Tuesday, November 21, 2017

The case against live tweeting

“Live tweeting” of conference presentations continues to be popular. The practice is defined as posting one or more tweets attempting to tell the Twitter audience what the presenter has to say. It is touted as a great way to convey information to those who are unable to attend the conference.

I’m not a fan of live tweeting, and here’s why.

The live tweets are also supposedly used as a substitute for notetaking. I have blogged about some of the studies showing retention of information is better when notes are taken on paper.

Many of the tweets are incomplete and/or incomprehensible because the description of them has to fit within 280 characters—at most two or maybe three sentences.

Good speakers will use short bullet points and verbally explain what they mean. This can be difficult to accomplish in a tweet.

Papers presented at meetings have not been peer-reviewed. [Okay, I understand that peer review is not perfect, but it is the current gold standard for evaluating published medical literature.] Some people may not know this, but program committees can only judge what is in an abstract—which can be misleading. The submitted abstract is usually worded to attract the attention of those deciding which papers will be accepted. When the paper is presented at the meeting, it sometimes only faintly resembles what was contained in the submitted abstract.

People who rely on live tweets for medical news assume the live tweeter understands what has been presented and is able to coherently communicate it. I worry that snippets of misinformation may be widely disseminated.

What about impressions. Some organizations brag about their combined meeting tweets having 240 million impressions. That doesn’t mean 75% of citizens in the US have seen a tweet. Impressions are simply an index of how many twitter accounts could possibly have seen a tweet. Most tweets are not at all. I have almost 18,000 Twitter followers. I average about 2000 impressions per tweet. Most of my tweets get fewer than 10% engagementsdefined as as clicking on a link, expanding detail, likes, and retweets.

Photographs of PowerPoint slides tend to be from bad angles and are often blurry. Here are some examples. Identifying information has been removed to protect the guilty.




The prosecution rests.

Friday, November 17, 2017

Residents, duty hours, and respect

The following is an email I received.

I, a surgical resident, would like to ask for help navigating conversations about resident duty hours. You had a very strongly worded post on the subject. My intent is not to contradict your perspective, but perhaps get and give some insight on this question. First, I wish to show you the conversation with a surgeon "fossil" as I experience it:

Fossil: "In my day we worked __ many hours and operated all night and never slept or ate and were glad of it. It made me the surgeon I am today. You will never have this privilege."

Me: "Wow, I agree. You had it much harder." Meanwhile, I am thinking:

Monday, November 13, 2017

Useless general surgical interventions that should no longer be done

England’s National Health Service (NHS) could save €153 million [$178 million USD] per year by scrapping 71 low-value general surgery practices says a recently published paper in the British Journal of Surgery.

The authors, from Imperial College London, extensively reviewed the literature and Choosing Wisely recommendations from a number of countries.

I agree with many of the 71 including performing a cholecystectomy during the first admission for a patient with symptomatic gallstones instead of waiting for another admission (saving more than €54 million) and not repairing minimally symptomatic inguinal hernias, which they estimate would save over €32 million.

The Telegraph reported, “The team also discovered that robotic surgery has ‘little or no advantage’ when compared with traditional keyhole operations and said it must be ‘considered a candidate for disinvestment.’” This probably wouldn’t fly here in the US, because—like guns—too many robots are already in the hands of users.

Friday, November 3, 2017

What does Jersey City have that New York City doesn’t? Two hospitals with Leapfrog Group “A” safety grades

Leapfrog just released its semi-annual hospital safety grades. Incongruities identified in my previous blog posts [here and here] appeared again.

New York City had no A grade hospitals, only four got Bs, and nationally known hospitals such as New York Presbyterian (Columbia and Cornell), New York University, and Mount Sinai received C grades.

Residents of New York City are in luck because several A-rated hospitals are located just across the Hudson River. Four of them—Jersey City’s CarePoint Health-Christ Hospital, Jersey City Medical Center, CarePoint Health-Bayonne Medical Center, and CarePoint Health-Hoboken University Medical Center—aren’t exactly household names, but they scored better on safety than their New York neighbors.


CarePoint has figured out how to achieve a top rating but can’t compare to the numbers of California Kaiser Foundation Hospitals scoring well on multiple Leapfrog evaluations. The current rankings show 19 of 26 Kaiser hospitals in California were A rated.

Friday, October 20, 2017

The lost sheep: They’re MDs but can’t find residency positions

I haven’t written about offshore medical schools since this post back in January, but yesterday I received communications from two graduates of those schools which moved me. Both are edited for length and clarity.

This was an email. I read your article on Physician’s Weekly about unmatched MDs. I am a bit down and looking for advice. I graduated from a Caribbean Med school. I have failed attempts and many gaps. Academically I dug myself into a deep dark hole, but my desire to practice medicine kept me going. I recently took Step 3 and just received my scored (failed by 2 points). I do not know anyone in medicine that can help me get a residency. I know I will be a great physician. I am just a horrible test taker.

I didn't apply for the match since I was told that I needed to pass Step 3 to even try to match which would still be almost impossible even with a good score. I know many people who have not matched and have just given up on it. I have so much debt and no way of paying for it. What do you suggest I do? A friend thinks I should just take it again and apply, but I no longer have the funds especially since my chances are so low. I wish there was something more for me.

Any words of advice would be really appreciated.


Monday, October 16, 2017

Is an autonomous robot better than a human surgeon?

That was the headline on the website BGR [“a leading online destination for news and commentary focused on the mobile and consumer electronics markets”].

Engineers working with the Smart Tissue Autonomous Robot (STAR) claim it can cut skin and tissue with more precision than a surgeon.

A paper they presented last month at the International Conference on Intelligent Robots and Systems featured a video supposedly proving the point.

STAR works “by visually tracking both its intended cutting path and its cutting tool and constantly adjusting its plan to accommodate movement.” The intended cutting path must be marked by a human beforehand. So, it is not really autonomous; rather it is semi-autonomous.

The video can be seen in its entirety here or you can watch two excerpts below. The first is the robot using cautery to make a straight 5 cm skin incision which is compared to an unidentified surgeon cutting a similar incision. Watch approximately 15 seconds of this clip.



As you can see, the surgeon strays from the intended path about halfway through the process. But note that the surgeon is not holding the cautery the way most surgeons would use it. The proper way to hold the instrument is as if it were a pencil. No human could possibly cut a straight line holding the instrument as far away from the tip as the video depicts.

A second video shows the STAR excising a geometrically shaped pretend tumor.


Note: Although the video is being shown at 4X speed, it is still painfully slow. It is not clear what would happen if the robot encountered a blood vessel that bled despite the use of cautery, which by the way is not the instrument of choice for excising many tumors.

What we have here is a nice example of a “straw man” which is comparing a new technique against a phony one to make the new one look better.

Another website, IEEE Spectrum, went with this headline:

The headline should have read:


[Type straw man or artificial intelligence in the search field to your right on my blog site for more posts about these two topics.]

