Why Are Artists Starving by Marc Charles

8:22 PM

Hi Gang:

Ive launched, bought, sold, and managed many businesses in 30 years. Ive slowed down on the buying and selling businesses in recent years, Im 55 years old.

But still love launching and advising startups, and writing about them.

Ive helped a good friend launch an art gallery. I advised against it, with facts, proof, insight, wisdom and actual numbers. But it was Mr Artists dream.

He had two things going for him -- he owned the building outright and volunteers (like me which he knows is a big deal).

But still....the first six months have been weak. In fact, Im the top sales person ...mainly from direct mail, Internet, parties and contacts.

The bottom line is this: artists create from their love, pain, passion or whatever.

Artists typically don;t care what the market wants. And this is why theyre starving.

But if artists want to increase sales they need to feed into the current, not future, market demand.

So.....thats my take on galleries and selling art.

Marc

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1 in 20 Americans are misdiagnosed every year

Really?

A paper published in April found that about 12 million Americans, or 5% of adults in this country, are being misdiagnosed every year. This news exploded all over Twitter. Anxious reports from media outlets such as NBC News, CBS News, the Boston Globe, and others fanned the flames.

The paper involves a fair amount of extrapolation and estimation reminiscent of the "440,000 deaths per year caused by medical error" study from last year.

Data from the authors prior published works involving 81,000 patients and 212,000 doctor visits yielded about 1600 records for analysis.

A misdiagnosis was determined by either an unplanned hospitalization (trigger 1) or a primary care physician revisit within 14 days of an index visit (trigger 2).

A quote from the paper [Emphasis added] : For trigger 1, 141 errors were found in 674 visits reviewed, yielding an error rate of 20.9%. Extrapolating to all 1086 trigger 1 visits yielded an estimate of 227.2 errors. For trigger 2, 36 errors were found in 669 visits reviewed, yielding an error rate of 5.4%. Extrapolating to all 14,777 trigger 2 visits yielded an estimate of 795.2 errors. Finally, for the control visits, 13 errors were found in 614 visits reviewed, yielding an error rate of 2.1%. Extrapolating to all 193,810 control visits yielded an estimate of 4,103.5 errors. Thus, we estimated that 5126 errors would have occurred across the three groups. We then divided this figure by the number of unique primary care patients in the initial cohort (81,483) and arrived at an estimated error rate of 6.29%. Because approximately 80.5% of US adults seek outpatient care annually, the same rate when applied to all US adults gives an estimate of 5.06%.
The diagnoses that were missed and the implications of the misses were not described, but one anecdote from a paper the study was based on mentioned carpal tunnel syndrome as one of the diagnoses.

Another quote from the paper: Although it is unknown how many patients will be harmed from diagnostic errors, our previous work suggests that about one-half of diagnostic errors have the potential to lead to severe harm. While this is only an estimate and does not imply all those affected will actually have harm, this risk potentially translates to about 6 million outpatients per year. [Emphasis mine]

Is a 14-day interval between the supposed miss of the diagnosis and an admission or a return visit really a huge problem?

Because we dont really know how many patients were actually harmed by these supposed diagnostic errors, we cant tell. If carpal tunnel syndrome was the delayed diagnosis, Id say "probably not."

Half of the patients in the study were from a VA and the other half were from a large clinic cohort so these diagnostic error rates may not be generalizable to the entire population of the US.

The words "misdiagnosis" and "error" were used interchangeably. As the authors admit, every misdiagnosis is not necessarily the result of a physicians error.

Among the limitations of the study noted in the paper [but omitted from all news reports] was that it was not designed to identify the root cause of the delayed care or missed diagnosis. For example, reviewers noted many cases where delays in follow-up were beyond the control of primary care providers, such as difficulty obtaining timely appointments with specialists [which we now know is a huge problem at many VA hospitals], or patients failing to show up at scheduled appointments.

No doubt diagnostic errors occur, but this paper does not tell us how many people were seriously harmed, what the root causes of the errors were, who was responsible for the errors, or most importantly whether diagnostic errors really occur in 5% of Americans.

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How does shrinking links for money work

Url shrinking for money allows you to earn money from every visitor to your shortened links. How this works is actually quite simple.

1. Create an account with at least one url shortening service from this list.
2. You will then receive a confirmation e-mail, follow the instructions in the email.
3. Login to your account.
4. Enter a long link website in the special field and click Shrink. Your shorl URL will be displayed and will look something like this http://adf.ly/1OCz96 (if you use ad.fly)

Now that you have an AdF.ly URL that is associated with your account, the work begins.

