Archive for the ‘Surgery’ Category

If physicians are “muggers” and co-conspirators in “taking money away from the rest of us”, then journalists and economists are pontificating parasites who produce no goods or services of any real value.

I don’t think either is true, but the recent attacks on physicians by economists Anne Case and Angus Deaton, and “media professional” Cynthia Weber Cascio, deserve to be called out. You could make a case for consigning them permanently, along with the anti-vaccination zealots, to a healthcare-free planet supplied with essential oils, mustard poultices, and leeches.

My real quarrel with them — and with the Washington Post, which published their comments — is that they have the courage of the non-combatants: the people who criticize but have no idea what it’s like to do a physician’s work. More about that in a moment.

Ms. Cascio was enraged by the bill from her general surgeon, who wasn’t in her insurance network at the time she needed an emergency appendectomy. She doesn’t care — and why would she? — that insurance companies increasingly won’t negotiate fair contracts, and it isn’t the surgeon’s fault that Maryland hasn’t passed a rational out-of-network payment law like New York’s, which should be the model for national legislation. She doesn’t care that Maryland’s malpractice insurance rates are high compared with other states, averaging more than $50,000 per year for general surgeons. She just wants to portray her surgeon as a villain.

The two economists are indignant that American physicians make more money than our European colleagues, though they don’t share our student loan debt burden or our huge administrative overhead for dealing with insurance companies. They resent that some American physicians are in the enviable “1%” of income earners. But do they have any real idea what physicians do every day?

Stress?  What stress?

I wonder sometimes what it would be like to go to work in the morning and NOT have to worry that I might kill someone. If journalists or economists get their facts or predictions wrong, it might be annoying, but it won’t be fatal.

If anesthesiologists have trouble getting enough oxygen into a patient’s airway for very long, permanent brain damage or death result. Every time we put in an epidural, for a woman in labor or a patient who needs one for post-surgical pain control, we know the epidural needle is mere millimeters from the spinal cord. Our ever-present fear is that we might injure our patients.

That’s a stress level most people wouldn’t even want to think about.

My stress level, though, is arguably less than the surgeon’s — especially when their day involves using a saw to cut directly through the breastbone, taking care not to saw through the heart in the process, or dissecting out a brain tumor millimeter by millimeter, where the smallest error could leave the patient unable to think or speak.

Even routine operations can turn quickly to disaster. Gynecologists perform laparoscopic procedures every day — but could puncture a hole in the aorta with their instruments. The gynecologist and the anesthesiologist are well aware of that, but we try not to dwell on it, or we wouldn’t have the nerve to come to work.

Ms. Cascio, in her Washington Post column, sounded irked that her operation only took 35 minutes, as if that somehow justified less payment. In fact, that’s a sign of an efficient and experienced surgeon, who didn’t puncture her intestines or her liver in the process, and kept her from being under anesthesia longer than necessary.

The primary care physicians aren’t exempt from fear and stress either. Think about it. A patient comes in with a persistent cough, and the internist or the family practice physician ponders whether this could be lung cancer, and how much grief the insurance company is going to cause if they try to get authorization for a CT scan. The pediatrician sees a child with a fever, and always has to worry if this is a self-limited viral illness — or the beginning of meningitis that could lead to death within a day.

I wish the economists, the journalists, the pundits, and the lawmakers could watch a busy OR getting started for the day. The ritual of putting on hats, masks, gowns, and gloves always reminds me of girding for battle. Everyone knows all that can go wrong, and we’ll do all we can to make sure that none of it happens that day, on our watch.

Even more gallant are the young interns and residents who are starting out in their careers. They’re often moving from one moment of anxiety (or terror) to another, before they start to gain some confidence and hit their stride. Our role as faculty is often to reassure and cheer on as much as to teach, and to let them know that we have their backs.

Regrets over choosing medicine

The tragedy that’s happening in medicine today is that the loss of respect and the constant threats to fair payment are making physicians regret that they ever chose medicine. They were fascinated with science and wanted to help people, and their reward is insult.

It’s no wonder that some newly trained physicians leave anesthesiology quickly; there’s little risk to running a hangover clinic in Las Vegas. Many physicians from all specialties get MBAs because they see that the real rewards in healthcare lie in becoming a CEO. Look at the salaries of top executives: the CEO of Anthem made more than $14 million in 2018, as an example, while insurance companies did everything they could to avoid or delay signing fair contracts and paying clinical physicians for patient care.