Thursday, October 5, 2017

The 2017 US medical school graduates: An in-depth look

According to a survey published by the Association of American Medical Colleges (AAMC), the 2017 graduating class has a median medical school debt of $180,000. The figure has remained stable for the last three years. Nearly 27% of students say they had no debt at all.

When the cost of pre-medical education is included the total debt climbed to a median of $195,000.

Despite those numbers, 54.5% said their choice of a career specialty was not based on the level of educational debt. Instead, over 98% said they chose their specialty based on its fit with their personality, interests, and skills.

The survey was offered to all 19,242 graduates of the 140 US medical schools with 15,609 (81%) responding. Some did not answer every question.

Most of the respondents (90%) were satisfied with the quality of their medical education. Only 7.6% said that if they could do it over they would not or probably would not enroll in medical school again; 9.1% gave a neutral response; 7.7% did not answer. Over the last five years, responses to this question have not varied much.

Tuesday, October 3, 2017

Why public reporting of individual surgeon outcomes should not be done


Please take a look at my latest post on Physician's Weekly. It's called "Why public reporting of individual surgeon outcomes should not be done."

Click here for the link.

Wednesday, September 27, 2017

Review of TV show "The Good Doctor"

Just when you thought there could not be another bad medical show, ABC TV presents “The Good Doctor.” It’s about an autistic young man going to California to become a surgical resident.

Just after he lands at the airport in San Jose, an overhead sign breaks and causes the unluckiest 8-year-old boy on earth to suffer three life-threatening injuries. The Good Doctor gives a bystander, who sort of sounds like a doctor but is not too confident, an anatomy lesson about where to hold pressure on a bleeding internal jugular vein. He then notices bulging of the left arm veins and diagnoses a tension pneumothorax.

He looks for a knife “with a seven-inch blade” at a TSA checkpoint, grabs a lesser knife, makes a chest tube and underwater seal from various supplies he finds in the airport, dumps half a bottle of whiskey on the kid’s chest, and inserts the makeshift tube. All of this happens on the floor of the airport concourse.

Of course the kid wakes up and starts breathing normally.

Meanwhile the board of directors of the hospital is debating the hiring of an autistic surgical resident. In this hospital, its president, who met The Good Doctor when he was 14, hires the residents, and the chief of surgery has no input. [Matching? What matching?]

Tuesday, September 26, 2017

Contradictory evaluations cause trouble, consternation

Two weeks ago I blogged about a resident who had been told she must repeat her fourth year of training. She countered with a lawsuit claiming that the surgery department and the medical school did not follow their policies in mandating her remediation.

She said written evaluations by faculty during her fourth year of residency were generally very good, but some oral feedback she received was negative.

From my experience as a surgical residency program director, I know inconsistent, vague, and unhelpful evaluations from faculty are common. For example, a medical student on Twitter recently posted the following:

The tweet prompted many comments from others; the best of which are these [names changed]:

That he seems well read and has a good depth of knowledge deprives him of good learning opportunities.

John sometimes stands too close when he presents.
3 months later. I don't understand why John stands so far away when he presents.

Tends to scare off new people./Makes everyone feel welcome & appreciated.

Dr. Doe, don't be too hard on the juniors. One week later. Dr. Doe, don't be too friendly to the juniors.

And my favorite

Jane should be aware of how she holds her shoulders. It changes the energy in the room.

Do you have similar evaluations to share?

Thanks to Natalie Wall (@nataliemwall) for allowing me to use her tweet.

Monday, September 18, 2017

A surgical resident’s legal battle with her program

My new post on Physician's Weekly is about a dispute between a resident and her surgical residency program that has escalated to court and the news media. Click here to read it.


Wednesday, September 6, 2017

The power of a photo in a tweet

Last week I did a little experiment on Twitter. No, I did not have IRB approval.

I wanted to see what the impact of attaching a photo to a tweet would be.

On August 30 at 10 a.m., I tweeted a link to a blog post I had just written about two new types of water—one that supposedly has “activated stabilized oxygen” in it and another that is “living crystal” water. Both are touted as having health benefits.

Here are the first tweet and its statistics.

Click on photo to enlarge it.
Of the 1299 impressions or unique Twitter accounts that could have been reached at 10 AM the time the tweet was posted, 11 (0.8%) people engaged with the tweet.

Three hours later I tweeted about the blog post again using similar wording but this time adding this photograph from the blog post.

Here are the tweet and its statistics. 


Wednesday, August 30, 2017

New varieties of water offer health benefits, but don't deliver

What if you could get more oxygen into your system by a method other than breathing?

A company says its oxygenated water, containing O4, also known as “activated stabilized oxygen,” can do just that. When you drink Oxigen [notice the clever spelling], O4 supposedly is absorbed under your tongue and in your stomach.

An article about this wonderful product states, “These aren’t just claims, but actual scientific processes supported by studies on stabilized oxygen.” Due to the limitations of space on the Internet, references to the studies are not provided.

The product “contains 1000 ppm of bioavailable oxygen” which is said to be about 20 times as much as the oxygen in tap water. Stabilized oxygen supposedly helps the body clear lactate and is beneficial for hangovers.

Friday, August 25, 2017

Quick takes on three recent stories

Handwashing

The magazine Popular Science reported on a paper which found after 20 subjects washed their hands at water temperatures of 100, 80, and 60 degrees, the temperature had no impact on bacterial counts. They also found antibacterial soap was no better than plain soap and water.

What did matter was time—10 to 20 seconds of lathering was better than 5 seconds, and 40 seconds was no better than 10 or 20.

The authors concluded that hands should be washed in water that was most comfortable for the individual.

In a blog post from last year, I pointed out that washing hands for more than 40 seconds, as advocated by a paper in Infection Control and Hospital Epidemiology, was impractical due to the excessive amount of time busy hospital staff would need to invest in doing so multiple times per day.

For example, 10 washes per hour at 40 seconds per wash is almost 7 minutes of hand washing times 8 hours equals 56 minutes.

Drivers who follow other drivers

The journal Frontiers in Psychology published a paper called “I’ll Show You the Way: Risky Driver Behavior When ‘Following a Friend.’” The authors, from the Human Systems Engineering department of Arizona State University, found that in order to keep up with the lead driver, drivers who don’t know the way took more chances when they followed someone.

The work was done by testing 16 college student subjects on a simulator. Drivers who followed were more likely to drive significantly faster, change lanes quicker, and in general “engage in riskier behaviors” than when listening to audible directions from a simulated GPS system.

The authors recommended that following another driver to a destination not be done. However if following is necessary, the driver of the lead vehicle should go slower and anticipate what the following driver might have to do to keep up.

1) I think most of us could have predicted the outcome of this research and come up with the same recommendations. 2) Does anyone who drives a car not own a smartphone in 2017?

What not to do with a hotel room tea kettle

According to the Metro.co.uk website, this is a thing that some people in China do when staying in a hotel. Whether travelers in Western nations also do so is not known.