You will now be paid for every person that clicks on your short link, so you need to give it maximum exposure. The easiest way is if you already own a website or blog, you can shrink URLs already on your website and replace them with short links. Then your website visitors click on them, you will earn money. The easiest way to give your site Paid Links. Is place a Full Page Script that automatically changes the links on the page to Paid Links. You just add the code to your site or blog and you will start making money!

It doesnt matter if you dont own a website, there are plenty of other ways to get people clicking on your short links (without spamming!). Here a few ideas:

1. Social networks. Got a great website to share with your friends? Shrink it with one of the services on this page first. Note that short links from some of the most popular paying url shortening services (Like Ad fly) may be blocked by some websites (i.e. Facebook), if this happens try other url shorteners that pay.
2. Forums. If you are helping people out on a forum and giving them the answers they require, shrink any website URLs and then include them in your post. Be absolutely sure you are not spamming though, otherwise you get your account suspended. Always abide by the forum rules.
3. Anywhere you normally post links! Use your imagination and get paid every month.

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Make Money By Clixies

At Clixies you earn money by completing free
offers. These offers will be to sign up with various companies online. You are
only to sign up with those that you are really interested in. Also some offers
are surveys where your opinion is asked for and all you have to do is
participate. You will start at the rate of $0.10 for every offer you take, but
you will be able increase this rate up to $0.25 by referring other members.

You can request payment as soon as you have at least $2.00 on your account.

You can also increase your earnings dramatically by referring other people to
join Clixies. We offer very high referral commissions 5 levels deep:

1st level – 20%

2nd level – 10%

3rd level – 10%

4th level – 10%

5th level – 10%

The referral compensation plan is shown in the chart below:



If you refer just 3 people and each of your direct and indirect referrals also
refers an average of 3 people, you will end up with 363 referrals in your
downline. And if they all complete at least 10 offers a day each, your daily
earnings will be US $36.60.

for sign up click this banner

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Effects of acupuncture on pain and inflammation in pediatric appendicitis

A paper [full text here] from The Journal of Alternative and Complementary Medicine says that "acupuncture may be a feasible and effective treatment modality for decreasing subjective pain and inflammation" in pediatric patients with appendicitis.

They studied six adolescents with appendicitis and administered acupuncture for pain control prior to surgery. Pain was assessed using three analog scales, and inflammation was measured using serial white blood cell (WBC) counts and C-reactive protein levels (CRP). CRP is a nonspecific indicator of inflammation in the body.

Figure 2 from the paper summarizes the results.

You can see that after 20 minutes of acupuncture, all three pain scores and WBCs declined. However, CRP continued to rise. Conspicuously absent from the figure and the text of the paper are any statistical analyses. This is due to the lack of a significant difference in any of these values because of the limited number of subjects studied.

The authors were undeterred and concluded "Although CRP as a general marker of inflammation stayed roughly the same on sequential blood draws, the median WBC showed a modest and noticeable drop. The implication of this finding is that the effectiveness of acupuncture may have a biophysiological basis." Look at the figure and decide for yourself if the WBC drop is really more noticeable than the CRP rise.

While the authors did mention some limitations of the study including the lack of statistics, they didnt discuss impediments to using acupuncture in patients who present to an emergency department. Whether patients were given antibiotics before or during the acupuncture session was not stated.

Even if the technique actually works [which is certainly not proven by this paper], how practical would it be to have an acupuncturist on call? Would she take in-house call? If not, how long would it take for her to get to the hospital? Would insurance pay for acupuncture? Would the acupuncturist be subject to work hours limitations?

The authors are not proposing acupuncture as a definitive treatment for appendicitis. So what is the clinical value of reducing inflammation? An even better way to reduce inflammation [and pain] is to remove the diseased appendix.

I know how difficult it is to publish papers and continue to do all the clinical and administrative work of an academic physician. As I have said on several occasions, many of my published papers were simply not very good.

But acupuncture to decrease inflammation in appendicitis patients? I doubt youll be seeing an on-call acupuncturist any time soon.

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Are today’s surgery residents poorly trained What can be done about it

A surgical resident writes

I’m sure you have read several recent studies suggesting that current general surgery residents are poorly trained and unprepared for independent practice at the completion of residency.

