Tuesday, January 17, 2017

More about adhesions and postoperative pain

In November 2016, I wrote about adhesions and whether they are the cause of chronic abdominal pain. I and several surgeons who commented felt they weren't.

Some new information from the February 2017 issue of the journal Surgery is just in. A randomized, double blind, placebo-controlled trial from The Netherlands was originally published in 2003 after one year of follow-up. At that time, there was no apparent benefit from an operation to lyse [divide] all adhesions laparoscopically in 52 patients compared to a placebo operation that involved performing only laparoscopy to assess the extent of adhesions in 48.

The current paper looked at outcomes 12 years after the original surgery was done. Follow-up was available for 73% of the patients—42 in the group who had adhesiolysis and 31 who had laparoscopy only.

The authors concluded, “Laparoscopic adhesiolysis was less beneficial than laparoscopy alone in the long term. Secondly, there appeared to be a powerful, long-lasting placebo effect of laparoscopy. Because adhesiolysis is associated with an increased risk of operative complications, avoiding this treatment may result in less morbidity and health care costs.”

Unfortunately the paper has a few flaws.

Friday, January 13, 2017

"Malpractice" from the viewpoint of a plaintiffs' attorney

Lawrence Schlachter is a neurosurgeon who after 23 years in practice, was forced to stop operating because of a hand injury. He went to law school, became a plaintiffs’ attorney, and wrote a book called “Malpractice.” Although it is intended for patients, physicians might want to read it to learn something about how a plaintiffs’ lawyer thinks.

I’m not surprised that Schlachter cites the heavily extrapolation-based Journal of Patient Safety study claiming 400,000 medical error-related deaths per year and the thoroughly debunked Makary study claiming 251,000 deaths per year due to medical error. He does a little extrapolating of his own and comes up with 562,000 patients per year.

I agree with Schlachter about many issues. He says the best way to avoid becoming a victim of negligence is to take good care of yourself. If you need to be hospitalized, aggressively be your own advocate or have a relative or friend do it. You cannot assume that mistakes will not happen.

Monday, January 9, 2017

How can we instill more confidence in our graduating chief residents?

For over six years, I have been writing about problems in surgical education. My seventh blog post ever was about the negative impact of changes in surgical residency training.

In that post, I cited a residency program director who felt that rules imposed by the Accreditation Council for Graduate Medical Education (ACGME) resulted in excessive supervision of residents who never had a chance to operate independently. Many feel that this is a major factor resulting in 80% of graduating chiefs opting to do one or more years of post residency fellowship.

Excessive supervision continues in 2016. In his presidential address to the Southwestern Surgical Congress, John R. Potts, III, M.D., a former surgical program director and now Senior Vice President of Surgical Accreditation for the ACGME, had a similar observation. He said, “I have personally encountered individuals finishing general surgery residency programs who have never completed any operation—regardless how simple and basic—without an attending surgeon being with them throughout that operation.” [Emphasis by Dr. Potts]

Wednesday, January 4, 2017

The occasional surgeon

On the Forbes website, Dr. Robert Pearl writes

"When I was selected to become CEO of The Permanente Medical Group, the Permanente half of Kaiser Permanente, the time required for my responsibilities forced me to give up doing surgery on a regular basis. But every year since then, during the week between Christmas and New Year’s Day, I have returned to the operating room. The timing works, as the leadership demands become minimal and it’s unlikely I’ll suddenly be needed to fly to another part of the country. It’s a magical time for me, contrasting dramatically with my world as CEO. For several hours each day, my focus is not on millions of Kaiser Permanente members—or, for that matter, on all the complexities of healthcare policy, politics and strategy—but, rather, on a single patient at a time."

Dr. Pearl is a Yale medical school graduate who trained at Stanford and has been board-certified in plastic surgery since 1979. The American Board of Plastic Surgery did not start requiring maintenance of certification every 10 years until 1995.

We do not know what specific surgical procedures he does during his magical time. Is he removing moles, performing reconstructive surgery, or doing facelifts and nose jobs? Do his patients know that he only operates a few days per year? What happens if a wound complication requiring revision surgery arises? Who follows up his patients?

