Buckeye Surgeon

Christie Gets a Band

2013-05-09T10:25:00.003-04:00

I had blogged a while ago about New Jersey governor Chris Christie's angry response to a former White House physician's opinion that he needed to think about losing some weight. Christie basically told the doc she needed to mind her own business. My take was that, morbid obesity being a risk factor for coronary artery disease, stroke, and early death, Christie's weight would be a issue I considered if and when he decided to run for the Presidency in 2016. In order to be reassured that he could withstand the stress and pressure of being the leader of the world's only superpower, I indicated that I would need to see recent stress test/cardiologist bill of good health records before I even considered casting him a vote. The blog was cross posted at KevinMD and subsequently set off a firestorm of conflicting opinions. Many commenters felt strongly that it was a form of bigotry to even mention his weight when considering him for higher office.

Again, I have no doubt that an obese person could be an excellent US President. But I would be more likely to vote for him if I knew he wasn't necessarily a ticking time bomb for a major heart attack. And publicized stress test results (just as melanoma survivor John McCain published his records from his oncologist when he ran for office in 2008) would go a long way in setting my mind at ease.

And now we find out that Mr Christie recently underwent Lap-Band weight loss surgery. Why would he do such a thing? I thought obesity was irrelevant to the discussion of higher office? According to the governor:

“For me, this is about turning 50 and looking at my children and wanting to be there for them."

I see. Sooooo, weight loss is.....good? I don't want to be a bigot.

But why did the dude get the Lap-Band? Doesn't he have a coterie of advisers and lackeys? The Lap-Band results in less long term weight loss than a gastric bypass and the complications/annoyances that develop over the long haul with the Bands often necessitate their eventual removal.

Anyway, best of luck to the Governor in in weight loss endeavors.

Defensive Medicine and the Drone Wars

2013-05-09T09:53:00.002-04:00

From my interview with Andrew Thompson the other day, the issue of a medical malpractice crisis was raised. Mr Thompson averred that such a concept is pure myth, a spook story older docs tell young interns around the campfire at night. And he may be right. In a paper from the Journal of Healthcare Quality, researchers at Johns Hopkins demonstrated, using data from the National Practitioner Data Bank, that "catastrophic claims" (those awards in excess of $1 million) totalled about $1 billion per year, a figure that represents just 0.05% of total national healthcare spending in this country.

Now one could retort that "catastrophic claims" account for only 36% of total claims over the time period (unduly neglecting the effects of smaller claims up to $1 million) or that the study doesn't include the settlements made with hospitals and healthcare corporations, only individual physicians. But the data are eye opening nonetheless. Total number of med mal cases have been dropping precipitously over the past ten years. The costs of waging a medical malpractice case are prohibitive for most law firms (discovery, expert witnesses, contingency based fees, physicians win 70% of cases that go to trial, etc). So why is tort reform still the linchpin piece of alternative national healthcare reform plans? Why do the GOP and physicians organizations continue to shout from the rooftops that medical malpractice represents the single biggest threat to American healthcare? Why has the refutable become dogma in the minds of otherwise intelligent people?

And what do physicians do to avoid the threat of this med mal crisis? We over test. We over treat. We practice defensive medicine. This is the true monetary cost of med mal fears. In the paper I alluded to above, defensive medicine contributes upwards of $60 billion to total healthcare costs. If the fear is exaggerated, why do we continue to order CT scans on every single patient who complains of a headache? Why does every post op patient with a HR over 100 get a CT angio to rule out pulmonary embolism? Why are all these dehydrated nursing home ladies with coffee ground emesis getting upper endoscopies every other year? What are we afraid of? Why do we continue to perpetuate the practice of fear?

It's been twelve years since the Twin Towers were taken down by a ragtag band of nihilists. Since then we have spent trillions of dollars to avenge that fateful day. We launched wars. We invaded a country that had nothing to do with 9/11. We ventured into the "dark side" and institutionalized barbarities such as pre-emptive war, rendition, indefinite detention in black site prisons, torture, and secret, unaccountable drone strikes against alleged "suspected" militants across the globe. The world is now our battlefield. Zero tolerance for terrorism has become a bipartisan consensus. Risk is not something to be managed judiciously; it must be eliminated altogether. And so we end up justifying the unimaginable---waterboarding, locking people up in a Caribbean Island cage indefinitely without charges, due process free state assassinations, etc etc. And now we are waging full blown drone warfare against targeted "militants" across the globe, shrouded in complete and utter secrecy. Certainly this form of state sanctioned violence mitigates the political fallout from soldiers being shipped back to America in coffins. But the blowback from the Muslim world is unquantifiably immense.

And what is the actual threat of terrorism? According to the Global Terrorism Database, 30 Americans have been killed in terrorist incidents since 9/11/01. And this includes non-Islamist attacks. According to Ronald Bailey and Reason.com:

Taking these figures into account, a rough calculation suggests that in the last five years, your chances of being killed by a terrorist are about one in 20 million. This compares annual risk of dying in a car accident of 1 in 19,000; drowning in a bathtub at 1 in 800,000; dying in a building fire at 1 in 99,000; or being struck by lightning at 1 in 5,500,000. In other words, in the last five years you were four times more likely to be struck by lightning than killed by a terrorist.

Similarly, the threat physicians face from malpractice litigation is probably far overrated. And we fail to appreciate our own unintended "blowback'' from the defensive medicine mindset. Our patients are subjected to unnecessary, potentially harmful, testing. We end up referring them for unnecessary invasive procedures. We compromise the sacrosanct doctor/patient relationship by adopting an adversarial, wary posture toward these people who come to us for answers and help. We are so cautious and worried about being sued that we put our own interests above those of the patient. It's sad. I fall into the same trap myself on occasion. And I fear that defensive medicine has transcended being simply a reaction to a perceived threat. At this point it has become reflexive, institutionalized behavior. We order that CT scan not because we are worried about being sued anymore; it simply has become second nature. Just as we now take off our shoes at the airport without even thinking about why and whether it actually does any good.

Risk is ever present, every day in both medical practice and counter terrorism. It lurks on the periphery. The mistake is acting as if risk is something we can eliminate. The more open we are, the more we acknowledge the reality and inevitability of rare breakdowns, the more likely it is we can implement strategies to minimize risk occurence over time.......

World Class

2013-05-03T11:15:00.002-04:00

This is what can happen when a private practice surgeon refers a complicated colon cancer patient to a medical oncologist affiliated with a certain multinational, gigantic world-famous non-profit health care system.

Let's say the surgeon is asked to see a patient with a large bowel obstruction. Perhaps the colonoscopy demonstrated a high grade constricting lesion in the distal sigmoid/upper rectum and the CT scan revealed a massive, locally infiltrating mass invading into the bladder and a possible liver lesion. Perhaps the patient has lost 30 lbs recently and has noted foul smelling material in her urine. The surgeon is concerned about diffuse tenderness on exam, possibly due to impending cecal ischemia. He books the case for the OR and curbsides a med oncologist on treatment options. Should I just divert? Would there be a role for neoadjuvant chemoradiation? Or best to just try and resect now with possible pelvic exenteration? The med onc guy isn't too certain. Whether there is liver involvement or carcinomatosis is key. But no time to determine that now given presence of an acute abdomen. He thinks the case ought to be presented to the tumor board and perhaps a multidisciplinarian consensus could emerge. The surgeon thinks this seems reasonable. He performs a laparoscopic diverting colostomy and places a mediport. CT guided liver biopsy is scheduled as an outpatient. She recovers from the surgery and is discharged home. Her instructions are to follow up with a med oncologist from the world-famous healthcare conglomerate close to her house, in addition to seeing the surgeon. Arrangements are made for the case to be presented at next week's tumor board. Patient's parting words to surgeon are: whatever you guys decide, I want you to do the surgery. I trust you

Two weeks go by and the surgeon has not seen the patient in his office. He doesn't see her name on any future appointment lists either. No one answers the listed phone number. His secretary tells him there is a Dr X on hold to discuss a patient. Dr X is the original med onc guy he had curb-sided. Dr X is energetically imperturbable and affable on the phone:

-Hey man, just wanted to give you an update on that one lady.
-OK. Did you ever talk about her in the tumor board downtown?
-Um yeah. She actually just had surgery.
-I'm sorry?
-Yeah, one of my colleagues saw her in the office. At tumor board we agreed that if the liver mass was benign then surgery would be the initial move.
-She had surgery?
-Yeah, my colleague referred her to Dr Y.
-That's nice to know
-I guess they had to do some sort of modified exenteration procedure, partial bladder resection, hysterectomy...
-Good to know. Good to know that when I refer patients to you guys that I will never see them again.
-Sorry man. My colleague saw her. He usually uses Dr Y for cases like that.
-Yes. Your colleague. Thanks for the update. I hope she does well.

Click.

These hypothetical situations can be rather discouraging....

Gitmo Force Feedings

2013-05-02T09:58:00.000-04:00

In response to over a decade of indefinite detention without charges or trial, with no foreseeable hope of ever being repatriated home, with no hope of ever seeing wives and children again, over 100 inmates at the American Gulag in Cuba are now participating in a mass hunger strike. Of the 100, our medical personnel in Guantanamo are now force feeding 21 of them using silastic nasogastric tubes. (The above image is the chair at Gitmo used to restrain prisoners while the tubes are forcibly inserted.)