A reporter for Gizmodo Australia asked a molecular biology professor from New Zealand’s Massey University to comment. She said, “It is super super super super gross” and pointed out that boiling does not necessarily kill spores formed by some types of bacteria.

Even if boiling killed all known living things, I still wouldn’t want to drink a cup of tea from a kettle that had contained someone’s skivvies the night before.


Wednesday, August 23, 2017

Bladder catheter + oxygen supply tubing = death

You may not be aware that I blog twice a month for the Physician's Weekly website. My latest post is called "Bladder catheter + oxygen supply tubing = death" and it can be read by clicking here.

How a pneumoperitoneum can kill.
This x-ray shows what happened to an elderly man whose oxygen tubing somehow became connected to his bladder catheter.

Tuesday, August 22, 2017

Three new studies confirm germs are everywhere

These ubiquitous germs don’t seem to be harming anyone, but reporting on the studies generates lots of clicks.

For many years kitchen sponges have been known to harbor bacteria. Now comes the news that cleaning those sponges not only doesn’t work, it may make the situation worse by promoting the overgrowth of potentially disease-causing bacteria—for example Moraxella osloensis.

The New York Times reports German researchers found kitchen sponges contained 362 different types of bacteria and as many as 82 billion bacteria per cubic inch of space. The senior author of the study said, “That’s the same density of bacteria you can find in human stool samples” [but not the same types of bacteria] and suggested replacing kitchen sponges frequently.

These revelations were based on bacterial DNA and RNA samples from 14 [yes, just 14] used sponges. Note the use of the word “potentially” to describe the pathogenicity of Moraxella. A PubMed search for this microbe back to 1968 yielded only 82 references, many of which were not pertaining to any human illnesses. The few case reports of infections involved patients who were immunosuppressed.

Wednesday, August 16, 2017

Fatal internal jugular vein cannulation by a misplaced NG tube

A case report published last month involves a 79-year-old man with multiple comorbidities including depression, alcohol abuse, hypertension, CHF, and COPD who was admitted because of abdominal pain and distention which was found to be a perforation of the right colon. 

He underwent a resection and did well until the seventh postoperative day when he became distended. A nasogastric tube was inserted. Its position was checked by injecting air through the tube and auscultating over the upper abdomen [a notoriously inaccurate method of locating an NG tube’s position].

A few hundred mL of dark blood came out. He was treated for a presumed upper gastrointestinal bleed. A chest x-ray showed the tube in good position but the tip was not seen.

When the patient’s vital signs deteriorated, a new NG tube was put in and drained 2 L of blood. The patient suffered a cardiac arrest and could not be resuscitated. At autopsy, the NG tube was found to have gone through the right pharyngeal wall and into the right internal jugular vein. The tip was in the superior vena cava.

Although I had never heard of this complication before, it has been reported in the literature at least one other time.

Wednesday, August 9, 2017

What to do when a normal looking appendix is found at surgery for appendicitis

For patients undergoing surgery with a presumptive diagnosis of appendicitis in Norway and other parts of Europe, the protocol is if the appendix looks grossly normal in the operating room, it is usually not removed.

This approach was mentioned as part of a paper on the readmission of post-appendectomy patients from Oslo University Hospital. Most of the patients underwent laparoscopy based on clinical diagnosis with only 160 having CT scans and 67 having ultrasounds.

Of the 710 patients in the Oslo series, 94% of the appendectomies were done laparoscopically, and 111 had a normal appearing appendix at laparoscopy. The appendix was not removed in 88. The other 23 patients had appendectomies for various reasons, and those appendices were normal at pathology.

The cumulative rate of operating for what turned out to be a normal appendix (88 + 23 cases) was 15.6%, which the authors attributed to “the low use of preoperative CT” due to concerns about radiation exposure. That over 100 patients had unnecessary general anesthesia and surgery was apparently not a concern.

Monday, August 7, 2017

Causes of death among residents

What is the leading cause of death among residents in all specialties?

A. Accidents
B. Neoplasms
C. Suicide
D. Miscellaneous diseases

If you answered C, you were wrong. The correct answer is B, neoplasms. Suicide was the second most common cause, followed by accidents and miscellaneous diseases.

A study in Academic Medicine looked at resident deaths over a 15 year period and found that of the 381,614 individual physicians in ACGME training programs, 66 died of suicide. For the over 1.6 million person-years studied, the suicide rate for residents was 4.07 per 100,000 person-years—well below the figure of 13.07 per 100,000 years in the general population of people aged 25-34.

Residents in age groups 35-44 and 45-54 had suicide rates higher than the 25-34 group and higher than the rates of those in comparable general population age groups.

More suicides occurred during the first and second years of training and during the months of July through September and January through March. In my opinion, the months that deaths occurred in can be explained as follows. In the first three months of the academic year, residents in the first and second years may feel overwhelmed and subject to self-doubt—the so-called "impostor syndrome." By the time January and February roll around, it is mid-winter, and it seems like the year will never end.

Residents had a much lower rate of death from accidents, including those related to automobile crashes, than the general population.

The overall death rate from all causes was also lower for residents than the rate of the general population at 16.91 per 100,000 person-years and 105.4 per 100,000 person-years, respectively.

The authors were surprised that resident rates of suicide were lower than age- and gender-matched populations especially because suicide rates for medical students and practicing physicians are higher.

They concluded that suicide was probably the only area in which prevention strategies, such as a supportive environment and medical and mental health services, could reduce the death toll.

Program directors, faculty, and residents themselves should probably show heightened vigilance in the first and third quarters of the academic year particularly for first and second year trainees.

Wednesday, August 2, 2017

Another chapter in “Surgical Cap Wars”

No one expected the AORN [Association of periOperative Registered Nurses] to meekly accept the conclusion of the paper which found no difference in infection rates when surgeons wore surgical skullcaps or a bouffant-style head coverings.

The AORN recently fired back with a letter to Neurosurgery, the journal that published the paper. It has not yet printed the letter or a response to it by the authors of the paper. I look forward to seeing both.

Meanwhile, Becker’s Infection Control and Clinical Quality revealed some tidbits an article entitled and “AORN experts respond to study on bouffant use and SSI rates.” [SSI = surgical site infection]

The AORN claims that it never mandated the use of bouffant headgear. It merely called for “a clean surgical headcover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of the neck should be worn” because “hair carries bacteria that could [emphasis mine] cause an SSI.”

Lisa Spruce, the director of evidence-based practice for the AORN, said, “It’s up to the facility to determine what’s the best way to get everyone’s hair covered.” This is rather disingenuous as everyone knows the only way to cover every single hair on the head is to wear a bouffant or a hood.

The AORN did not offer any evidence that hair causes infections. Instead Spruce and the other AORN experts chose to nitpick the Neurosurgery study by pointing out a single scatter plot that showed what they said was a decrease in SSI rates after bouffants were worn.