My questions for you:

1. In general, do you agree that current general surgery residents are poorly trained and unable to operate independently at the completion of residency?

2. What should we do differently? I personally don’t feel that “more simulation activities”, which many have suggested, is an adequate solution.

Thank you for the excellent questions.

I have been out of the surgical education loop for a few years and no longer have first-hand experience, but the literature does indicate that some surgical residency graduates are not ready to practice by themselves.

In 2013, I blogged about an Annals of Surgery paper reporting as many as one third of subspecialty general surgery fellowship directors felt that about one-third of incoming fellows were deficient in several areas and unable to independently perform a laparoscopic cholecystectomy or 30 minutes of a major case unsupervised.

Click on the table to enlarge it. You can see the responses of the program directors.

This paper was criticized by some because the fellowship directors surveyed were not subspecialtists recognized by the ACGME. The implication was that fellows in these programs might not be representative of all surgical graduates. However, many of them were minimally invasive fellowship programs which continue to be highly sought after.

Does it really matter? Some general surgery graduates apparently can’t operate by themselves.

In 2011, I blogged about a paper that reported 27% of all graduating surgical residents surveyed were not confident performing surgery by themselves. That was approximately the same percentage identified by the fellowship program directors.

Regarding what can be done about the issues of confidence and traing, I agree with you about simulation. You can simulate all you want, but being alone at 2 AM with a patient who is bleeding out cannot be adequately simulated.

The American College of Surgeons created a Transition to Practice Fellowship in 2013. They later change the name from a fellowship to a program. Of course, I blogged about this too. As far as I know, not many hospitals are involved. How many graduating residents have enrolled in this fellowship program is unknown.

Henry Buchwald, a prominent senior surgeon, recently advocated establishing “open surgery” fellowships and wrote, “I submit that it would behoove our training programs to return open surgery schooling to their curricula.” However, he doesn’t explain how this could be done or where one would go to do a fellowship and open surgery.

Life imitates art. In a post last year, I cited the visionary surgeon Leo Gordon who saw it coming in 2002. He predicted the need for a "macrolaparotomy" course, and said it could be run by the newly created "American Board of Open Surgery."

The lack of confidence stems from the gradual increase in supervision of residents over the last 15 to 20 years. In yet another blog post, I pointed out that many of today’s residents rarely if ever operate independently during residency training. To realize you are on your own as a full-fledged surgeon without ever having performed a case by yourself must be frightening.

With all the ACGME regulations, medicolegal concerns, and extensive scrutiny surgeons and trainees are subjected to, I don’t see this problem going away anytime soon.

All you can do as a surgical resident is to try to scrub on as many cases as possible and take care of as many patients as you can. With luck, you may have faculty who have enough confidence in themselves to allow you some autonomy and decision making in the OR and when managing patients pre-and postoperatively.

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CPR in space is possible maybe

Last summer I wrote about the many problems associated with performing surgery in outer space. [Link here.]  Not surprisingly, I was highly skeptical about such issues as training astronauts to operate on each other and the difficulties in taking along enough supplies to deal with unexpected trauma and surgical diseases.

At least one commentor on that post felt that NASA had all the answers. But another said, “What NASA never wants to discuss publicly is the scenario: If X happens then you die.”

Not to be outdone, the European Space Agency recently released a YouTube video illustrating how cardiopulmonary resuscitation could be carried out in a weightless environment.



You can see that the technique is rather awkward and questionably effective. To my knowledge, the rescuer falling on the victim is not currently recommended in the latest CPR guidelines.

Assuming that by some miracle the victim survives CPR, what would happen to him? Would he be transferred to the intensive care unit on the spaceship? Would there be a ventilator? What about an endotracheal tube and someone to insert it? Who would monitor the patient? Would that person be subject to work hours limits?

Here’s what I think.

If you have a cardiac arrest on the way to Mars, you’re not only in deep space, you’re in deep doodoo.

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Are zombiestat uglystat and adsensewatchdog real views

No, they are not.

If like me you have a blog that attracts no visits at all, you may be surprised and delighted that these referrals show up as visitors.

Unfortunately, they are just an automated spam bot, that visits large numbers of blogs.

The good thing is that they seem to be harmless.  They dont screw with your ranking or do anything that Google doesnt like - and given that you and I are not the only ones being visited - it is safe to assume there are no bad consequences.

The purpose of them is to gather the occasional person who say "Who is this visiting me" and visits their websites to see.  That is when you realise the point.  It is to get visitors to their own sites.