There is a growing shortage of physicians, not just in primary care but in specialties too. The American Association of Medical Colleges (AAMC) estimates that the US will be desperately seeking surgeons in the next 10 to 12 years, and looking for more anesthesiologists to work with them. As older physicians retire, and younger ones aren’t willing to work the long hours that used to be routine, this will only get worse, while increasing numbers of older Americans will need more complex medical care.

Maybe your barber will learn to operate on you, just like the barber surgeons of old, and your local gun store will sell you a bullet to bite on. Best of luck.

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Gentle readers:

Please be aware that I will not publish further comments to this post on scope-of-practice issues, or on the role of non-physician professionals in healthcare. Enough has been said already — perhaps too much.  Comments about the actual issues discussed in this post are welcome.

It is difficult for all of us to know what we DON’T know, but the more education and experience we have, the less likely the knowledge gaps are to cause harm to a patient. I will always be happy to work on a medical team with anyone who wants to work with me, and I will always oppose the elimination of the physician from the team.

Yours very truly,

Karen Sibert, MD, FASA

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Recommended reading:

Nobel prize winner insults all doctors, by Skeptical Scalpel

If doctors wanted to be wealthy, they would have become UPS truck drivers, by Neil Baum, MD

 

The real surprise – to me, at least – came more than halfway through Dr. Atul Gawande’s keynote address at the opening session of the American Society of Anesthesiologists’ annual meeting in Boston.

Much of his talk on October 21 celebrated the virtues of checklists and teamwork, topics that have turned into best-selling books for the well-known surgeon and professor of public health. “We are trained, hired, and rewarded to be cowboys, but it’s pit crews we need,” he said.

Then Dr. Gawande posed this question to the packed room: “What are the outcomes that matter?”

He answered his own question somberly. “The most unsafe operation is the operation that shouldn’t be done,” Dr. Gawande said. “Does the operation serve the patient’s goals or not?”

“We’ve all been there,” he continued. “Taking people to the operating room and wondering what we’re doing.”

Those are comments I’ve heard from anesthesiologists many times before, but I never thought I’d hear them from a surgeon.

Flogging the dead

For any of us who practice anesthesiology in a major hospital – doing cardiac, thoracic, or liver cases, for instance – there are days when all our efforts are spent on behalf of a patient whose health is unsalvageable. “Flogging the dead” is a phrase sometimes used to describe prolonged and futile care in the operating room or ICU.

Sometimes aggressive interventions are driven by a family that wants “everything” done, because in their innocence the family members have no idea how terrible and dehumanizing the process of postponing death can be.

In other circumstances, however, the decision of whether to do surgery is driven by the mission and the financial motivation of the health system to provide care. If care doesn’t occur, if the surgery isn’t done, no one gets paid.

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Is it always wrong for a surgeon to book cases that will be done in two operating rooms during the same timeframe?

If you’ve paid much attention to the overheated commentary on social media since the Boston Globe published its investigative report, “Clash in the name of care“, you might easily conclude that the surgeon who runs two rooms ought to be drawn and quartered, or at least stripped of his or her medical license.

John Mandrola, MD, a Kentucky cardiologist who I’ll bet doesn’t spend a lot of time in operating rooms, weighed in on Medscape with a post called “The Wrongness of a Doctor Being in Two Places at Once“, accusing surgeons of hubris and greed.

Respectfully, I disagree.

The Globe’s story tells the dramatic tale of how a prominent surgeon at Massachusetts General Hospital often scheduled two difficult spine operations at the same time. According to the Globe’s reporters, the surgeon typically moved back and forth between two operating rooms, performing key parts of each procedure but delegating some of the work to residents or fellows in training.

On one particular day, a complex case ended with a tragic outcome. The patient, a 41-year-old man, sustained spinal cord injury at the level of his neck, leaving him permanently unable to move his arms or legs. Another prominent MGH surgeon leaked details of the case to the press, and was summarily fired.

Of course, I have no special access to information about what goes on at the MGH, and can’t comment on the specific cases highlighted in the Globe’s report. But I’ve been giving anesthesia for a long time in first-class hospitals. On countless occasions, I’ve seen surgeons run two rooms, and have administered anesthesia to a patient in one of them.

Have I ever seen a patient come to harm because the surgeon scheduled concurrent cases?  No.