They claim the figure below indicates fewer infections occurred late in the 13 month period of bouffant usage because it took some time for everyone to comply with bouffant use.
Blue is skullcap. Red is bouffant. Time in months
They offer no proof that adoption of the bouffant took several months. In my experience, when hospitals go from skullcaps to bouffants, the transition is abrupt. On the day the mandate takes effect, skullcaps are no longer available. And by the AORN's logic, one could argue that the plot shows a spike in bouffant-associated SSIs at months 4 and 5 of use.

What about statistical significance? The table directly above the figure they cited clearly shows that there was no significant difference in the SSI rate between the two types of headgear for all operations in the hospital, spine cases, or craniotomy/craniectomy procedures.
Click on table to enlarge it.
In fact if you believe in trends, there were slightly more infections for overall operations and spine cases in the bouffant group.

The AORN wants all hair covered. What about the eyebrows? As I mentioned in a post back in May, an outbreak of SSIs that occurred after some plastic surgery operations in Israel was traced to an organism found in the surgeon’s eyebrows.

Bottom line: If the AORN cannot cite evidence proving that scalp or facial hair causes infections, its experts should do their own research and publish it—otherwise stop damaging the organization’s already marginal credibility.

Thanks to Artiger, a loyal reader of my blog posts, for sending me the link to the Becker's article.



Monday, July 31, 2017

"Move that defibrillator paddle so I can finish the case"

A plastic surgeon in Sydney was reprimanded by the New South Wales Professional Standards Committee for continuing breast augmentation surgery after a patient had been successfully resuscitated from a cardiac arrest.

According to a report, the surgeon, Dr. Niroshan Sivathasan, defended his actions two years after the incident saying he operated for another 30 minutes after an ambulance arrived because he hadn't finished inserting the left breast prosthesis or closed both wounds, and he was concerned about infection if he aborted the case.

The committee didn't buy that excuse correctly pointing out that the patient could have had another cardiac arrest and said he "demonstrated almost no insight into the nature of his conduct or how he failed his patient."

He was also told he must undergo mentoring and submit a report documenting all of his complications every three months.

Sivathasan works at The Cosmetic Institute, Australia's largest plastic surgery center, which has had some problems in the past. In 2016, the Health Care Complaints Commission found six patients had experienced potentially life-threatening complications — tachycardia, seizures, and cardiac arrest—during breast implant surgery done over a 12 month period.

The complications were thought to have been due to the use of large amounts of local anesthesia with epinephrine. In addition, the facility was licensed for administering conscious sedation only, but some patients had undergone general anesthesia without their consent.

The 21-year-old woman who survived the cardiac arrest in 2015 was interviewed back then for an article in the Sydney Morning Herald. She described waking up in the hospital and finding she had received CPR and cardiac defibrillation. She said Sivathasan told her there was a problem with the anesthetic.

Regarding her surgeon, she said, "If it wasn't for him I wouldn't be alive. That place is so prepared for whatever. Literally, they saved my life."

I don't think they have Press Ganey scores in Australia, but if they did, no doubt the surgeon and the facility would have received 5-star ratings from this patient.

UPDATED ON AUGUST 14, 2017

Dr. Sivathasan, the surgeon involved in this case, emailed me with comments which shed some light on why he continued the operation. They are published without editing below.

I felt it important to write to you just to highlight a few things that were ‘not’ correctly reported in the press release:

1) the operation was close to being finished when the patient developed ventricular fibrillation;
2) hardly any local anaesthetic was used in this case (only 10mL of 1% ropivucaine);
3) by good fortune, there were TWO specialist anaesthetists (one being a senior cardiac anesthesiologist) who were managing the patient, and the patient responded very quickly to their efforts;
4) the ambulance service despatched two incorrectly equipped ambulances, and a THIRD ambulance was required to transfer the patient.  This entailed a delay;
5) it was UNANIMOUSLY agreed by FOUR doctors (both anaesthetists and both surgeons who were present) that we ought to use the window to give the most definitive outcome for the patient.

At the end of the day, the patient, a sizeable percentage of the public, and a considerable number of doctors supported us for our actions.  They recognized that it takes more judgement and nerve to finish a procedure under such stressful circumstances, than it does to just ‘whack in a few staples and down tools’.

Unfortunately, due to the regulatory processes in place, two doctors who were not present during the incident, were able to judge upon the actions of four doctors (all of whom were in agreement).  This is simply illogical and is, certainly, an indictment of the regulatory board’s processes.  Furthermore, neither of the two doctors that were presiding over the case is an expert in critical care – one was a retired surgeon and the other was an emergency physician.

Accordingly, what those two doctors failed to recognize, in my strong opinion, is that a patient whom has been salvaged from a nasty situation remains unstable and should not immediately be in the back of an ambulance; rather, the patient shall be better served when under the care of two anesthesiologists maintaining anaesthesia (which is relatively cardioprotective given the high catecholamine situation (which may provoke another episode of VFib)).  The VFib was ‘not’ secondary to haemorrhage or anything surgical, and therefore to capitalize on the undesirable situation by finishing an almost-finished operation appeared to be the best decision (as opposed to requiring a GA in the future, where the induction may be a lottery).  

Experienced doctors shall appreciate that medicine, and especially surgery, involves judgement calls.  This patient in question has had a positive outcome.  Unfortunately, the institution where the problem occurred has been the subject of debate due to a few suboptimal practices by the management team, and this ended-up biasing the outcome.

Wednesday, July 26, 2017

Controversies in OR infection control

Like professional athletes, Skeptical Scalpel sometimes talks about himself in the third person. A recent article in Clinical Infectious Diseases [CID] confirms what Skeptical Scalpel has said about a couple of controversial topics in infection control.

The article by surgeons from the University of Washington was published online in late May of this year and gives historical context to some of the standard operating room practices we currently argue about.

Regarding operating room headgear, the authors dissect and refute the positions endorsed by the Association of periOperative Nurses (AORN) that hair and airborne bacteria cause infections. In fact, they say wearing of any kind of hat in the OR may actually disperse more bacteria due to the effect of the hat rubbing against the hair and causing an increase in bacterial shedding.

They conclude “there is little reason to support the AORN recommendations regarding head covering.”

Wednesday, July 19, 2017

What were attrition rates in surgical residency programs 25 years ago?

Last month I blogged about the 20% attrition rate of general surgery resident over the last 25 years, and a recent paper presented at a national meeting that found after following the general surgery resident class of 2007, 20% had dropped out for one reason or another.

A reader who calls himself Artiger commented on that piece asking, “Is there any data on resident attrition prior to 1992? Just curious if this has been a problem for more than the past 25 years.”

I responded that I wasn’t aware of any such studies but I would try to find out.

Most of the few papers written about attrition back in the day focused on one residency program or one medical school’s graduates.

Until the middle of the 1990s, many surgical residency programs were pyramidal—that is, they took more categorical first-year residents than they had chief residency positions. For example, when I began my training in 1971, my program had 12 first-year residents, decreasing to 8 in the second-year and only 4 chiefs.