The American Medical Association (AMA) has again gone on the record condemning the practice of forced feedings. In a letter to Defense Secretary Hagel, AMA President Dr. Jeremy Lazarus wrote:

“Every competent patient has the right to refuse medical intervention, including life-sustaining interventions,” Lazarus said, adding that the AMA took the same position on force-feeding Guantánamo prisoners in 2009 and 2005.

“The AMA has long endorsed the World Medical Association Declaration of Tokyo, which is unequivocal on the point: ‘Where a prisoner refuses nourishment and is considered by the physician as capable of forming an unimpaired and rational judgment concerning the consequences of such a voluntary refusal of nourishment, he or she shall not be fed artificially.’”

Let us be clear: force feeding constitutes an assault on human dignity. It violates a physician's ethical obligation to respect a patient's autonomy. Whoever these physicians are at Gitmo who are supervising and ordering the forced feedings ought to have their medical licenses revoked immediately.

Our President's excuse is that "I don't want these individuals to die". I wonder what he would think of a physician who performed an unwanted laparotomy on a patient for colon cancer without the patient's consent and then gave the excuse that if he didn't do the surgery the patient was sure to die? Maybe we should perform CPR on all 90 year old nursing home residents during a code blue regardless of dictates from a living will because, otherwise, without the CPR the patient would die. It's an absurd, self-indulgent, self-congratulatory statement from a morally compromised President. Why doesn't he want them to die? Because he cares about them? Because of his strong moral conscience? Or is it that the scandal of mass deaths from self-starvation at a modern gulag would represent blood on his hands?

It's difficult to imagine the degree of despair and hopelessness that would drive someone to consider death by starvation. Living here, in the suburbs with good schools and superstores and soccer practices and traffic jams and sports talk inanity and SUV's and wide expanses of useless manicured green lawns and all the fineries of middle class American life, it's unfathomable to consider the circumstances that would lead to such a choice.  It's just unimaginable; to voluntarily embark upon a course of self-annihilation by denying such a core human drive as hunger

But our President thinks the solution is to demand that healthcare professionals violate a core ethic by forcibly feeding these prisoners, thereby crushing the last vestige of personal autonomy they have left. Enough is enough. It's time to close this dark chapter in American history.

Interview with the Lawyer

2013-05-01T17:36:00.001-04:00

My interview series continues, this time with local ~~vampire~~ litigation attorney Andrew Thompson, Esq. The topic this time is medical malpractice. I asked him a bunch of questions. He answered. See what you think.

Background on Andrew Thompson:

I attended Syracuse University Newhouse School of Journalism, transferred to CWRU and received a BA in Political Science in 1996. I obtained my J.D. from CWRU School of Law in 1999 and passed the Ohio Bar Exam. In addition to Ohio, I have handled cases in courts in Pennsylvania, New Jersey, Florida, and West Virginia.

I was an Associate at Chattman, Gaines & Stern in Cleveland until that firm dissolved in 2001. I moved with a partner from CG&S to Stege & Michelson Co., LPA, and became a partner at that firm a few years later. In October 2010, I left that firm to start a litigation firm in Beachwood -- Dubyak Connick Sammon Thompson & Bloom, LLC. The firm has a focus on litigation, and my practice concentrates on railroad law, labor/employment and personal injury matters mostly from the plaintiff’s side, including medical malpractice. Every firm that I’ve worked at has handled medical malpractice cases.

#1: In your opinion, is there a medical malpractice crisis in this country?

No. This is not even a close issue. The concept of a “crisis” or dramatic increase in the number of medical malpractice cases is a fabrication created by the U.S. Chamber of Commerce and the insurance industry. High-priced public relations firms have been hired to disseminate this message to the general public to generate support for tort reform bills. For the most part, the effort has been successful. The average person firmly believes there is a crisis, and tort reform bills have been passed in many States, including Ohio in 2003.

The Supreme Court of Ohio maintains statistics on civil (non-criminal) cases filed in the State. The following is a list of new cases filed statewide in Ohio from 2000 to 2011 that are classified as “professional torts.” Professional torts include not only medical malpractice claims against doctors, but also claims against lawyers and/or accountants. 2000 – 2,704 cases; 2001 – 2,650 cases; 2002 – 2,972 cases; 2003 – 2,683 cases; 2004 – 2,250 cases; 2005 – 1,908 cases; 2006 – 1,502 cases; 2007 – 1,483 cases; 2008 – 1,411 cases; 2009 – 1,368 cases; 2010 – 1,422 cases; and 2011 – 1,230 cases. As a percentage of all civil cases filed in Ohio, professional torts represent about 0.25% to 0.5% of the total.

As these numbers make clear, the number of malpractice cases filed in Ohio was never at a level which indicated a problem with our justice system, even before the passage of tort reform. This impression grew because of the amount of money invested by the insurance lobby and the Chamber of Commerce into their “public relations” budgets, not because of the reality of what was actually occurring. Consider, by comparison, the number of foreclosure cases in Ohio. In 2000, there were 35,382 new foreclosure cases filed in Common Pleas courts statewide; by 2010, that number grew to 85,483. Those numbers may actually indicate a problem, however there are not many lobbyists pushing for a bill to limit the banks’ access to the courtroom when they have been “wronged.”

#2: Talk about the concept of “frivolous lawsuits.” To what extent does it occur?

It is difficult to try to quantify a precise number of “frivolous” lawsuits because the concept is subjective. At what point does a case that is close on the issue of liability become frivolous? The answer to that question certainly would differ depending on whether you ask the family of a patient or the treating physician. I can generally state that it is not a common practice, particularly in the area of medical malpractice, for one very obvious reason – a lawyer will go broke very quickly if he is filing and investing money in frivolous cases. A better way to explain this, and answer your question, is to look at how a “frivolous” lawsuit is handled by the justice system.

The idea that a lawyer can file suit for virtually any injury, regardless of the circumstances, and bully a doctor or insurance company into paying money in a settlement is unrealistic. Since the vast majority of medical malpractice cases result in a verdict in favor of the defendant, insurance companies rarely settle matters before litigation unless the liability of the physician is clear-cut. This forces an attorney to spend significant amounts of money on expert reviews of a case, which is required before a malpractice lawsuit can be filed. As a part of tort reform, a malpractice complaint must be accompanied by an Affidavit of Merit, which is a sworn statement by an expert in the subject medical field stating that the defendants’ actions in a case fell below the applicable standard of care, and the plaintiffs were damaged as a direct result. After the case is filed, discovery and depositions begin, including multiple expert depositions, before an insurance company will typically even consider settling a case. At this point, the plaintiff’s attorney’s investment has reached into the tens of thousands of dollars. If the case is frivolous, and there are experts for the defendant to support that notion, the plaintiff will most certainly lose the case and all of that investment.

In addition to the financial disincentive, there are procedural safeguards in the system to prevent the filing of such claims. A judge can dismiss a claim without a trial if the facts do not support a case against a defendant. The judge also has discretion to sanction an attorney who has no basis for the lawsuit (although this admittedly is rarely done). If a case is clearly “frivolous,” it will almost certainly not make it to a jury. But even if it does slip through the cracks, the ultimate filter for such cases is the jury itself. After being bombarded for years with stories of good doctors fleeing the state because of lawyers filing suit, it is virtually impossible to convince a jury to award money for a “frivolous” case.

But what about the McDonald’s coffee case, you ask? I won’t waste a lot of time on that issue other than to say that the facts of that case are much different than the public was led to believe. The woman who was injured did not receive the huge sums that were reported (because the system works), and the case under the circumstances was not as “frivolous” as you might think. The documentary Hot Coffee, which was recently shown on HBO, touches on a number of those issues in more detail than I can discuss here. See http://www.hotcoffeethemovie.com/

#3: What is your stance on personal injury lawyers/firms advertising on TV/radio/Cavs games for business?

If it is done properly, I think it is not only acceptable, it is necessary. As discussed even on this blog recently, there tends to be different levels of justice in this country based on how much money you have to invest in good attorneys. If you are a wealthy individual or a big company, you probably have lawyers on retainer that you can call anytime an issue arises. If you are poor, and become an accident victim, it is important that you know that you have equal access to the court system and you can call an attorney who will talk to you for free. In this way, lawyer advertising that educates the public is beneficial. The poor accident victim would probably not know anyone to call without some form of advertising of legal services.

And then there’s the Hammer. Obviously, this type of advertising does not send the right message. Each State has its own ethical rules to limit certain types of attorney advertising, but apparently the rules can’t stop the Hammer. As with any business for profit, people will sometimes do whatever they can to attract clients/customers. The legal business is no different. Accountants put people dressed as the Statute of Liberty on the side of a busy intersection with a spinning sign during tax season, and attorneys will buy commercials starring the Hammer. Although distasteful, I think it’s a necessary evil to achieve the first goal I stated above.

#4: What could doctors do to limit their liability, reduce possibility of lawsuits.