Tuesday, December 27, 2016

My top 7 blog posts of 2016

I’ve written over 700 posts since I started blogging in July 2010. Here are my seven most viewed posts of 2016.

My perspective on the notorious “study” claiming medical errors are the third leading cause of death in the United States. Are there really 250,000 preventable deaths per year in US hospitals?

I followed up by commenting on the negative impact of naive reporting about that preventable death study in When bad research is not critically reported by journalists.

Radiologist Saurabh Jha and I discussed the risks of radiation and rationale for ordering a CT scan for the diagnosis of appendicitis in this post Irrational fear of CT scans in appendicitis.

Another post about appendicitis was my critique of a meta-analysis claiming that antibiotics were safe and efficacious for treating simple appendicitis. Needless to say, I disagreed. Antibiotics vs. surgery for appendicitis.

The issue of surgeon headgear doesn’t seem to go away. The traditional surgeon cap is being banned by some states and nursing organizations. This post, It's time to discuss surgeon headgear again, was popular. Bonus eighth post: The subject came up again when the Association of periOperative Registered Nurses and the American College of Surgeons had a dustup about it later in the year. OR head covering controversy: ACS versus AORN.

I reported on a controversial paper about the relationship between surgeons and anesthesiologists How frequently do surgeons and anesthesiologists lie to each other?

One of my favorite topics is the lack of consistency among the multitude of hospital rating systems. I gave some examples in this post Why hospital rankings are bogus.

Thanks for following my blog and reading my posts. Happy New Year.

Friday, December 23, 2016

Good patient safety news you didn’t hear about

In the last five years, there’s been a 21% reduction in hospital acquired conditions (HACs) says a report by the Agency for Healthcare Research and Quality. This means that patients suffered 3.1 million fewer HACs than if the HAC rate had stayed at the 2010 level.

Since 2011, the decrease in HACs has reduced healthcare costs by an estimated $28.2 billion and has saved almost 125,000 lives.

This graphic summarizes the AHRQ findings.
Central line-associated bloodstream infections have fallen by 91%, and postoperative venous thromboembolism by 76%. Here’s a chart that shows the percent decreases in HACs.

The report said the reasons for these improvements “are not fully understood,” but might be due to the following:
  • Financial incentives created by the Centers for Medicare & Medicaid Services (CMS) and other payers’ payment policies,
  • Public reporting of hospital-level results,
  • Technical assistance offered to hospitals by the Quality Improvement Organization (QIO) program, and
  • Technical assistance and catalytic efforts of the HHS PfP [[Pay for Performance] initiative led by CMS.
An thorough Google search found a few articles about this important and positive AHRQ report. Were they in the New York Times, Washington Post, Newsweek, US News, or The Daily Mail?

No. the news could only be found on HealthcareIT Analytics, Fierce Healthcare, the website of the Healthcare Association of New York State, Pharmacy Practice News, and HealthcareIT News where I obtained the multicolored graphic above.

Why do you suppose no major media outlet reported the story?

Good news doesn’t get clicks.

Wednesday, December 21, 2016

No improvement in complication rates after instituting an operating room checklist

A before and after study at the University of Vermont Medical Center found that a 24-item operating room checklist did not significantly reduce the incidence of any of nine postoperative adverse outcomes.

More than 12,000 cases were studied, and outcomes included mortality, death among surgical in patients with serious treatable complications, sepsis, respiratory failure, wound dehiscence, postoperative venous thromboembolic events (VTE), postoperative hemorrhage or hematoma, transfusion reaction, and retained foreign body (FB).

After the checklist was established, respiratory failure rates decreased significantly on the initial analysis, but the difference disappeared when the Bonferroni correction* was applied to the data set.

Why didn’t the checklist work? I have discussed this in previous blog posts here and here. As was true in previous papers of this nature, many of the complications studied—respiratory failure, wound dehiscence, transfusion reaction, postoperative hemorrhage or hematoma—could not have been prevented by a checklist.