Sunday, July 9, 2017

Parathyroids Anonymous

A One Act Play by Leo Gordon, MD

Dedicated to Parathyroid Surgeons
------------------ 
All proceeds from the production of this play go to Parathyroids Anonymous--An international organization dedicated to the well-being of those who perform parathyroid surgery

Scene: A sparsely furnished church basement. Rain is beating against the window panes. Folding chairs are arranged in a semi-circle. Participants are drinking from plastic cups. Some are in scrub suits. All appear tired.

Don: Hello. My name is Don and I’m a parathyroid surgeon.

All: Hello Don

Don: I will be your facilitator tonight. We have a new member so let me set the ground rules. All of us in this room are parathyroid surgeons. We maintain our anonymity as we discuss the mental and physical distress that parathyroid surgery engenders. There are no boundaries at our meetings. We speak openly and freely. Use your first name only. And of course, no patient names. Who wants to begin?

Miriam: (Nervously) Hello. My name is Miriam and I am a parathyroid surgeon.

All: Hello Miriam

Miriam: I’ve been here a few times but I’m a little bit nervous.

Don: Don’t be nervous Miriam. We all share the same problems.

Miriam: Well… last week. (Begins sobbing)

Don: Now Miriam, just relax. Please continue.

Miriam: I had a 56 year old woman referred to me with hypercalcemia. She had had elegant localizing studies at our hospital. Both studies – nuclear and sonographic - stated with metaphysical certainty that there was an adenoma of the right lower gland. Yet (sobbing) when we explored the area, there was no adenoma present. All we found was a normal sized parathyroid gland!

Al: (Hands Miriam a handkerchief)

Don: Go on, Miriam

Friday, July 7, 2017

The problem of “copy and paste” in electronic records

As opposed to text that is copied and pasted or imported from another part of the electronic record, the average amount of manually entered information in a progress note is

a. 18%
b. 29%
c. 43%
d. 55%
e. 70 %

A study of 23,630 internal medicine progress notes written by 460 different hospitalists, residents, and medical students found that a mean of only 18% of the text was created by hand with 46% copied and pasted from previous note or somewhere else and 36% imported from another part of the record such as a medication list.

The analysis, done at the University of California San Francisco*, was possible because the Epic electronic medical record used there can provide the provenance of every character entered in a progress note.

Medical students had the highest percentage of manually entered text and wrote longest notes—averaging 7053 characters, but even the shortest notes, by hospitalists, averaged 5006 characters. For reference, this post contains 1189 characters.

Manual entry comprised 11.8% of resident notes with 51.4% of the remaining information copied and pasted and 36.8% imported.

Think about it. For all groups, less than one-fifth of every progress note they wrote was original material. For resident notes, it was closer to 10%.

The authors cautioned that their study was limited to a single service at a single institution, but I suspect the results would be fairly similar in many if not most hospitals.

*Location of the study corrected on 7/7/17.

Tuesday, June 27, 2017

How to fix the problem of general surgery resident attrition

Over the last 25 years, about 20% of general surgery residents have failed to complete their five years of training. This compares unfavorably to other specialties such as orthopedics, obstetrics-gynecology, and medicine with attrition rates of < 1%, 4.5%, and 5%, respectively.

A paper presented at the American Surgical Association in April looked at the factors associated with attrition in one year’s resident class. In 2007, 1047 residents began their training and after 8 years of follow-up, 80% had become surgeons. How many non-finishers left programs by their own choice is not clear.

Some highlights of the research are as follows:

24% of women and 17% of men left general surgery training.

Size mattered because 23% of men and 25% of women left large programs compared to both sexes leaving smaller programs at a rate of just 11%.

Tuesday, June 20, 2017

Some general surgery residency graduates may not be competent to operate

A new study says 84% of general surgery residents in their last six months of training were rated as competent to perform the five most common general surgery core procedures—appendectomy, cholecystectomy, ventral hernia repair, groin hernia repair, and partial colectomy. However the percentage of those judged competent varied from a high of 96% for appendectomy to a low of 71% for partial colectomy.

When analyzing the other 127 core operations of general surgery, the investigators found that 26% of residents in their last six months of training were felt to not be competent to perform at least some of those procedures.

The study was presented at the annual meeting of the American Surgical Association in April 2017 and reported in ACS Surgery News.

Data were compiled from ratings of 522 residents by 437 faculty yielding 8526 different observations.

For all of the procedures rated, maximum resident autonomy was observed for 33% of cases, and the more complex the case, the less ready the residents were to perform it on their own.

The lead author of the study, Dr. Brian George of the University of Michigan, was asked whether the duration of surgery training should be increased. He answered, “The 20,000 hours of surgical residency should be enough to train a general surgeon to competence—it's up to us to figure out how.”

Thursday, June 15, 2017

Surgical residents have lots of problems, need more time off

A recent survey of surgical residents regarding their personal and professional well-being revealed that while most of them enjoyed going to work, they had many serious issues.

All 19 surgical residency programs in the New England region were invited to participate, and 10 did so. Of 363 trainees contacted, 166 (44.9%) responded to the survey with 54% of respondents saying they lacked time for basic health maintenance. For example, 56% did not have a primary care physician and were "not up to date with routine age-appropriate health maintenance such as a general physical examination, laboratory work, or a gynecologic examination."

I am not surprised that young men and women averaging 30 years of age or less have no primary care physician? I wonder what percentage of young people who are not surgical residents have one.

Should asymptomatic people in this age group or anyone in any age group have a general physical examination and lab work?

Thursday, June 8, 2017

More on artificial intelligence in medicine and surgery

Part 1

A survey published in the journal arXiv predicted with a 50% probability that high-level machine intelligence would equal human performance as a surgeon in approximately 35 years. See graph below. 
Click on the figure to enlarge it
We have already seen a machine beat the world’s best Go player. Although Go is a complicated game, it lends itself to mathematical analysis unlike what one might experience when doing a pancreatic resection.

A potential flaw in this study is that the surveyed individuals were all artificial intelligence researchers who predicted that machines would not be their equal for over 85 more years with the 75% likelihood of this occurring being over 200 years from now.

I suspect if surgeons were asked the same questions, we would say it would take over 85 years for machines to be able to operate as well as we can and 35 years until artificial intelligence researchers would be replaced by their creations.

[Thanks to @EricTopol for tweeting a link to the arXiv paper.]

Part 2

Similar to the question “who is responsible if a driverless car causes an accident?” is “when artificial intelligence botches your medical diagnosis, who’s to blame?” An article on Quartz discussed the topic.

[Digression: The article matter-of-factly states “Medical error is currently the third leading cause of death in the US… ” This is untrue. See this post of mine and this one from the rapid response pages of the BMJ.]

If artificial intelligence was simply being used as a tool by human physician, the doctor would be on the hook. However indications are that artificial intelligence may be more accurate than humans in diagnosing diseases and soon may be able to function independently.

If a machine makes a diagnostic error, are the designers of the software responsible? Is it the company that made the device? What about the entity owns the system? No one knows.

The Quartz piece did not address this. Who is responsible if a nonhuman surgeon makes a mistake during an operation?