I recently met with a man in southern Ohio to discuss a possible malpractice case where his wife of 43 years died somewhat suddenly after a routine test in the hospital. The man is very conservative, and felt quite uncomfortable discussing the situation with an attorney. He did not like lawsuits, and believed there was something immoral about suing somebody, as if it would be a direct attack on the person. His wife was in her mid-80’s at the time of her death, so although it was unexpected, the outcome might have just been caused by her body wearing down after a long and active life.

So why did he call me? What raised his suspicions in this case? It turns out that something went wrong during the routine test, but nobody in the hospital, including the treating doctor, ever notified the family. The man first became aware of the problem when a doctor doing rounds in the intensive care unit mentioned the issue (likely assuming the family already knew). When the man later confronted the treating doctor about the situation, the doctor became very defensive, denied that the mistake was an issue, and concluded by telling the grieving man, “If you think I did something wrong, go ahead and sue me, I have insurance.” The man was so offended by the doctor’s attempt to hide his mistake and his lack of compassion for their loss that he felt compelled to explore the possibility of a malpractice case.

From my perspective, I think one of the best ways to avoid lawsuits is to be honest with your patients. If routine mistakes are made during treatment, people may be forgiving if you let them know immediately what happened and what you are doing to correct the issue and give the best care to their loved ones. I can state definitively from meeting people like the man in the example above that if the treating doctor would have been honest about what happened, and expressed some compassion, I would never have been consulted.

Before all of your readers in the medical field question my motives here and think the plaintiff’s lawyer is simply trying to get us to admit fault so he can sue us later, the very conservative Ohio legislature has you protected. Ohio Revised Code Section 2317.43 makes any expression of sympathy or apology by a medical care provider following an unexpected outcome in treatment inadmissible in a civil case. So not only is that apology inadmissible, in my opinion it will more often than not keep a case from ever being filed.

#5 What are your ideas on proposals such as “health courts” and “no-fault compensation” paradigms, seen in other countries?

There is no more fair system of justice, whether in a medical malpractice case or a death penalty trial, than a presentation of facts before a jury of your peers. I am generally opposed to any system that removes from a person his or her Constitutional right to a jury trial. The underlying assumption in consideration of such a system is that our current legal system is not working; as I suggest above, that basic assumption is not accurate. Without the myth of frivolous lawsuits and runaway jury verdicts, there becomes no need to even consider health courts.

Instead of changing a legal system that is not broken, I would suggest that politicians consider further regulation of the insurance industry. To the extent doctors are fleeing a state because of malpractice, they are doing so because their insurance rates have gone up so dramatically that they can’t afford to continue in practice. Are those rates skyrocketing because of lawsuits, or poor returns on investment of premiums? Statistics suggest the latter. If public policy demands protecting good doctors who rarely make mistakes, then limit the amount that insurance companies are permitted to raise malpractice insurance rates in a given year. These good doctors will then know that, even if they make a mistake and get sued, they will be able to afford to continue their medical practice. There will be less of a need to practice “defensive” medicine, and patients who are injured have access to the legal system.

#6 As doctors increasingly find themselves in employed positions, do you think lawsuits will increase or decrease? Will instead patients seek redress against large healthcare providers, i.e. Cleveland Clinic, Kaiser?

The employment relationship between physician and hospital does not significantly affect the likelihood that a physician will be named in a lawsuit. If the physician is an employee, both the employee committing malpractice and the employer hospital can be found liable under the legal theory respondeat superior. If the physician is an independent contractor, the hospital may still be held responsible for the actions of malpractice under agency theories if the patient looked to the hospital, not the independent physician, to provide competent medical care. For example, if a patient rushes to the Emergency Room at University Hospitals, he or she is not looking for a particular doctor, but is going because UH has a good reputation. If the doctor commits malpractice while treating the patient, even if the doctor is an independent contractor, UH may be held responsible for the acts of its ER physician.

Although the employment relationship is not particularly important, other factors in the legal system actually do increase the chances that you will see your name in a lawsuit. For example, the statute of limitations for malpractice cases is too short. By the time most attorneys are first contacted by a patient regarding a medical malpractice claim, there is insufficient time to fully flush out the issues and identify the proper parties. As a result, lawyers are forced to name in the lawsuit every physician that had input into the client’s care. (This is equivalent to “defensive medicine” in the legal system). Those physicians that are later found to not be involved are dismissed from the case. This is a small consolation for a doctor who now has to list the lawsuit on his malpractice insurance. If the statute of limitations was expanded to two or three years, there would be sufficient time for attorneys to identify only those parties that are responsible and narrow the pleading.

#7 Absolute transparency is a terrifying notion for most practitioners. We all have bad outcomes and make mistakes. Do you think public disclosure of all hospital/doctor/surgeon outcomes would improve the current somewhat antagonistic relationship the general public sometimes adopts toward physicians or would it make things worse?

Although many plaintiff lawyers would love public disclosure of outcomes, I think from a practical perspective it is a terrible idea. Whether you are resolving a lawsuit set for trial or treating a seriously ill patient, there are too many variables that influence an outcome to allow the public to determine whether the result was “successful.” Publicizing an admitting diagnosis, treatment, and discharge diagnosis does not tell the full story, and would likely unfairly influence the public’s perception. If grandpa goes in for a hip replacement, and a previously undiscovered underlying medical problem causes his death during the operation, should the orthopedic surgeon be publicly charged with causing his early demise? How many resources are we going to devote to making sure public disclosure of medical procedures are accurately reported?

Although full disclosure to the public is not an idea I support, I would again emphasize that absolute transparency to the patient and family is important. Nothing has a greater impact on the decision of whether to pursue litigation, and the outcome of litigation, as a physician who intentionally withholds mistakes from his or her patients.

#8 What are three things a physician can do to reduce his/her legal liability?

Be honest. Focus on mitigating the effects of a mistake instead of covering up its existence. Most patients and their families will forgo litigation against a doctor they trust, even with knowledge that malpractice might have occurred. And even if your patient ultimately sues, any statements you make to them as an apology are not admissible.

Keep good records. Particularly with increased use of electronic medical records, attorneys will find out not only what you wrote in your records, but when you looked at them or made any changes. There are many cases in which physicians try to “edit” a patient’s chart after it becomes clear that a malpractice case might be on the horizon. Juries typically do not appreciate such tactics, and it will show in the size of a verdict. If you are thorough with your recordkeeping, no changes to the chart will be necessary, and your attorneys will be better prepared to defend you.

Educate yourself about the legal process from independent sources. Too many physicians I talk to have completely bought into the propaganda being pushed on the general public about greedy attorneys filing lawsuits over every bad outcome and runaway juries awarding multi-million dollar verdicts. It would be stressful for any physician to practice medicine while believing The Hammer lurks behind every corner. Find out the facts, and understand what happens when you are named in a lawsuit. Armed with this knowledge, you will be far less concerned with litigation and more focused on your patients.

Complications and Profits

2013-05-01T17:36:00.000-04:00

This paper from JAMA had the health blogosphere in a tizzy recently. The Boston Consulting Group reviewed surgical discharge data from a 12-hospital system in the southern US to see if there was a "relationship" between surgical complications and hospital profits. Their findings were obvious and unsurprising:

When a privately insured patient experiences one or more complications -- such as blood clots, stroke, infection, septic shock, pneumonia or cardiac arrest -- hospitals' profit margins are 330% higher compared to a patient with no complications, the report found.

For Medicare patients with complications, hospitals' profit margins are 190% higher, according to the report...

So if a patient develops a medical condition that requires further medical treatment with utilization of resources and involvement of other specialists then we are supposed to be astounded that the resultant costs will be higher? This may sound controversial but who cares? Why is this an issue? The problem is being painted as one of doctors expecting to be paid for doing the hard work of managing a surgical complication. Complications are part of medicine, especially surgery. A major part of what makes a good general surgeon is his ability to manage a difficult case, including the judgment as to when to return a patient to the operating room. Anastomotic leaks in Crohn's patients on steroids will happen. Bile leaks from the liver bed will occur at a fairly regular statistical probability. Old ladies who undergo major abdominal resections will develop post op pneumonias despite the best preventative measures. Sometimes you have to try to make a chocolate cake out of mud and stones. You do the best you can. Success is not measured in terms of cost overlays but as to whether or not you can get the patient from the ICU to a rehab bed in a safe, timely fashion.

Barry Rosenberg MD sort of tip toes around the implications:

Hospitals make more money the longer a privately insured or Medicare patient stays, said Rosenberg, a partner with BCG's health care practice. As a result, they may lack financial incentives to take steps to reduce surgical complications, he said.

"Insurers are rewarding hospitals when there are complications," he said. "This is not the type of incentive you want ... in the healthcare system for your family."

So what do you mean by that Barry?

The report isn't suggesting that complications are caused intentionally, said Dr. Rosenberg, a co-author of the study. But he hopes the findings provoke discussion on the "absolute need for payment reform,"

Ah, that's nice. He doesn't "believe" that doctors are causing complications intentionally in order to gin up a few extra buckaroos. That sort of validation ought to set everyone's mind at ease. Jesus. Healthcare workers intentionally harming patients for cash. It's like a plot line out of a bad Robin Cook novel.

