to reduce autopsies and enhance his reputation amongst peers/patients. But by no means can one use such behavior to infer that the physician also caused the patient's death through avaricious conduct. It's a malicious, misleading headline that attempts to re-assign after the fact vices as the precipitating factor that led to the event in question. In other words, if a kid knocks over his aunt's thousand dollar Chinese vase and attempts to cover it up by lying because he knows she will make him pay for it you could rightly infer that his greed led to his deceitful post-event behavior. But you wouldn't ever state that the kid's greed led to the vase getting knocked over in the first place would you?? It's absurd.

The piece furthermore leads the casual reader to infer that doctors are engaged in a nation-wide conspiracy to cover-up the causes of death in hospitals, like some cheesy Robin Cook novel. Do you think this is true? Are doctors actively trying to talk family members out of autopsies on their dead loved ones? I don't think so. I know for damn sure if I lost a loved one in the hospital and a bedraggled doctor immediately tried to talk me out of getting an autopsy, the first thing I would do would be to demand an autopsy STAT. I think the fact that fewer autopsies are performed has less to do with doctor practices/behaviors than with our preferences as a society. We aren't comfortable with actual death (unless it's the patriotic, hyper-violent, glorified kind you see in video games and American pop culture). It's a sociocultural issue. We can let Malcolm Gladwell figure that one out. The reality is, when someone dies in the hospital, a doctor has to fill out the death certificate. On that certificate, we have to indicate whether or not the incident qualifies as a coroner's case (mandatory autopsy) and whether or not the family decided to pursue an autopsy.

The article Sullivan links to contains this paragraph:
Autopsies play a critical role in helping to advance understanding of the progress of a disease and the effectiveness of various treatments. At the same time, they may identify medical conditions that clinicians and high-tech imaging miss or misdiagnose. For example, Elizabeth Burton, deputy director of the autopsy service at Johns Hopkins Hospital in Baltimore, recalls that when she autopsied a 50-year-old alcoholic patient, what appeared to be cirrhosis of the liver was actually cancer.

You know what a risk factor for liver cancer is in this country? Cirrhosis, either from alcohol or viral hepatitis. So in the above example, the autopsy revealed something that, although undiagnosed at the time of death, didn't necessarily cause the patient's demise (almost certainly the cirrhosis did) and is a clinical finding most clinicians would find unsurprising.

In the 1960's we often had no idea why in the hell people died. We didn't have CT scans or coronary angiography or high tech hemodynamic monitoring devices like we do today. Nowadays we can explain to patients with a reasonable degree of certainty that patient X died "likely due to condition X, Y, and Z." Autopsies in the 60's gave families and doctors closure. A family member just wants to hear something other than "I don't know what happened".

I'm a Sullivan fan, generally (torture, Palin, etc). But he's out of his league on the health care issue.

Tuesday, May 17, 2011

Health Costs: Blame the Doctors?

I'd like Andrew Sullivan to square his stance that simply allowing the SGR-determined cuts on Medicare reimbursement to physicians to stand (due to be about 29% in 2012) with the below graphs. He seems to think that all we have to do is chop physician reimbursement and a big chunk of the spiralling health care deficit can be bridged. Well, you can't squeeze a gin martini from a cold stone, buddy. We surgeons get paid 3% less than what we were paid in the mid-nineties for a laparoscopic cholecystectomy. I have a feeling that your local plumbers or lawn mowing companies aren'tcharging 3% less than what they did ten years ago to plug a leak or mulch your lawn.

Laparoscopic Adrenalectomy

I love these cases. A patient was sent to me with an adrenal mass that had been increasing in size over the past 2 years. You can see it in the above image (hint: look above the right kidney). Adrenal masses over 6 cm (or even 5 cm in women) have a high likelihood of being malignant. But before you get them on the OR table you have to do some boring doctor-work first. Specifically, you have to make sure you aren't dealing with a functional adrenal adenoma. That means sending off a barage of blood/urine tests to rule out aldosteronoma, pheochromocytoma, or a cortisol-producing tumor.

The big one to worry about is a pheochromocytoma. Pheos produce catecholamines (adrenaline) and indentification of one prior to surgery is crucial. At least two weeks of pre-operative alpha blockade (a specific anti-hypertensive agent) is required to protect the patient from the surge of adrenalin release that can occur during the operative manipulation of the tumor, and also the sudden drop in systemic catecholamine levels once the tumor is removed.

This particular tumor ended up being a benign adenoma. The case hinges on identifying and controlling the adrenal vein. The little bastard is about two centimeters long and it enters directly into the cava. If it tears you end up with torrential bleeding. Which sucks. Until you get clips on the vein, snip it, and watch the bulging blue vena cava gently roll away from the gland it's a very high tension environment. I keep the music down and, believe it or not, I can get a little snippy and high maintenance. Sliding my Maryland dissector under the vein, then slowly spreading to break up the adventia, watching it flatten and whiten and elongate, stretching out away from Big Blue, nearing its maximal tensile strength.... shit, I'm getting beads of forehead sweat just thinking about it. But once it's controlled, it's time to blast the Playing in the Band and have a good time. All that's left is to hack the gland out of the retroperitoneal fat with my harmonic scalpel. For Academic Endocrine Surgeons, the hacking out part is probably a bothersome distraction, best left to the fourth year resident who, heretofore, had been assigned to camera-holding duty. But I like it.

Torture as Party Platform

Outrageously, we are now a country where potential candidates for President of the United States can raise their hands at primary debates and aver their unabashed support for torture without suffering any backlash. Listen to the audience roar their approval to see three of five hands held aloft. Waterboarding has always been considered a form of torture. The definition doesn't change just because America sanctioned it during the Bush regime. Torture is torture. It is illegal, a moral transgression of the highest order, and a permanent stain on the integrity of this country. And apparently it has now become a litmus test for Republican party purity.....Unbelievable.