I’m sorry I won’t be around 35 years to hear how this is settled.

Tuesday, June 6, 2017

Radiologists have an identity crisis

Here's a question that has been debated for several years: Should radiologists talk to patients about their imaging results? Citing several issues, I came down solidly on the "No" side in a 2014 blog post which you can read here.

Two major radiology organizations have committees looking into the concept, and New York Times article said, "they hope to make their case [for it] by demonstrating how some radiologists have successfully managed to communicate with patients and by letting radiologists know this is something patients want."

However, a recent paper presented at the annual meeting of the American College of Radiology raised a new issue.

Apparently patients need more basic information before talking to radiologists—namely what exactly is a radiologist and what does a radiologist do?

A group from the University of Virginia surveyed patients waiting to have radiologic studies performed and came up with some remarkable results. Of 477 patients surveyed, only 175 (36.7%) knew that a radiologist is a doctor, and 248 (52%) knew that radiologists interpret images.

Based on those findings, the investigators developed an educational program of PowerPoint slides which was shown to a new series of 333 patients in the waiting room. When surveyed after viewing it, 156 patients (47.7%) said they were aware that a radiologist is a doctor, and 206 (62.2%) knew that radiologists interpret images.

Both responses were significantly better after the educational presentation, but still, less than 50% of patients identified radiologists as doctors. Maybe the problem was the PowerPoint. Maybe radiologists need to wear scrubs or drape stethoscopes around their necks.

This is only a small study from one institution. Nevertheless before taking the big step of talking with patients, it suggests radiologists need to do a better job of explaining who they are and what they do.

We surgeons think we have an image problem when people say to us, "Oh, are you just a general surgeon?" They don’t know what we do, but at least they know we are physicians.

Thursday, June 1, 2017

The opioid epidemic: What was the Joint Commission's role?

Last year the Joint Commission issued a statement written by its Executive VP for Healthcare Quality Evaluation, Dr. David W. Baker, explaining why it was not to blame for the opioid epidemic. If you haven’t already read it, you should. Here is the first paragraph of that document:

“In the environment of today’s prescription opioid epidemic, everyone is looking for someone to blame. Often, The Joint Commission’s pain standards take that blame. We are encouraging our critics to look at our exact standards, along with the historical context of our standards, to fully understand what our accredited organizations are required to do with regard to pain.”

With the help of an anonymous colleague, I looked at some of the historical context.

In December 2001, the Joint Commission and the National Pharmaceutical Council (founded in 1953 and supported by the nation’s major research-based biopharmaceutical companies) combined to issue a 101-page monograph entitled “Pain: Current understanding of assessment, management, and treatments.”

Here in italics are some excerpts from it. My emphasis is added in bold.

Thursday, May 25, 2017

Are incentive spirometers useless?


Has this ever happened to you? You walk into a patient's room on postoperative day 1 and find the incentive spirometer still in its plastic wrap. And it's on a windowsill 10 feet from the patient's bed.

Here's another question. Does it matter?

A friend just had a 4-vessel CABG at a major academic center. Despite a lack of evidence that incentive spirometers are effective, he was told to use one in the hospital and to use it hourly at home which he has faithfully done.

That’s right. The effectiveness of incentive spirometry in postoperative cardiac and abdominal surgery patients has never been proven.

Three Cochrane Reviews (2007, 2012, 2014) have been done. In the 2014 review analyzing 12 studies with 1834 subjects who underwent abdominal surgery, the authors noted problems with study methodologies and lack of data on compliance with the use of spirometers. For preventing pulmonary complications, spirometry was not superior to deep breathing exercises or no respiratory intervention at all.

Monday, May 22, 2017

Finally, evidence clarifies the surgical caps controversy

A study of clean surgical cases found no significant difference in wound infection rates for 13 months before and 13 months after the use of bouffant surgical caps became mandatory. Infection rates for the 7513 patients operated on when surgeons were allowed to wear traditional skullcaps, was 0.77%, and for the 8446 patients who had surgery after the bouffant cap mandate, the infection rate was 0.84%. Subgroup analyses of only patients having spine or cranial operations showed similar insignificant differences in wound infection rates.

The study, from a group in Buffalo, New York, was published online in the journal Neurosurgery.

At the 2017 Americas Hernia Society meeting, Dr. Michael Rosen, director of the Cleveland Clinic Comprehensive Hernia Center, presented the results of a survey of 86 surgeon members of the society's quality collaborative.

Ventral hernia repairs were done in 6210 patients with a 4.1% incidence of wound infection. Risk factors for surgical site infection were obesity, hypertension, width of hernia, operation duration greater than two hours, and female sex. The type of cap worn was not associated with the occurrence of a wound infection or any other surgical site complication such as seroma, wound dehiscence, or enterocutaneous fistula.

Of the 79% of surgeons who responded, 48% said they wore disposable skullcaps, 9% wore cloth skullcaps, 29% wore bouffant caps with ears exposed, and 16% wore bouffant caps covering their ears.

[I know that adds up to 102%, but that's what the General Surgery News article about the paper said.]

The report mentioned a series of postoperative infections caused by a mycobacterium at an Israeli hospital in 2004. At the time, a newspaper account of the 15 breast plastic surgery patients said an investigation found the source was a surgeon whose hair and eyebrows were colonized from his home Jacuzzi.

In 2016, the surgeon published a paper about the incident. The organism had never been identified before and was christened M. jacuzzii. Several patients suffered persistent infections and required removal of implants. In the paper, the surgeon revealed he wore a standard paper cap [presumably a skullcap] and the organism was also found on his facial skin.

While some might suggest this paper justifies the use of bouffant caps, the surgeon could still have contaminated the operative field with organisms from his facial skin or eyebrows. Other than with a space helmet, complete coverage of the eyebrows and facial skin is impossible.

The paper from Buffalo had some limitations. It was from a single hospital and was not a randomized trial. However, it was sufficiently powered to detect a difference in infection rates.

The hernia study was not as scientifically rigorous as the Buffalo study, but enough procedures were analyzed to detect a difference in infection rates had one been present.

In the GSN story, the Association of periOperative Registered Nurses (AORN) response to the American College of Surgeons statement supporting the use of skullcaps was quoted. “Wearing a particular head covering based on its symbolism is not evidence-based [nor is the AORN's bouffant cap rule] and should not be a basis for a nationwide practice recommendation.”

Now that we have evidence that skullcaps are not linked to increased infection rates, will the AORN at last get over its obsession with bouffant caps?

My previous posts on this topic can be found here and here.

Friday, May 12, 2017

Can a med student who flunked Step 1 still become a surgeon?

I received these emails (italics) recently. The writer gave me permission to publish them. They have been edited for length and some details have been changed to protect his anonymity.

I'm a third year medical student at an allopathic state medical school. I've always wanted to do surgery. My problem is I failed USMLE Step 1 the first time and got a 207 on my second attempt. I hadn't failed anything else throughout first and second year, with the majority of my grades being my school's equivalent of Bs.