What I would like to see is a discussion not so much on payment reform but on the baseline costs of healthcare. Why do medical device companies operate at such obscenely high profit margins? Why are the pricing data at large hospitals so shadowy and obscure? Why can't Medicare negotiate reasonable prices with Big Pharm? If the starting costs were a little more reasonable, then it wouldn't be so controversial for a physician to expect to be compensated for his/her work.

MRCP: Stop Already.

2013-03-23T12:13:00.001-04:00

A typical general surgery scenario plays out like this. Patient comes into ER at 1AM with RUQ pain, gallstones on US, elevated WBC and mildly abnormal LFT's. The patient is admitted, hydrated and started on antibiotics with the plan to re-assess in the morning. I see my ICU patients, do a 7:30 case and then check the overnight admit's morning labs. The WBC is now normal and the bilirubin is slightly improved (down to 1.4 from 1.9).  I go to see her but she's gone. I query the nurse. Nurse says she's off to MRI. I sit down in patient's room, watch TV for a bit, perhaps eat one or two of the sausage links off the plate of her sleeping roommate. No, I don't do that. I just go drink some more sour free coffee and see other people, silly.

I tell the nurse to text page me when she gets back. She does so. I race back between cases. The patient "feels much better". Her abdominal exam is rather unremarkable.  We shoot the shit for a while re: biliary pathophysiology (involving crudely drawn anatomic diagrams on the back of patient satisfaction survey forms; I like the way I draw the stomach but my gallbladder/biliary ductal rendition looks rather like the way a kindergartner would draw equine procreation). There's an opening in the afternoon. She doesn't want to ever experience the sort of pain she had last night.  I commiserate. I can imagine, I say, although I can't, having never experienced a gallbladder attack myself so to reproduce empathy I imagine that one time I spilled lye on my leg working at a metal treatment plant in the summer and the lye ate through my jeans, my epidermis, the dermis and bits of the subcutaneous fat.

In the OR I do a cholangiogram, AS PER USUAL. The c-gram is completely fine. No filling defects.  Patient grateful and happy. She is discharged that evening.  As I type all the mindless useless discharge info into the EMR I notice the MRCP report has finally gone live. The MRCP is normal. I fall to my knees and thank the Lord.  I tell the nurses who eye me suspiciously that I am falling to the floor and praying in an ironic fashion, as a way to amuse my internal voice. The patient never asks about it.  I muse fleetingly about who actually ordered it.

From the American Journal of Surgery is a retrospective review of the accuracy of MRCP when correlated with intraoperative cholangiogram findings. The results are sad sad sad:

Results
Four hundred twenty patients who underwent IOC were reviewed and met criteria for the study. Seventy patients had preoperative MRCP. Accuracy of MRCP when compared with IOC was 70%.

Conclusions
MRCP has a high rate of false normal results compared with IOC and is not as accurate as more invasive techniques. There is no need for preoperative MRCP in patients with suspected choledocholithiasis caused by stones.

MRCP (magnetic retrograde cholangiopancreatography) is a costly imaging modality (although one would have no idea how much it costs due to pricing opacity and lack of published data---I spent 30 minutes googling "how much does an MRCP cost" without finding a reliable estimate, try it yourself). I have found it to be one of the most overused studies in modern American medicine. Typically a GI doc or a surgeon will order one when there is pre-op suspicion of choledocholithiasis (stone in the common bile duct). The idea is that by getting the MRCP, and it is positive, then one can proceed to ERCP/stone extraction with a certain degree of confidence. Similarly, a negative result gives the surgeon a mandate to proceed straight to the OR for lap chole. The problem, as the above study shows, is that MRCP studies are highly unreliable. I can't tell you how many times I have obtained intra-operative cholangiograms on patients with ostensibly normal bile ducts (based on a pre-op MRCP) who were found to have....stones in the CBD.

The problem is that not enough surgeons perform routine intra-operative cholangiography. Those who don't do it on every case will miss a certain percentage of CBD stones (overall incidence of 10-15% per the literature). So they try to make up for it by getting these pre-op MRCP's in order to assuage their consciences or whatever. It's wasteful and useless. Do a cholangiogram in the OR. Every time. You'll leave the OR feeling confident every single case.

I mean, if you feel strongly that the patient has a CBD stone (jaundiced, dilated CBD on US) then just do the damn ERCP. If the liver tests are trending down and the patient is doing well clinically, it's likely he passed the stone. So take him to the OR and do the lap chole/grams. If the cholangiogram is positive, then you know for certain the ERCP will be efficacious. It really ought to be a lot simpler than we make it out to be...

Ten Years

2013-03-20T13:52:00.000-04:00

The picture above is from the height of the Iraqi insurgency in 2006. Click on the picture and magnify it. What it shows is a dead boy, 3 years old perhaps, with half his head blown off after an American raid in Baghdad. The flap of translucent scalp catches the sun's rays. His grandfather carries him from the morgue. All of us have an obligation to spend a few minutes staring at that picture. It is one of thousands.

This is what we did. That was a child we exterminated. WMD. Liberate Iraq. The one true incontrovertible crime of the 21st century so far. Aggressive war. Pre-emptive war. False pretences. It has been ten years since we charged into disgrace. Perhaps this ought to be a time for national reflection and collective shame.....

Robot Rebuked

2013-03-20T10:42:00.000-04:00

Once again, a paper has come out evaluating the efficacy and cost effectiveness of daVinci Robotic surgery. From Diseases of the Colon & Rectum comes a retrospective review assessing elective robotic vs laparoscopic colectomy from 2008-2009 (over 12,000 procedures):

Patients undergoing robotic and laparoscopic procedures experienced similar rates of intraoperative (3.0% vs 3.3%; adjusted OR = 0.88 (0.35–2.22)) and postoperative (21.7% vs 21.6%; adjusted OR = 0.84 (0.54–1.30)) complications, as well as risk-adjusted average lengths of stay (5.4 vs 5.5 days, p = 0.66). However, robotic-assisted colectomy resulted in significantly higher costs of care ($19,231 vs $15,807, p < 0.001). Although the overall postoperative morbidity rate was similar between groups, the individual complications experienced by each group were different.

This comes on the heels of a study in the gynecology literature that demonstrated similar conclusions. It is becoming increasingly clear that robotic surgery, as presently constituted, is starting to define itself out of mainstream surgery (although certainly it will continue to play a niche role for certain procedures like prostate surgery, bariatrics, and low rectal resections). The data simply doesn't support the PR blitzkrieg that has overtaken hospital systems throughout the country and the rush to buy million dollar robots and implement them for every conceivable procedure. The results are incontrovertible. For most surgical procedures the robot adds significant cost burden without providing any meaningful improvement in outcomes, morbidity, or patient satisfaction.

In this era where exploding health care costs remains one of our nation's primary long term challenges, I find it hard to believe that the robotic surgery can be justified to the extent that the good people at daVinci would have us believe. Unless.... we implement a single payer health care system and grant it the power to unilaterally negotiate reasonable reimbursement rates with market oriented ventures like Intuitive Surgical....

Alone

2013-03-18T14:19:00.001-04:00

We have this book of children's poems I've been reading at night to my daughter. Most of them are stupid, nonsense-type verse about magpies and talking cows and little boys who wish for things that always come true but then there are a few from people like Shel Silverstein that are actually pretty decent. The other night we came across an e.e. cummings selection I remember reading in high school called "Maggie and Milly and Molly and May":

maggie and milly and molly and may
went down to the beach(to play one day)

and maggie discovered a shell that sang
so sweetly she couldn't remember her troubles,and

milly befriended a stranded star
whose rays five languid fingers were;

and molly was chased by a horrible thing
which raced sideways while blowing bubbles:and

may came home with a smooth round stone
as small as a world and as large as alone.

For whatever we lose(like a you or a me)
it's always ourselves we find in the sea

After I read it she said to me, "daddy when we're alone, where does everyone go?" and I said "that's a very good question, sweetheart" and I got very sad but also proud; happy because she was able to identify the essence of a complex poem from a master of the form, and sad because maybe she is starting to realize that life is sometimes hard and lonesome and not everything stays the same and that there isn't always going to be someone around to tell you where to go or what to do. I didn't have an answer right away. She turns four this week. I hope to be able to speak with greater wisdom when she is older....

Costs

2013-03-18T13:41:00.001-04:00

Ezra Klein writes:

There is a simple reason health care in the United States costs more than it does anywhere else: The prices are higher. That may sound obvious. But it is, in fact, key to understanding one of the most pressing problems facing our economy. In 2009, Americans spent $7,960 per person on health care. Our neighbors in Canada spent $4,808. The Germans spent $4,218. The French, $3,978. If we had the per-person costs of any of those countries, America’s deficits would vanish........We spend less time in the hospital than Germans and see the doctor less often than the Canadians. “The United States spends more on health care than any of the other OECD countries spend, without providing more services than the other countries do,” they concluded. “This suggests that the difference in spending is mostly attributable to higher prices of goods and services.”