So these traffic hits are a minor irritation, harmless and I guess Google cant or doesnt need to do anything about them.  If you dont visit them then they cant get you to buy their offer or ask for your email details.

The best thing to do is to get some real traffic from somewhere by writing useful searched for stuff that ticks a visitors box.  Heres hoping - it might happen one day.

Then the zombies will fade into insignificance.

Oh yeah.  Add vampirestat to that list.  Ill add more depending on how much they annoy me. 

tkdot.com
yandex.ru
www surfsidecoupons com
blogsrating

Clearly the bots have got a keen interest in me.  Poor traffic, writing a rubbish blog - I must be a prime target for the spammers who will tell me a hundred ways to earn money.

At least you know now - it is not just your blog they are picking on.  Just tune them out and hopefully you have some real traffic too.  And dont visit these spammers - it will only encourage them.

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Are guidelines a safe harbor against malpractice suits

Several months ago, Physicians Weekly featured an article describing a bill that was introduced into the House of Representatives called HR 1406 The Saving Lives, Saving Costs Act. It would create a "safe harbor" for physicians who could show that they followed best practice guidelines when faced with a malpractice suit. At the end of the piece, a question was asked, "Do you think this bill will help safeguard physicians against the influx of federal rules and regulations?"

Knowing little about the bill at the time, I tweeted that such a bill would never pass.

I couldnt list the reasons in a tweet, but here are a few.

Although guidelines are useful, they can be controversial too. Take the guidelines on screening mammography and PSA testing. When they came out, there was so much criticism that it would be difficult for any lawyer to use them as safe harbors. Plaintiffs experts would simply say they disagreed with any guideline. A seed of doubt would be planted in the minds of jurors, and the safe harbor defense would fail.

The Dr. Whitecoat blog published a conversation between an emergency physician and a plaintiffs lawyer. It should be read in its entirety, including the comments, to be appreciated.

The conversation was mostly about the Choosing Wisely campaign, in which specialty societies publish guidelines listing certain tests and treatments that they feel can be avoided.

The lawyer said, "There will be a lot of bad discharges, refused admits, procedure delays, diagnoses delays, all in the name of ‘costs.’ Your societies and hospitals are masking this as evidence based practice, etc. But I can get a jury to see that very differently. A lot of physicians will be paying out before long, as will hospitals…Testing is what makes diagnoses, saves people.

"I have a pretty set script here. To the effect of ‘so Doctor, you just didn’t care enough about my client to order this test?’ Or ‘so my client was just a statistic, just a percentage to you?’… [Juries] love that stuff!”

A post I wrote last year about a supposed set of common goals shared by lawyers and surgeons had these comments from another plaintiffs lawyer.

Regarding the use of guidelines as a malpractice defense which some have labeled a "safe harbor," the lawyer said, "The safe harbor concept becomes unacceptable if it allows guidelines to be used as a get out of jail free card. Guidelines must be useful in exonerating and implicating clinician wrongdoing." My interpretation of what he said was that its OK to use a guideline to prove a clinician did wrong, but following guidelines should not be a fail-safe defense strategy.

Just for fun, I looked up HR 1406s history. It was introduced on February 27, 2014 and immediately referred to three committees—the Energy and Commerce Committee, The Judiciary Committee, And the Subcommittee on Health. On March 20, 2014 it was referred to the Subcommittee on the Constitution and Civil Justice, and it hasnt been heard from again.

A website that tracks bills lists its status as "Died in a previous Congress."

I dont think you will be sailing to a safe harbor any time soon.

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Please stop this There are more than Ebola victims in the US

I get it. Can we please stop comparing the number of Ebola victims in the United States to all sorts of irrelevant things? PS: Its not that funny either.

The following are directly copied from recent tweets. Links have been removed for your protection.

There are more Saudi Princes than Ebola victims

Kim Kardashian has had more husbands than Ebola victims in the US

More Americans have been dumped by Taylor Swift than have died from Ebola

Fun Fact: More #kids die annually due to #faith healing than #Ebola.

FACT: Katie Price has claimed more victims than Ebola.

NYC traffic. another thing thats much more dangerous than #Ebola, courtesy of @bobkolker via @intelligencer

There are more people in this tram than ebola victims in America.

Ive lost more followers than US Ebola victims [I didnt tweet this or any of these other tweets.]

@lbftaylor fewer #ebola victims in US than drunk Palins in a #PalinBrawl.