My surgery shelf exam was a week after I received my Step 1 score and, despite studying hard, my low score on that exam got me the equivalent of a C in surgery even with very good clinical evaluations. The rest of my third year has been good with most evaluations saying I'm well-liked and a team player.

Should I give up and go into a different specialty with better odds of matching? Apply to prelim surgery programs and categoricals? Or even apply to all of those things at once? I'm in a large pickle, paralyzed with indecisiveness, and would immensely appreciate your advice.


Disclaimer: This is my opinion. I do not presume to speak for all program directors. I'm going to be honest.

Thursday, May 4, 2017

Can surgical residents please have some autonomy?

A comparison of appendectomy outcomes for senior general surgeons and general surgery residents revealed no significant differences in early and late complication rates, use of diagnostic imaging, time from emergency department to operating room, incidence of complicated appendicitis, postop length of stay, and duration of postop antibiotic treatment.

The only parameter in which a significant difference was seen was that attending surgeons completed the procedure significantly faster by 9 minutes—39.9 vs. 48.6 minutes, but this may have been influenced by the fact that attending surgeons used laparoscopic staplers 13.5% of the time as opposed to use by the residents in only 2% of cases, also a significant difference.

This before-and-after study of more than 1600 appendectomy patients was published in JAMA Surgery. Between 2008 and 2012, residents were permitted to perform appendectomies without direct supervision by an attending surgeon. The pre-2012 group included 548 operations performed by general surgery residents alone. Because of a policy change, all of the appendectomies from 2012 to 2015 were performed by attending surgeons alone or directly supervising a resident.

Friday, April 21, 2017

Resources 3rd-year medical students study during general surgery clerkships

At the University of Florida medical school, the answers to that question varied widely. According to a paper published ahead of print in the American Journal of Surgery, students at UF use review books, e-books such as UpToDate, government agency and professional organization websites, textbooks, journals, and more.

The recommended textbook for the course is Lawrence’s Essentials of General Surgery, now in its fifth edition.

The authors surveyed the 133 members of the 2014-2015 third-year class, and 92 (69.2%) responded. Regarding each resource used, they could answer with one of four choices: always, usually, sometimes, never.

Friday, April 14, 2017

Should a consultant pass through the ED to see what's up?

A couple of weeks ago, this tweet appeared.
I could relate to it for two reasons. One, I lived in New York City in 1975, and here is the other.

Early in my career, I thought it was a good idea when leaving the hospital at night to exit via the emergency department to see if there were any potential surgery cases brewing. I was hoping to avoid going all the way home, getting paged to the ED, and having to go right back to the hospital. I soon learned to stop that practice because it was similar to poking a skunk.

Tuesday, April 4, 2017

Bizarre medical stories ripped from the virtual pages of the Internet

A 30-year-old California woman died after a naturopath gave her an intravenous infusion of turmeric—yes, turmeric, a spice used in curry, supposedly has anti-inflammatory properties when taken by mouth.

An naturopath who only uses turmeric orally was quoted in a San Diego ABC news report, "There are some doctors who use turmeric extract in IV form to try and heighten the physiological effects, so the anti-inflammatory effects of the turmeric. It hasn’t been well studied. It’s more theoretical, so it’s more investigational.” Unlike most naturopathic treatments, IV turmeric hasn't been well studied.

According to NBC San Diego, the medical examiner said she died of a heart attack and ruled the death an accident. In fact, the story was headlined "Tumeric Solution Through IV To Blame, in Part, For Women's Death: ME." In part?

The naturopath has yet to be named in any news story. How is this not manslaughter or criminal negligence? If an MD had given say, oregano intravenously, would it still have been an accident? Would the doctor's name still be unknown? I think it would be on Yahoo's front page.

Friday, March 31, 2017

Surgical fellowship match results for 2017

Two weeks ago, I reviewed the preliminary results of the 2017 main NRMP match. Data for the specialty match, also known as the fellowship match, recently became available. Here are the outcomes for the subspecialties of general surgery.

For abdominal transplant surgery, 36 of 58 programs filled, comprising 51 of 74 positions. There were 75 applicants with 24 going unmatched. The number of transplant programs has dropped from 69 in 2013 with a concomitant decrease in the number of available positions from 84 to 74. Applicants numbered 116 in 2013, and except for a slight upturn in 2016, interest has steadily declined. Consistent with the previous four years, US grads filled 31% of the positions in 2017.

Colon and rectal surgery filled all 56 programs and all 95 positions; 35 of the 130 applicants failed to match. Colorectal has filled 100% of positions available in three of the last five years. US grads filled 75% of the slots which is fairly consistent with previous years.

Pediatric surgery’s 44 programs filled all but one of the 45 available positions. This is the first time in the last five years that pediatric surgery did not fill 100% of its slots through the match. There were 96 applicants this year, and 52 of them did not secure a position. US grads filled 80% of the slots which is a slightly lower percentage than previous years.

Tuesday, March 28, 2017

An expert witness goes the extra mile

A Canadian dermatologist was found guilty of professional misconduct by a disciplinary committee of the Ontario College of Physicians and Surgeons. He had been accused of rubbing his penis against the legs of two patients he was examining.

In his defense, the doctor said it couldn't have happened because he was so obese that his penis was covered by abdominal fat.

After 38 days of testimony, the committee was in effect a “hung” jury regarding the penis allegation but found against the doctor for rubbing his abdomen against the patients without "any form of warning, apology or excuse." The committee found the conduct "disgraceful, dishonorable or unprofessional."

One of several fact witnesses, not a direct party in the case but having seen the doctor, was asked how she knew it was a penis rubbing against her. She said, “I’m a woman of almost 70 years; I know what a penis is and what it feels like. I have no doubt at all that it was a penis.”

The doctor was also found guilty on charges of touching a patient's breasts under her bra without a valid clinical reason for doing so and for not giving patients a warning or explanation before removing some of their clothes.

The most interesting part of the hearing was that both the defense and the college had retained expert urologists to examine the dermatologist to see if the patients' allegations would have been possible.

The defense expert examined the dermatologist with and without an erection and said it would not have been possible for him to have done what the patients alleged.

The urologist for the college pretended to be the patient on the examining table with the dermatologist reprising his role as the examiner. At three different table positions, the urologist said he was able to feel the dermatologist's chemically induced erection.

I tried to imagine the conversation between representatives of the college and their expert witness prior to his encounter with the defendant.

College: Are you willing to be our expert?
Urologist: Yes. What do I have to do?
College: You must determine if the accused's erect penis can be felt at various heights of the examining table.
Urologist: How should I do that?
College: Just give him a drug to produce an erection, lie on the table while the defendant presses up against you, and testify about what you feel.
Urologist: Say what?

I tweeted a link to one of the newspaper articles about this case, and @Laconic_doc said he knew all along “the evidence wouldn't stand up in court.”

References:
Globenews.ca
The star.com

Thursday, March 23, 2017

Evidence? We don’t need no stinkin’ evidence

One of my posts requires clarification. The post "A paper of mine was published. Did anyone read it?" went live in August 2014 and has been viewed 5133 times to date.