But.... but.....I thought the problem in this country was that the ranks of doctors were filled with profit motivated dickheads like those in McAllen, Texas? I thought the sole problem was our fee-for-service reimbursement system that rewarded more and more interventions and allowed doctors to game the system in order to enrich their coffers? I thought the solution was to convert all doctors into salaried employees, to completely disincentivize them from any profit-maximizing motivations and allow the Good, Noble giant healthcare conglomerates like Mayo or the Cleveland Clinic be in charge of carefully doling out just the appropriate amount of healthcare services this country needs?

Klein goes on:

The result is that, unlike in other countries, sellers of health-care services in America have considerable power to set prices, and so they set them quite high. Two of the five most profitable industries in the United States — the pharmaceuticals industry and the medical device industry — sell health care. With margins of almost 20 percent, they beat out even the financial sector for sheer profitability.

Again, this does not jive with the agitprop we were fed during the Obamacare debate and subsequent passage. We were very clearly told, IN NO UNCERTAIN TERMS, that the problem with American healthcare was surgeons who would rather cut off somebody's leg to make 30 grand than take the time to provide less lucrative preventative services. Evil Surgeons! Doctors bad! McAllen, Texas! Gawande has hit the nail on the head!

The reality is far from the fantasyland that people like Atul Gawande and Barack Obama and Andrew Sullivan and Matthew Yglesias would have you believe. Physicians are an easy target because we are a motley, disorganized assortment of self-interested factions. Much easier to demonize an entire profession than get into the weeds on issues like opaque, arbitrary hospital chargemaster pricing or medical device profit margins or hospital CEO salaries or the fact than bullshit laws prevent Medicare from negotiating reasonable reimbursement schedules with the pharmaceutical industry.

Too Many Scopes

2013-03-18T12:44:00.000-04:00

Colonoscopy is overdone in this country. This is an observable fact. I see patients every single day who get scoped every 2-3 years for no discernible reason. I see inpatient 90 year olds who present with "GI bleed" (really just a little coffee ground emesis from dehydration/mild peptic ulcer disease) who end up getting black tubes snaked through their mouth and anus before they are returned to the nursing home from whence they came. This happens constantly. A study from Archives of Internal Medicine elucidates this phenomenon:

The colonoscopists with percentages significantly above the mean were more likely to be surgeons, graduates of US medical schools, medical school graduates before 1990, and higher-volume colonoscopists than those with percentages significantly below the mean.
A large percentage of colonoscopies performed in older adults were potentially inappropriate: 23.4% for the overall Texas cohort and 9.9%, 38.8%, and 24.9%, respectively, in patients aged 70 to 75, 76 to 85, or 86 years or older.

I post about this because, although the main problem with rampant, out of control healthcare expenditure in this country occurs at the macro-level via the health-industrial complex of hospitals, Big Pharma, the insurance carriers and the medical device industry, it doesn't excuse unscrupulous physicians acting like greedy assholes and the role individual doctors play in driving up costs. Whether it's cardiologists performing unwarranted cardiac stent procedures or general surgeons taking out robin's egg blue gallbladders, we have to be able to shine the light on such behavior and shame those who betray basic medical ethics.

HRT for Menopause?

2013-03-17T14:27:00.002-04:00

This article I saw on Yahoo News is an example of why patients ought not to go scouring the Internet for all their medical information. The title of the article "Doctors Clear Up Confusion Over Hormone Therapy" is rather misleading. Hormone replacement therapy (i.e. supplement estrogen and progesterone pills) has long been known to be the best intervention for refractory menopausal symptoms. Unfortunately, a Women's Health Initiative study from a decade ago demonstrated that subsets of post-menopausal of women who took hormonal replacement therapy (HRT) medication increased their risk of developing breast cancer by 25%. Afterwards, enthusiasm for HRT sort of tapered off. As you could imagine. This new statement avers that:

...while the therapy comes with risks, its benefits generally outweigh the harm for women under age 60, or those who've been in menopause for fewer than 10 years. The increased risk of breast cancer also appears to disappear a few years after treatment is stopped......doctors recommend low doses of HRT for women whose menopausal symptoms are limited to vaginal dryness and pain during intercourse. HRT is not recommended for women who've had breast cancer

So if you're under 60, have had symptoms less than 10 years, never had breast cancer, and your symptoms are limited to vaginal dryness and dyspareunia, then HRT is for you. I'm a little wary myself. Curiously absent from the "consensus statement" are doctor's groups such as the American Medical Association, the National Cancer Institute, the American Cancer Society, the American Society of Breast Surgeons, and the American Breast Cancer Foundation. The Asia Pacific Menopause Society, which I'm sure is a fine organization, just doesn't have the carry the same cache for me....

Cardiac Outcomes

2013-03-13T20:14:00.001-04:00

Alice Park reviews David Jones' counter intuitive new book on the history of cardiac surgery and coronary angioplasty in most recent issue of Harvard magazine. Jones, also a physician, is a professor of medical history at Harvard. His latest book explores the rise of interventional cardiology and cardiac surgery since the 60's and how much of the rationale for such a procedure-dominated treatment strategy is undergirded by some surprisingly shoddy data.

The first randomized clinical trial of bypass surgery’s efficacy, using data from a collaboration of Veterans Administration hospitals, was not published until 1977. Such trials were then becoming the gold standard of medical research (and still are). “Surgeons said trials were totally unnecessary, as the logic of the procedure was self-evident,” says Jones. “You have a plugged vessel, you bypass the plug, you fix the problem, end of story.” But the 1977 paper showed no survival benefit in most patients who had undergone bypass surgery, as compared with others who’d received conservative treatment with medication.

It's funny, coming from the perspective of surgical training, I don't recall ever hearing from disgruntled cardiac surgeons the actual reasons why bypass surgery had started to fall out of favor during the nineties and oughts. All I heard was that fellows were having a hard time scoring jobs because bastard cardiologists were snaking all the cases. Never did we discuss studies outlining the lack of survival benefit from CABG. It seems obvious now that such an inquiry was a trip down the existential rabbit hole--- no one wanted to find out that the profession one had spent a third of one's lifetime preparing and training for was, in the end, no better in terms of providing survival benefit than simply telling someone to stop smoking, to eat better, and to get off the couch.

Cardiologists come off no better in the piece.

In 2007, a study of more than 2,000 patients with stable coronary disease showed that compared to drug therapy alone, stents in combination with drug therapy such as blood-pressure medications and cholesterol-lowering agents did not lower the risk of having a heart attack or improve survival during a seven-year follow-up period. But instead of curbing stent use, two years later, a survey showed that the share of patients receiving drug therapy merely as a first-line treatment, before getting stents, remained unchanged at 44 to 45 percent

We may be too far gone to change anything. The coronary intervention/surgery sector is a $100 billion industrial complex. It won't just fade away like the open cholecystectomy or peptic ulcer surgery. We've successfully propagated this myth that all cardiac procedures are life saving. It is the economic engine that drives many hospital systems. Some myths have staying power, especially if your 5% profit margin is riding on its continued perpetuation.....

Tylenol: That will be $16.95 please

2013-03-13T05:59:00.000-04:00

I just have to highlight this. In the AHA release in response to the Brill article, they address the issue of why it costs $17 for a single tylenol when you're an inpatient:

A dose of Tylenol provides a good example. In order to take medications in a hospital, even over-the-counter medicines, they must be prescribed by a doctor (a little bit of cost for the doctor), that order gets transmitted to the pharmacy (a little more cost), the order gets filled by a pharmacist or pharmacy tech who retrieves just one Tylenol pill and individually packages that one pill (still more cost), the pill gets transported from the pharmacy to the nursing unit where the patient resides (a little more cost), then the pill is retrieved by a registered nurse who personally gives the pill to the patient and then must document the administration of that pill in the patient medication administration record (a little more cost). All of this process to give a patient a single dose of Tylenol in a hospital bed is regulated by agencies that accredit hospitals – a condition of participation in the Medicare program. In other words, this is what hospitals must do to administer a pill in compliance with all pertaining regulations (a little more cost).

Apparently this was not written as an intentional parody. At least I don't think so. It's always possible that they're putting us on. But maybe not. Maybe they really have conducted thorough internal audits on the costs of "transporting the pill from the pharmacy to nursing unit" and "individually packaging a single pill". Bureaucracies have been known to do worse.

It's like when you get sucked into going to Applebee's and everything on the shit menu is $13.99 or more and you ask the waitress, why the hell does boxed pasta noodles with pesto sauce from a can cost so seemingly much? And the overly enthusiastic waitress, the kind who intermittently widens her eyes while talking, to emphasize particular points, to connect with you or whatever, probably while squatting down by your table so she's at eye level because some corporate higher up read somewhere that levelling the eye contact playing field makes the customer feel more in control and better about himself-- she, while chomping some sort of fluorescent aqua gum flavor, squats beside you and says, "well hun, you see, someone has to open that box of rotini (a little cost) and pour it into a boiling pot of water (stove usage cost!), while another guy in the back has to retrieve the pre-cooked chicken chunks from the walk in cooler (doesn't cool itself for free, ya know!) and then a pre-determined volume of sauce has to be measured out (still a bit more cost, copyright charges on the recipe) and then once it all gets whipped together someone has to arrange it on your plate (cost!) and transfer said plate to the larger tray where similar orders for your wife and children have already been arranged (costs, hun!) and then I get notice and so I grab the nearest expediter to help me transport a not inconsequentially heavy order all the way from the kitchen to your table (costs indeed!). So, ya know, it's like $13.99 is sort of a good deal, once you break it all down". She smiles a ghastly smile, whips her head to the side to wink at my terrified daughter. And then she is gone.