Have I ever been annoyed because a surgeon delayed the start of my patient’s case because of the demands of the case in the other room? Yes, but I always agreed with the decision to delay, and the wisdom behind it. If the surgeon is at a critical portion of the first case, we have no business starting the second case until the surgeon gives the go-ahead.

Have I ever been thankful that the surgeon had two rooms? Yes indeed. Here’s why.

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“Twilight” is a movie

How the advent of propofol — the drug associated with the deaths of Joan Rivers and Michael Jackson — changed the meaning of the term “sedation”

“Twilight! She has to have twilight,” insisted the adult daughter of my frail, 85-year-old patient. “She can’t have general anesthesia. She hasn’t been cleared for general anesthesia!”

We were in the preoperative area of my hospital, where my patient – brightly alert, with a colorful headband and bright red lipstick – was about to undergo surgery. Her skin had broken down on both legs due to poor circulation in her veins, and she needed skin grafts to cover the open wounds. She had a long list of cardiac and other health problems.

This would be a painful procedure, and there would be no way to numb the areas well enough to do the surgery under local anesthesia alone. My job was to figure out the best combination of anesthesia medications to get her safely through her surgery. Her daughter was convinced that a little sedation would be enough. I wasn’t so sure.

“Were you asleep the last time your doctor worked on your legs?” I asked the patient. “Oh, yes,” she said. “Completely asleep.”

“But she didn’t have general,” the daughter interrupted. “She just had twilight.”

Propofol revolutionized anesthesia care

Though “twilight” isn’t a medical term, people often use it to mean sedation or light sleep as opposed to general anesthesia. Most patients don’t want to be awake, even if their operation doesn’t require general anesthesia. They prefer an intravenous “cocktail” to make them oblivious to pain and unaware of anything that’s happening. Today, the main ingredient is likely to be an anesthetic medication called propofol.

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No one wants a hospital-acquired infection—a wound infection, a central line infection, or any other kind.  But today, the level of concern in American hospitals about infection rates has reached a new peak—better termed paranoia than legitimate concern.

The fear of infection is leading to the arbitrary institution of brand new rules. These aren’t based on scientific research involving controlled studies.  As far as I can tell, these new rules are made up by people who are under pressure to create the appearance that action is being taken.

Here’s an example.  An edict just came down in one big-city hospital that all scrub tops must be tucked into scrub pants. The “Association of periOperative Registered Nurses” (AORN) apparently thinks that this is more hygienic because stray skin cells may be less likely to escape, though no data prove that surgical infection rates will decrease as a result.  Surgeons, anesthesiologists, and OR nurses are confused, amused, and annoyed in varying degrees.  Some are paying attention to the new rule, and many others are ignoring it.  One OR supervisor stopped an experienced nurse and told to tuck in her scrub top while she was running to get supplies for an emergency aortic repair, raising (in my mind at least) a question of misplaced priorities.

The Joint Commission, of course, loves nothing more than to make up new rules, based sometimes on real data and other times on data about as substantial as fairy dust.

A year or two ago, another new rule surfaced, mandating that physicians’ personal items such as briefcases must be placed in containers or plastic trash bags if they are brought into the operating room.  Apparently someone thinks trash bags are cleaner.

Now one anesthesiology department chairman has taken this concept a step further, decreeing that no personal items at all are to be brought into the operating room–except for cell phones and iPods.  That’s right, iPods, not iPads.  This policy (of course) probably won’t be applied uniformly to high-ranking surgeons or to people like the pacemaker technicians who routinely bring entire suitcases of equipment into the OR with them.

What’s particularly irrational about this rule is that cell phones likely are more contaminated with bacteria than briefcases or purses, even if they’re wiped off frequently.  And I have to ask how an iPhone 6+ meets eligibility criteria while the barely-larger iPad mini doesn’t.  Again, please show me the data demonstrating that this will reduce infection rates, unless someone is making it a habit to toss briefcases and iPads onto the sterile surgical field.

Show me the money

I wish I could say that the driving force behind hospitals’ fear of infection is simply the wish for patients to get well. Unfortunately, it’s probably driven as much by financial motives as benevolent ones.  Today, Medicare won’t pay for care related to surgical site infections, and it fines hospitals whenever too many patients need to be readmitted within 30 days of discharge.  In 2014, a record 2610 hospitals–including 223 in California–were penalized, and will receive lower Medicare payments for all patients over the next year, not just those who were readmitted.

What does this mean at the grassroots level?

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