A reader had emailed me to ask if I might know why two papers he had written did not cause much of a stir in the orthopedic world. One reason might have been that the papers appeared in an obscure orthopedic journal.

I then wrote: "A paper in Physics World claims that that 90% of published papers are never cited and 50% are never read by anyone but the authors and the journals' peer reviewers." This is simply not true.

The link in the above paragraph originally went to a nebulous Indiana University web page and eventually became a "file not found." The source of the 2007 Physics World paper remained elusive. The subject came up again about a week ago on Twitter and a follower, @TirathPatelMD, sent me a link to the full text.

Friday, March 17, 2017

Brief summary of 2017 residency match data

Here are some snippets from the NRMP Advance Data Tables for the 2017 Main Residency Match.

The number of PGY-1 positions offered was the highest total ever. US allopathic medical school seniors in the match numbered 18,539, which is also a new high. Only 5.7% of US seniors failed to match. That was a slightly lower percentage compared to 2016 and 2015.

The numbers were not as good for previous graduates of US allopathic medical schools with only 46% of 1472 applicants matching. Osteopathic graduates fared better with 81.7% of 3590 applicants matching.

I have blogged about the prospects for international medical school graduates. Of the 5069 US citizen graduates of international medical schools, 54.8% matched—a rate consistent with the totals for the last four years.

Wednesday, March 15, 2017

Nonoperative treatment of appendicitis in children: Is it safe?

After writing my 21st post about appendicitis back in November, I swore I would not write about it again for the foreseeable future.

Well, the future is now because investigators from the United Kingdom and Canada just published a meta-analysis including 10 papers and 413 children about the efficacy and safety of nonoperative treatment for appendicitis in children.

They concluded that nonoperative management is effective in 96% of children with acute uncomplicated appendicitis during their initial hospitalizations with just 17 (4%) children requiring appendectomy before discharge. An additional 68 (16.4%) developed recurrent appendicitis later, and 19 of these patients were treated with the second course of antibiotics. The other 49 underwent appendectomy with histologic evidence of recurrent appendicitis.

Another 11 patients underwent appendectomy in the follow-up period for various reasons. In all, 77 (18.6%) patients initially treated with antibiotics eventually underwent appendectomy.

Although the initial hospital length of stay for appendectomy was shorter than that of patients treated with antibiotics, complication rates were similar.

These findings were met with headlines like "Antibiotics, not surgery, could treat appendicitis in children, study suggests" from The Guardian and "Is Surgery Always Needed for Kids' Appendicitis?" from US News.

What are the problems with this paper?

Wednesday, February 22, 2017

Vacation notice

As of the evening of February 22, I will be out of the country with limited Internet access. I'll be back on March 12.

Comments left on posts may not be approved for a few days. Please be patient.

Thanks for reading.

Friday, February 17, 2017

Will robots eliminate the need for surgeons?

A medical student from Germany emailed me saying he had always wanted to be a surgeon, but someone told him that by 2030 surgeons would no longer be needed because robots would be doing all the operations. He worried that after years of studying and hard work, he might lose his job to “R2-D2.”

He mentioned IBM’s Watson and a recent paper that appeared in the journal Science Translational Medicine about a robot that can handle and suture bowel.

He asks, “What do you think about the future of surgery?”

Thank you for your email and the link to the paper.

I read the paper and was amused by its title "Supervised autonomous robotic soft-tissue surgery" which is an oxymoron. The definition of autonomous is "acting independently or having the freedom to do so." This “supervised” robot is not really autonomous.

The robot is capable of performing a nearly technically perfect intestinal anastomosis but still needs a human surgeon to open the abdomen, prepare the bowel for the procedure, tidy up, and close. I'm not sure that this is any different than when surgical staplers were introduced. This robot is simply making the operation easier and possibly more precise.

Surgeons will still be needed in case the robot makes a mistake like causing bleeding while placing a suture near the mesentery. If bleeding in that area is not promptly controlled, a large hematoma can develop and possibly compromise the blood supply to the anastomosis. And will the robot be able to decide who needs an operation and when to do it?

One worrisome byproduct of surgical stapling is that many graduates of residency programs within the last 15 or 20 years have little experience in performing a hand sewn bowel anastomosis. What will they do if the hospital runs out of staplers? Soon, I guess they could consult the (somewhat) autonomous robot.

I have written about automation and the erosion of surgical skills. This problem also affects pilots. I have also addressed the concept of  robots operating alone. I don't see it happening any time soon.

I think there will always be a need for surgeons. Even the smartest robot is going to have some trouble dealing with a trauma patient who is hypotensive.

The future will take care of itself. In the 1980s, people were concerned about the demise of general surgery. Opinion pieces with titles like “Will the general surgeon become extinct?” and “Is general surgery a dying specialty?” appeared in major journals like JAMA and the World Journal of Surgery.

Then in 1990, laparoscopic cholecystectomy opened the door to a whole new area of general surgery that no one had ever dreamed of.

Good luck with your studies and your surgical career.

Tuesday, February 14, 2017

Can a cop’s baton accidentally slip into a man’s anus?

I doubt it.

A French police officer has been charged with rape after a black man who was being arrested suffered severe anal injuries.

After witnessing an officer slap someone, the 22-year-old had allegedly approached a group of policemen. The victim claims he was handcuffed, called names, and beaten. He says his pants were lowered and he felt pain in his buttocks.

At the police station another officer noted that he was covered with blood. He was taken to a hospital and diagnosed with the anal trauma which required “major surgery” including a colostomy. The family was told incontinence may result.

Doctors said the injury had been caused by a police baton which had been forced into his anus.

The Washington Post quoted the findings of a police investigation: “The violent sodomy was accidental and occurred when the officer’s expandable baton happened to slip into the victim’s anus.”

According to another story, “a French police union spokesman said there was no evidence so far that ‘the truncheon was actually introduced’ into the victim's rectum. And if that actually happened, it was likely done ‘accidentally.’”

A third story said, “a lawyer for the officer charged with rape said ‘the blow had been carried out in a totally involuntary manner, without his being aware of any injury.’” The word “his” must be referring to the officer because I have no doubt the victim was quite aware.

Based on my 40+ years of experience as a surgeon, I can assure you the police version of the incident is highly implausible. A patient who does not wish to undergo a rectal examination by a physician with a gloved and lubricated index finger can easily prevent it from occurring by voluntarily contracting his anal sphincter and gluteus muscles.

I would imagine a healthy 22-year-old man would react in exactly the same way if a policeman’s baton “happened to slip” with the end anywhere near his anus.

The incident has sparked many protests in France and has been widely reported by news media. Of the several accounts I have read, not one has asked a surgeon to comment on the nature or possible cause of the injuries.

Bottom line: A police baton slipping into a man’s anus is about as likely as a man accidentally falling on a woman and penetrating her.

From International Business Times
Thanks to @Tosk59 for the tip on the International Business Times story.