Profits and Hospital Systems.

2013-03-08T15:51:00.001-05:00

The American Hospital Association has come out with a rebuttal to Steven Brill's Time Magazine article. Brill had claimed that non-profit hospitals operate at a 11.7% profit margin. According to some internal AHA survey, the actual number may be closer to 5.5%. In the context of typical corporate profit margins, this adjusted number does not exactly make one weep for the hospital industry. To wit, according to recent industry trends, even a 5.5% profit margin out-performs private stalwarts like the auto manufacturing industry, major airline carriers, textiles, heavy construction, and even the tobacco industry.

I mean, the hospitals aren't raking in 25% profits like real estate investment trusts, but 5.5% isn't too shabby. They do just fine. CEO's of places like the Cleveland Clinic and Mayo and Johns Hopkins earn well over seven figures. Even mid-level hospital executives usually take home twice or three times as much as the salaried docs who actually take care of patients and make sure all the billing information is filled out appropriately.

Are we OK with hospital systems who don't pay a cent in federal or local taxes generating bottom lines that American Airlines would take in a heartbeat? This is not merely a question of pragmatics--- i.e. whether or not, given the exploding cost curve in the health care sector, it is feasible to expect hospitals to remain so profitable with their million dollar robots and Renaissance Hotel-esque entrance lobbies and 42 inch flat screen TV's in every room and outrageous facility fees and $18 charges for two Tylenol pills.

The question, like it or not, transcends pragmatics. It is the defining moral question of our time...

Understanding Sub-concussive Head Trauma

2013-03-08T15:51:00.000-05:00

The link between Chronic Traumatic Encephalopathy (CTE) and repeated subconcussive head trauma (as in football) has been well documented. What is less well understood is the pathophysiologic mechanism by which this process occurs over time. This paper suggests that a disruption in the blood brain barrier (BBB) occuring after sub-concussive head trauma can elicit an auto-immune response, whereby auto-antibody production and infiltration of the brain could potentially lead to the long term cognitive damage as seen in CTE.

This is only the beginning. Science lurches toward the truth. And Pop Warner leagues can flip that hourglass over any minute now. The end of football as we know it is coming, and quickly.

Matthew Yglesias Thinks Doctors are the Problem

2013-03-02T16:04:00.001-05:00

The liberal blogger Matthew Yglesias' take on the Steven Brill's health care crisis tome is a strange one. Rather than focus on Brill's substantive points about the medical-industrial complex, he elects to point out the one facet of health care spending that Brill downplays; i.e. doctor compensation. Yglesias, from the Gawandean school of Avaricious Physicians, apparently, feels that we need to crack down even harder on physician reimbursements. After all, doctors in the United States earn more than doctors anywhere else in the world. To back such a claim he cites this chart from the OECD:

Put aside such mitigating factors as medical school costs in the United States compared to other countries. Ignore cost of living considerations in the world's wealthiest nation. Put aside the obvious correlative between being the richest nation in the world and having professionals who correspondingly earn more than counterparts in less wealthy nations. His cited evidence is simply shoddy. When measured in the context of the ratio to relative wage per country, the average general practitioner in the United States is remunerated no differently than practitioners in other westernized countries like Germany, the Netherlands, Iceland, and the UK. Furthermore, although GP wages have been on the upswing in countries with more socialized medical subsidization schemes, in the United States the story is the opposite:

In several countries, the growth of GP remuneration has been relatively modest. In Canada, the remuneration level of GPs in real terms grew by about 5% between 1997 and 2004. In Austria and the United States, the average remuneration of GPs in real termdeclined by around 5% between the mid-1990s and 2003.6 In Austria, the decline in average remuneration may be due at least partly to a change in the proportion of part-time practitioners during that period (since the data include both part-time and full-time GPs). In the United States, the decline of GP incomes in real terms was driven mainly by a reduction (in real terms) of fee levels paid by Medicare and private insurance (Center for Studying Health System Change, 2006).

Again, this is all from the same OECD report that Yglesias initially used to argue for more Draconian cuts in physician compensation.

It's a dreadfully incomplete, sloppy piece of reasoning from a guy who's usually pretty sharp.

The Chargemaster and Non-Profit Charity Care

2013-03-02T08:11:00.002-05:00

In Steven Brill's article, the main take home message is that pricing for hospital based services is arbitrarily far too high. The starting point for negotiations between hospitals and the various third party payors (Medicare, private insurance plans) begins from a price listed in the hospital "Chargemaster", an all-encompassing compendium of charges for everything a hospital can bill for (example here). No one knows where prices listed in the chargemaster originate from. And so you end up with absurd situations where itemized bills will show that the tylenol the ER gave you for a headache got charged at $18.50 per pill. Paper surgeon's gown for $32. IV tubing priced at $125.00. Troponin lab tests for $199.50. The CT of your head, several thousand dollars. Now hospitals themselves don't pay any attention to the chargemaster. Those patients with Medicare or private insurance don't pay anywhere near the listed chargemaster price. But if you have no insurance or some sort of shoddy, limited-reimbursement plan, then the bill you receive, when itemized, will include charges on ridiculous items that insurance plans routinely disregard as part of the facility fee, and all the prices will come directly from the chargemaster.

So yes, those who are least able to pay get charged the most. And many hospital systems adopt strict non-negotiation stances toward patients who are in financial difficulty. Unpaid bills are quickly turned over to collections agencies, written off as "free care", or sometimes the hospital will actually litigate to squeeze everything they can from patients already teetering on the edge of financial catastrophe.

And this concept of "free care" is where hospitals are suddenly very interested in the chargemaster. Those without insurance get charged the full monty. An inpatient stay that would normally net a hospital $1500 or so from a patient with Medicare will go on the books as a $100,000 bill for the uninsured patient. And this is the number that gets reported when it comes time for a non-profit hospital to tally its amount of charity care over the course of a fiscal year.

In all, the amount of charity care that the nation's non-profit, tax exempt health care organizations provide is of a magnitude of less than 5% of total operating revenue. When hospitals report their yearly contributions to "charity care", it's important to take the numbers with a grain of salt. However many millions in free care is claimed, be sure and knock off about 75-80% from the total; it's a number they would never have collected even 100% of their patient population having some form of insurance. It's a pure figment of imagination. Once again, as Brill notes:

In fact, when McKinsey, aided by a Bank of America survey, pulled together all hospital financial reports, it found that the 2,900 nonprofit hospitals across the country, which are exempt from income taxes, actually end up averaging higher operating profit margins than the 1,000 for-profit hospitals after the for-profits’ income-tax obligations are deducted. In health care, being nonprofit produces more profit.

Cost Not-So-Conundrum

2013-02-28T10:16:00.001-05:00

Steven Brill's long form report on the "cost conundrum" in American healthcare has occupied my free time the past several days. To say that this is the most important piece in decades explaininge how health care spending occupies 17% of our GDP would be a gross understatement. Brill's meticulous documentation of the what ails us, both at the macro and micro levels, represents everything that journalism ought to aspire to. Brill simply exposes the rot that lies at the heart of a system that incentivizes the marketization of a profit-driven American health care infrastructure.

I need to break down an analysis of the piece over several posts, but for now I just want to draw attention to the radically different conclusion Brill outlines arrives at compared with Atul Gawande's celebrated New Yorker article from a few years ago. Gawande, recall, spent a week visiting with doctors at a private for-profit hospital in McAllen, Texas who, collectively, accrued higher utilization rates and billing charges than similar sized cities in the area. His conclusion was that our current fee for service model was flawed and easily corrupted by greedy, profit-driven individual physicians and group practices and that the solution was to transition to a system where doctors worked as employees for large, monopolistic heath care behemoths, incentivized to provide "quality care" at, presumably, much lower costs.

The New Yorker piece was lauded across the spectrum. President Obama even mentioned it in one of his many speeches leading up to the PPACA passage. Nevertheless, from the beginning I found the article unconvincing. My dissents can be read here and here.

Brill has written a 28 page masterpiece of investigative journalism. I encourage all to print it out online and spend an hour reading it ASAP. His take is that the problem transcends individual doctors, fee for service models, and greedy local for-profit health care providers. Brill determines that the problem is that health care systems have grown too large, too monopolisitic and are therefore able to dictate to insurance companies more favorable reimbursements. By starting from an arbitrary price index, called the chargemaster, larger hospitals are able to maximize profit margins. Further, he argues that the "non-profit" institutions are a bigger potential problem, cost-wise, than the smaller, for-profit institutions in towns like McAllen:

In fact, when McKinsey, aided by a Bank of America survey, pulled together all hospital financial reports, it found that the 2,900 nonprofit hospitals across the country, which are exempt from income taxes, actually end up averaging higher operating profit margins than the 1,000 for-profit hospitals after the for-profits’ income-tax obligations are deducted. In health care, being nonprofit produces more profit.