@pbolt @robertjbennett Also, there are more ex-wives of Larry King than there are ebola victims int he US.

Rush Limbaugh has more ex-wives than USA has Ebola victims!

@xeni Menudo has had more members than 3x the number of American Ebola victims...

Put #ebola in the context of vaccination preventable dz: 118,000 children < 5 yrs old die from measles per year

@Tiffuhkneexoxo @LeeTRBL more dc team quarterbacks have played this year than there are US ebola victims

Rest assured, there will always be more American guns in Africa than Ebola victims. Everything is fine. Relax

As #Enterovirus spreads faster x country & kills more than #Ebola, sure victims parents must b sad congress isnt demanding an ED68 czar.

We are all far more likely 2 be victims of identity theft than #Ebola. Obama has a plan to fix that

Americans spend more money on Halloween costumes for their pets than the UN spends on helping Ebola victims and fighting ISIS combined.

@mikebarnicle 9900 gunshot victims since Newtown, much scarier than Ebola.

So FYI... More people die from the #flu than #ebola .

Fear hospital infections not Ebola. 1 in 25 patients are infected. 75,000 die yearly.

Every day in America around 100 people lose their lives to mostly preventable car crashes. #Ebola

There are more experts on CNN right now talking about Ebola in America than people with ebola in America.

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Why in hospital deaths are not a good quality measure

You may be tired of hearing about the Surgeon Scorecard—the surgeon rating system that was recently released by an organization called ProPublica. Like many others, I have pointed out some flaws in it. You can read my previous posts here and here.

I had decided to stop commenting about it because enough is enough, but a recent paper in the BMJ raises a question about one of the criteria ProPublica used to formulate its ratings.

ProPublica defined complications 1) as any patient readmission within 30 days and 2) "any patient deaths during the initial surgical stay."

The authors of the BMJ paper randomly selected 100 records of patients who died at each of 34 hospitals in the United Kingdom. The 3400 records were reviewed by experts to determine whether a death could have been avoided if the quality of care had been better.

The number of patient records in which a death was at least 50% likely to have been avoidable was 123 or 3.6%.

There was a very weak association between the number of preventable deaths and the overall number of deaths occurring at each hospital. By two measures of overall hospital deaths, the hospital standardized mortality ratio and the summary hospital level mortality indicator, the correlation coefficient between avoidable deaths and all deaths was 0.3, not statistically significant.

From the paper: "The absence of even a moderately strong association is a reflection of the small proportion of deaths (3.6%) judged likely to be avoidable and of the relatively small variation in avoidable death proportions between trusts [hospitals]. This confirms what others have demonstrated theoretically—that is, no matter how large the study the signal (avoidable deaths) to noise (all deaths) ratio means that detection of significant differences between trusts is unlikely."

The Surgeon Scorecard was derived from administrative data. No individual analysis of patient deaths was undertaken. According to a ProPublica article discussing some key questions about their methodology, "As for deaths, we took a conservative approach and only included those that occurred in the hospital within the initial stay."

Maybe that wasnt such a conservative approach after all.

And maybe we need to rethink that 2013 paper claiming that medical error caused up to 440,000 deaths per year.

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Should radiologists tell patients their test results

Radiologists discussing test results with patients, a subject that has been lurking under the radar for a while, recently came to light because of an article in the New York Times. The idea is that patient anxiety while waiting to find out a test result could be alleviated by an immediate discussion with a radiologist.

That would be very nice, but there are potential problems, some of which are detailed in a post that appeared on the website of The Advisory Board and others in an editorial by radiologist Saurabh Jha accompanying a paper on the subject..

In the Times, Dr. Christopher Beaulieu, chief of musculoskeletal imaging at Stanford, said, “[T]he radiologist may be capable of transmitting the information but the obvious next question for the patient is, ‘What do I do now?’ which, as nontreating physicians, radiologists are not trained to answer.”

Both The Advisory Board and Dr. Jha speculated about the potential liability exposure of a radiologist whose advice might differ from that of the referring doctor causing concern for the patient and hostility from the doctor.

Unless the radiologist performs a history and physical examination, he will not know much about the patient. A lack of clinical context might cause a radiologist to misinform the patient.

Heres a scenario. A radiologist tells a patient she has a suspicious mass in her adrenal gland on a CT scan but cant tell the patient what should be done about it. Instead of anxiety about not knowing the test result, the patient would then have anxiety about having a mass and no plan to deal with it.