More to come .....

Robotic Hysterectomy: Everybody's Doing It!

2013-02-22T10:15:00.003-05:00

A cohort study done by Columbia University evaluating the rise of robotic hysterectomy from 2007-2010 had some pretty breathtaking findings.

Use of robotically assisted hysterectomy increased from 0.5% in 2007 to 9.5% of all hysterectomies in 2010. During the same time period, laparoscopic hysterectomy rates increased from 24.3% to 30.5%. Three years after the first robotic procedure at hospitals where robotically assisted hysterectomy was performed, robotically assisted hysterectomy accounted for 22.4% of all hysterectomies.... In a propensity score–matched analysis, the overall complication rates were similar for robotic-assisted and laparoscopic hysterectomy (5.5% vs 5.3%).......Total costs associated with robotically assisted hysterectomy were $2189 (95% CI, $2030-$2349) more per case than for laparoscopic hysterectomy.

So here we have an exponential rise in robotic hysterectomy over a relatively short period of time without any tangible benefit to the patient.  Will anything come out of this? Or will hospitals across the country continue to advertise their very own robotic programs on highway billboards and quarterly mailings?

In a nutshell, this is the very essence of why healthcare costs are spiralling out of control. We never hesitate to implement the "latest hot innovation" no matter how expensive it is, no matter how little it improves the quality of care.  When a nation collectively decides to treat health care provision as just another commodity-- as a good to market and sell, a source of pure profit--- then it has embarked on a course of fiscal and moral bankruptcy.

Full disclosure:
I have gone through the credentialing and training process for the DaVinci robot and have now done a small series of robotic assisted laparoscopic procedures. My motivation for doing so is multi factorial. One, the robot is quite nice. The technical improvements compared with straight stick laparoscopy are sometimes quite extraordinary. (Although, for the majority of general surgery cases, these benefits are irrelevant/extraneous). The ability to articulate the end of the instrument like a human wrist adds a layer of dexterity and elegance that one just cannot get from straight laparoscopy. So, two, I didn't want to end up like one of those old school surgeons who decided that laparoscopy was a "fad" back in the nineties and then were quickly relegated to irrelevance once the technique became the standard of care. Three, I don't like to judge things without first experiencing them myself. Four, the application to single site surgery makes intuitive sense to me in so far as the improved coordination gained by the robot sticks offsets the awkwardness of pushing three instruments through a single access port.

At this point in the game, I think the robot does have a future role, albeit a limited one, in general surgery. If the costs can be controlled (single payer anyone?) then I see a real potential in using the robot for single site colon/bowel/even gallbladder surgery. Situationally, I can see it evolving into the standard technique for rectal surgery, hiatal hernia repairs, and complex pancreatic/biliary surgery.

Buckeye Eviscerated on KevinMD

2013-02-21T23:11:00.000-05:00

The medical social media Godfather Kevin Pho will occasionally cross post some of my work on his hugely popular and successful blog KevinMD. Earlier this week he chose to include my relatively recent post on an article I had read in the Economist last fall about physician assisted suicide (PAS). I was in one of those moods when I wrote it. I suppose I was looking to achieve a certain degree of shock value by writing it as a straight satire of what it could mean to be an actual doctor who participated in PAS. I mused about how a general surgeon might get involved in such a vocation. This musing involved several proposals for procedures that a general surgeon would have within his skill set to do if requested, including but not limited to...um... bilateral carotid artery ligation, aortic transection, and trachea clamping. The KevinMD readership did not take kindly to such apparent insouciant treatment of a sensitive issue.

To wit, from the comment section:

-It is apparent that you have never been in 'a situation with another who was suffering horribly with months to live'.

-you come off as cynical, judgemental and ignorant all at once. what kind of parallel are you trying to highlight comparing acne vulgaris to a terminal disease? pointless article.

-Dr. Parks,
You might want to read a medical ethics textbook and learn the difference between physician assisted death and euthanasia. I doubt any doctor (usually the doctor that was taking care of that terminally ill patient) is motivated to assist someone in their death by monetary gain. In terms of economics, the live patient is always worth more to the doctor than the dead one. Maybe instead of vilifying these doctors you should do some more research to hear their stories

-Wow. I'm kind of surprised Kevin accepted this post. Setting aside the offensive nature of it's (sic)jokes, this writer has a very limited view of the role of the physician. It is our job not only to heal the sick but to attend to the dying. I am all for an adult discussion of PAS, but this is not it.

-Doctors like you are a disgrace. You are nothing more than a heartless, drug-dispensing medical-billing machine that is more than happy to prolong someone else's suffering for your own benefit. You can hide behind your oath, but this is the real world and, for the patient and their family, death and dying is as real as it gets. I am thankful that I live in a state where we have passed a Death With Dignity law. We have the ability to take the decision about how we die out of the hands of people like you, Dr Parks.

-Your satire is not satirical. You come across as an arrogant, judgmental know-it-all. I am glad that I will not have you to deal with when I am facing death. I cannot imagine having to deal with your self-righteous sanctimonious BS on top of dying.

I realize that by blogging, I take the risk that someone is going to take great offense to something I write, that not everyone will agree with my views, and that sometimes I may even be called out for factual inaccuracy. Online, you have to have a pretty thick skin. But in this case I felt I was being attacked, to some extent, unfairly. It seems most commenters missed the satire and moved on to condemning me as anti-palliative care, an uncaring, money-grubbing pill pusher, someone who hooks dying patients up to machines just for sadistic kicks, and various other personal insults. Given the exposure that Kevin's blog has, I felt the need to reply in the comments section. Here's what I wrote:

I think many of the commenters are talking past the content of the post. Why is it monstrous to delve deeper into the actual content of what it means to be an advocate for physician assisted suicide? I think it's important to determine what exactly it is that people are objecting to in the post. Is it the fact that I question the role of a physician in providing the materials/instructions in hastening someone's death? Or is it merely the grotesque examples I have provided? I think that if you want to be an apologist for physician assisted suicide, you should say so. If you think that doctors ought to provide direction on how to end your life, then say so. If you think euthanasia and physician assisted suicide ought to fall under the rubric of palliative care medicine, then say so. Only understand that by doing so you accept the unpleasantness of what it actually means, in real practice, to end someone's life. If the end result is the same, why should it matter what the means are that one chooses to implement such an end. What is truly the difference between overdosing someone on morphine vs. "performing bilateral carotid occlusion surgery"?

It's an uncomfortable post, I grant you that. I appreciate that Kevin had the balls to put it up (he chooses all my posts, I don't submit anything to this blog). I would just try to reiterate once again that I am not satirizing palliative care or hospice medicine. This was not a post about palliative care or end of life issues as we face in the United States. This was a post about physicians who volunteer their services for the express purpose of ending some one's life. To me, such an endeavor has nothing to do with the concept of "physician", in the Hippocratic sense. To me, whether you intentionally end some one's life via an IV cocktail or any of the absurd examples I provided is the same thing--- a violation of the very essence of what it means to be a doctor. If, as a society, we want to legalize assisted suicide, then we need to create carve out an entirely new cadre of professionals who will perform these services, apart from the physician fraternity.

Anytime you are challenged so forcefully in public, once the adrenalin of defending yourself wears off, it's natural to retreat somewhat into a posture of reflective contemplation. It's obvious that we, as a nation, are still quite uncomfortable with end of life issues.  To joke about or satire the dying process is to risk automatic expulsion from acceptable discourse. And honestly, I don't have a firm enough grasp on death--- how I will handle its encroachment either on those close to me or, hopefully decades from now, when my reckoning comes-- to be able to whimsically shrug off the self righteous objections to my post. It affected me, I admit. It made me reconsider whether I ought to have written it. I hate pissing people off, dammit.

People used to just die in their own homes. Families would gather round for a vigil and when the event occurred, it was without drama or fanfare.  Death was a shared process. Dad was just upstairs dying. Death as a facet of life. Too often nowadays it is sealed off from anything remotely resembling life in semi-sterile, ventilation-controlled, institutionalized ICU rooms with wires and tubes everywhere and strange beeping mechanical noises and never knowing if it's day or night and families collapsed like fallen toy soldiers on stiff, too-small couches in the waiting area with strangers. We don't want to "pull the plug" because we can't stand the thought of having our loved one die in that damn ICU bed. Stay alive long enough to get him home, is what we think. But Dad has already been sucked into the vortex of the system. He's already marionetted in a cold white sheeted mechanical bed and it doesn't seem possible to cut him loose. And so we look for alternatives. Maybe the kind pain management physician who adjusts his morphine every evening could help. Maybe the patient oncologist who has been with you and Dad all along could provide an out. Anything to end the seemingly endless pain, torture, and futility.

And this is where I draw the line. In general I am not some sort of unyielding ideologue, making grand pronouncements on acceptable human behavior. But I do try to adhere to "first, do no harm". In my line of work, more than others, we sometimes unintentionally implement strategies, perform operations that lead to a worse outcome than if we had done nothing at all.  And the idea of intentionally acting to end some one's life, no matter the circumstances, strikes me as a gross violation of the physician calling. I'm not talking about withdrawal of care or simply providing comfort measures for the terminally ill. I am speaking specifically of active intervention, the hastening of some one's demise.

In time, we may find the rise of a new cadre of heath care professionals who offer their services to specific subsets of dying Americans who have had enough, who don't want to simply "wait it out" in stylized hospices.  They may come from a background of anesthesiology or palliative care medicine. But it ought to be very clear that they have broken off from these ancestries and speciated into something else entirely.  It will be absurd to even think about calling them doctors, to the same extent that we perceive police officers as different entities from military personnel. But I think we're a long way from this happening.

We don't even know how to start talking about it without a rational discourse being submersed under a torrent of fear, anger, and prejudice. But we have to start talking. The status quo is untenable.  Every disease and infirmary may well have newer and more potent treatments, but the body and soul housing that disease grows weary with time.  And a time comes when it just wants to rest.

Roger Goodell: Marlboro Man

2013-02-21T12:57:00.000-05:00

Roger Goodell, the NFL commissioner, earned over $29 million in salary and bonuses last year. The current TV contracts negotiated with NBC, ESPN, CBS, and FOX will guarantee the league's owners over $7 billion to be split amongst themselves.

Remind me again why anyone would possibly doubt Mr Goodell's sincerity when he says that his primary concern is the safety and well being of NFL players? Remember his quote from the Bob Schieffer interview:

In fact, we’re all learning more about brain injuries, and the NFL has led the way,” he declared. “We started a concussion committee back in the mid-90s with the players’ association to study these issues and advance science. We’re obviously now learning more and more, and we’re investing more and more. And I think that’s going to lead to answers, even outside of brain injury, even to brain disease.”

What cannot be emphasized enough is that this committee (the Mild Brain Trauma Injury committee) was led not by an independent neurologist or neurosurgeon, but by a salaried rheumatologist named Elliot Pellman. Now for those unfamiliar with medical terminology, a rheumatologist is a doctor who typically manages auto-immune mediated diseases such as lupus, rheumatoid arthritis, and psoriasis. The only logical explanation for appointing a rheumatologist to head your ad hoc head injury committee is to guarantee message control. They may as well have named a dentist to head the committee. Rarely does one come across such a flagrant example of cynical self interest. The NFL was so arrogant, so dismissive of player safety that they didn't even feel the need to appoint a stooge specialist within the field of head trauma.

It's truly astounding.

And Roger Goodell is laughing all the way to the bank.

Leaks

2013-02-20T13:18:00.001-05:00

This retrospective review from the Archives sheds some light on every surgeon's worst nightmare when it comes to rectal surgery: the anastomotic leak. This study is a retrospective review of over 70,000 low anterior resections, nationwide, from the years 2006-2009.

Results The AL rate was 13.68%. The AL group had higher mortality vs the non-AL group (1.78% vs 0.74%). Hospital length of stay and cost were significantly higher in the AL group. Laparoscopic and open resections with a diverting stoma had a higher incidence of AL than those without a stoma (15.97% vs 13.25%). Multivariate analysis revealed that weight loss and malnutrition, fluid and electrolyte disorders, male sex, and stoma placement were associated with a higher risk of AL. The use of laparoscopy was associated with a lower risk of AL. Postoperative ileus, wound infection, respiratory/renal failure, urinary tract infection, pneumonia, deep vein thrombosis, and myocardial infarction were independently associated with AL.

An anastomotic leak is truly a malevolent, disruptive event.  Foremost, the patient suffers. Sometimes you can get away with treating a small leak non-operatively, with drains, bowel rest and antibiotics. But more often than not, the patient has to go back to the OR emergently, under less than ideal circumstances. Most commonly, they end up with a colostomy or some form of intestinal diversion.  The abdominal sepsis that results can set off a chain reaction of pathophysiology leading to multiple organ failure and even death. And if the unfortunate soul survives the acute leak, then, if they want to get put back together again, they would have to contemplate undergoing a third surgery to reverse the stoma, and with that, all the accompanying risks of another leak, another take back, etc etc ad infinitum.

When a patient has a leak, it also is psychologically traumatic to the operating surgeon. All the statistical and professional reassurances in the world (i.e. that leaks happen, no one is immune, technically you wouldn't have done anything differently) are little solace when you have to walk into an ICU room and see a patient, previously healthy and vibrant, reduced to an ashen gray shell of vitality, tubes coming out from everywhere and stool filling up an unanticipated colostomy. Every day on rounds is like re-enacting your own personal failure. Every day you have to look the patient in the eye, a wife, his kids, and tell them things will get better, that you are sorry events turned out the way they did. You go home and feel guilty that it's not you trapped in that hospital bed, that you are the one who can play with your kids, take your wife out to dinner, and get up and go to work in the morning.  Everyday you see his name on your patient list and its like a scab getting scraped off all over again.

Papers like this ought not to serve simply as a salve to apply to our wounded sense of professional competence. They ought to instead prompt us to ask why leaks happen so often. This paper quotes a 14% figure. When you review the literature, you'll find leak rates ranging from 5-18%. Either way, that's just a shit load of pelvic anastomotic problems.

Pelvic leaks generally can be attributed to three factors: too much tension at the connection, poor blood supply, and poor protoplasm. Tension is something the surgeon has to be able to recognize at the time of the operation. When you perform a colo-rectal anastomosis, you have to mobilize the descending colon/splenic flexure enough to allow for a tension-free drop down of proximal stump to the rectum. If you find yourself yanking on the proximal end or putting the patient severe steep reverse Trendelenburg to get it to reach, the patient is trying to tell you to "go get some more length".

Poor blood supply is a trickier one. Certainly, frank ischemia of the proximal descending stump is hard to miss. No one I know would try to plug a bluish colon into a rectal stump. But sub-clinical ischemia, where the collateralization from the marginal artery is perhaps just enough to maintain serosal perfusion, is dicier to predict and determine. I sometimes wonder, especially in elderly patients, or patients with known atherosclerosis, if would be a good idea to study the arterial arcades feeding the left colon with a preoperative CT angiogram of the mesenteric vessels. In oncologic resections, we generally take the IMA at its origin and so the entire descending colon must rely on collaterals coming over from the middle colic pedicle.

The third factor requires a minimum of functioning brain cells in the operating surgeon. If you make a habit of trying to re-anastomose brittle, malnourished patients, or patients presenting with frank pelvic sepsis and gross contamination, then you're going to find yourself presenting rather frequently at hospital M&M meetings.

Student Loan Bubble, Continued

2013-02-17T21:35:00.000-05:00

From Salon, a stinging rebuke of the student loan racket that threatens to set off another credit-fueled systemic financial crisis:

In effect, the system allows any 22-year-old American University chooses to admit to borrow a sum equal to the average home mortgage, but without a single one of the actuarial controls that are supposed to minimize the risk that homeowners will borrow too much money.

After all, even at the height of the housing bubble, home buyers who got so-called liar loans that misstated their actual income still had to jump through certain hoops to do so. In addition, if they defaulted on their loans, there was a house the lender could foreclose on that in most cases still had some value. Of course, that system proved to be far too unregulated, and led to a financial disaster that would have wrecked the nation’s banking system if not for hundreds of billions of dollars of federal bailout money.

Still, even that system was a model of rationality in comparison to the federal government’s funding of higher education. As long as they are technically “nonprofit” institutions, schools can charge whatever they like, without having to provide a shred of proof that their graduates will be able to pay back the incredible debt loads they will be incurring. And, of course, when graduates default on these loans there’s no house to sell off to cover at least some of the deficiency.

This is all a foregone conclusion. The coming student loan credit bubble is due to burst and there isn't anything of tangible value, like a physical house, to sell off in order to salvage something from the implosion. People are graduating with over 200 large in student loan debt ALL THE TIME and no one wants to think about the consequences of a mass default, along the lines of the housing crash.

We rightfully put a premium on higher education. An educated population is the crucial factor in differentiating between wealthier nations and the third world. It is the key to maintaining a sustainable, broad-based middle class. It's crucial that college education remain a viable option for the average American. We cannot allow the complete commercialization of higher education wherein a college degree becomes just another commodity to market and sell for maximum profit. Harvard and Yale and Stanford are sitting on billion dollar endowments. For-profit institutions like University of Phoenix rake in billions every year. And yet if a 24 year old grad has a hard time landing a decent job after forking over $150,000 for a degree from Penn or Cornell, she is on the hook for the entire amount. She has no recourse to bankruptcy. Student loan debt is entirely non-dischargeable.

It's about time we subject the world of higher education to the same quality metrics and performance evaluations that health care is now subject to. For now on, if taxpayers are going to fund incoming freshman classes, we need to see the results. What are the graduation rates? What percentage of grads are getting jobs and what is the average salary? How many are able to meet loan payments without declaring "financial hardship"? This should all be reportable information. Those institutions that fail to meet standards ought to be subject to cuts in the federal student loan treasure chest.

Or better yet, why don't we use some of this expected post-Iraq, post-Afghan "peace dividend" and expand the number of need and merit based scholarships. Institute tuition freezes/cuts at state schools. Make college education, for the those who have the intellectual tools, a guarantee of citizenship. Our youth shouldn't have to mortgage their future for a piece of paper that guarantees nothing.