What about incidental or equivocal findings? Dr. Jha wrote, "Such findings, for example, could potentially, albeit immensely improbably, turn out to be cancer. Radiologists will find that the burden of ‘clinical correlation’ will fall upon them, and this task will be all the more challenging at a single time point."

A study found that a radiologists discussion with the patient about a CT scan took a little more than 10 minutes. Would that time be reimbursed and if so, how? Dr. Jha pointed out that the discussion would have to be documented and the decrease in radiologist productivity would have to be made up somehow.

Since they rarely, if ever, talk to patients, radiologists may be extremely uncomfortable with this new role. Ive known a few radiologists who are not even comfortable talking to other physicians. Many radiologists dont choose a career being sequestered in a dark room because they are "people persons."

The Times article described one patients interaction with a radiologist. He said the radiologist "seemed physically afraid of me."

The real solution is for radiologists to communicate more rapidly with referring physicians and for those physicians to communicate more rapidly with their patients.

Here is what needs to happen. 1) A critical or unexpected result of radiologic examination should always be immediately discussed in a telephone call from the radiologist to the doctor who ordered the test. 2) Every doctor or her staff must promptly communicate the results of any radiologic test to a patient.

If those actions occurred on a regular basis, radiologists wouldnt need to talk to patients, and litigation due to overlooked important findings could be avoided.

So what I really would like to see is pathologists talking to patients.

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Dr Topols bad day

Dr. Eric Topol is a cardiologist, author, editor-in-chief of Medscape, and genomics professor. In 2009, he was named one of the 12 Rock Stars of Science by none other than GQ magazine.

But even rock stars occasionally have a bad day. After blogging for almost 5 years, I sometimes have trouble thinking of things to write about. This apparently happened to Dr. Topol the other day. He published a Medscape article with an accompanying video about how doctors are being squeezed by many outside forces that require them to do things they dont want to do.

It was kind of a rambling discourse in which he suggested that doctors should offload the responsibility to do these "more mundane aspects of care" to the patients. He thinks this would make medicine more exciting "the way it used to be."

Dr. Topol offered this cartoon to illustrate the outside forces that are squeezing doctors.

Genomics is a focus of Dr. Topols research, but I dont think a lot of doctors are concerned that they lack knowledge about it.

His post created a lot of controversy prompting Medscape to take down all of the comments.

With great foresight, one physician, Dr. Kristin Held, preserved her comment with a screenshot which I have thoughtfully provided for you below.

What do you think she really wanted to say with the start of her second paragraph? Could it have been "How about growing a _ _ _ _ of _ _ _ _s?

Like Dr. Held, I have no idea which of the "mundane aspects of this new world" Dr. Topol had in mind to offload on the patients. Of the 16 forces squeezing doctors that he illustrated, I dont see many of them being taken over by patients. They already control patient satisfaction and whats written on Yelp. Maybe they can cover the lack of genomic knowledge too.

Its sad that an influential doctor like Topol is so lost in the woods. However, the bright side is that gave me something to write about.

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“Code Black” should be pronounced dead

A new television series called “Code Black” debuted last night on CBS. The show’s name supposedly means the emergency department has too many patients and not enough staff. In my over 40 years in medicine, I’ve seen many busy, understaffed EDs but never heard anyone call it a "Code Black."

There is the usual array of standard medical characters—the inexperienced new residents on their first day at work, the savvy nurses, and the cocky, overconfident attendings. This one has a few twists. The world-weary head nurse is a Hispanic man, and the headstrong know-it-all attending is a woman, Dr. Leanne Rorish. She has early conflict with the handsome, more cautious Dr. Neal Hudson, but I see romance in the future should this show manage to stay on the air.

It takes 5 people to push an empty gurney at Angels Memorial

The show started off with a gunshot wound to the neck that the docs had to retrieve from a car which had been abandoned in the hospital parking lot. Although no one had been putting pressure on the damaged carotid artery for an undetermined period of time and blood was visibly spurting out of the wound, the patient pulled through the resuscitation thanks to Dr. Rorish who replaced all his blood with cold IV fluid. She spiced up the resuscitation by asking the new residents questions about what she was doing.

A man with head trauma and a Glascow Coma Score of 3 was brought in and declared brain-dead on the spot. The transplant team was on its way in. Apparently Angels Memorial Hospital has no brain death protocol.

Another man came in with expressive aphasia due to a stroke, received tPA, and promptly woke up and told his wife he loved her. That’s not the way it works.

My favorite vignette was the arrival of a young boy who was short of breath. Learning that he was Norwegian, Dr. Rorish immediately diagnosed a pneumothorax and assigned an unsupervised new resident to insert a chest tube. He of course was a bit nervous. It was touch and go for a while, but he eventually got the job done. The patient was remarkably calm despite not receiving any local anesthesia which, by the way doesn’t work too well for chest tube insertions anyway.

In the midst of all the chaos, Dr. Rorish fired one of the new residents, a woman who disobeyed her by ordering a urine toxicology screen on a patient who was discharged and later determined to be suffering from carbon monoxide poisoning.

I won’t bore you with the details but the fired resident somehow ended up going in an ambulance to get the patient at her home. On the way back to the hospital, they got stuck in traffic. Drs. Rorish and Hudson talked the resident through a cesarean section which she performed in the ambulance without any assistance.

Did I mention that Dr. Rorish was doing a burr hole on a patient with an epidural hematoma while all this was going on? This scenario was plausible since it can often be difficult to get a neurosurgeon to come to the hospital.

At this point, Id had enough.

Here’s an idea that I’d like to pitch to the networks. It’s a show about the fast-paced world of nursing homes, and it’s called “Code Brown.” For those of you who don’t know, a Code Brown is called whenever a patient poops so much that it takes four people to clean up.

ADDENDUM: I had heard about more crazy stuff in the second episode of Code Black. Against my better judgment, I watched it. To read my review of that one, click here.

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Are surgeons the cause of high postoperative readmission rates

No, according to a recent paper published online in JAMA Surgery.

The authors concluded, "The majority of the variation in readmission was attributable to patient-related factors (82.8%) while surgical subspecialty accounted for 14.5% of the variability, and individual surgeon-level factors accounted for 2.8%."

The investigators looked at data for over 22,000 surgical patients treated at Johns Hopkins and found the overall rate of readmission within 30 days was 13.2%. After the exclusion of those who performed fewer than 21 operations per year, 56 surgeons made up the study cohort.

Multivariable analysis showed significant non-modifiable patient-related factors associated with readmission were African-American race/ethnicity, more comorbidities, occurrence of postoperative complications, and an extended length of stay.

Variation in readmission by subspecialty ranged from 2.1% after breast, melanoma, or endocrine surgery to 37% following cardiac surgery.

The authors pointed out that this study "echoes growing concerns regarding the use of readmission as a quality metric based on its current methods."

Lets compare it to the controversial ProPublica Surgeon Scorecard.

Both the Surgeon Scorecard and the JAMA Surgery paper used data from the years 2009 through 2013. The scorecard involved only eight high-volume low-risk in-patient procedures while the paper looked at in-patient surgery of all types.

From an article written by the authors of the Surgeon Scorecard: "If a patient was readmitted to any hospital (not just the hospital where the surgery was performed) within 30 days of a surgery for one of the conditions we identified, we counted the case as a complication for the surgeon who performed the initial procedure."

What we learned from the JAMA Surgery paper raises some questions about the the Surgeon Scorecard. On Twitter, I asked for comment from Marshall Allen, the lead author of a white paper [not peer-reviewed] describing the methodology of the Surgeon Scorecard.

Between attacks on my credibility because I choose to use a pseudonym, he said that they did not count most readmissions as complications. It is unclear from the article, the white paper, or its appendices exactly which complications were included. For clarification, we could ask the "surgeon experts" who advised ProPublica, but their names have not been disclosed. They are anonymous, just like me.

According to the white paper, surgeons were blamed for 64,367 (46%) of all complications incorporated into the Surgeon Scorecard. Table 3 of the white paper lists the 20 most frequent complications. The top three, comprising 26,795 complications, were postoperative infection, iatrogenic pulmonary embolism, and infection/inflammatory reaction due to internal joint prosthesis.

Other studies have shown that not all occurrences of those three complications are attributable to a surgeons misdeed. Among the rest of the top 20 causes of readmission were postoperative pain, fever, and dysphagia (difficulty swallowing)—again possibly not the fault of a surgeon.

So the JAMA Surgery paper says surgeons are responsible for 2.8% of readmissions within 30 days, but ProPublicas self-published white paper says 46% of all readmissions are due to something a surgeon did or did not do.

Who to believe?

Note added at 7:27 a.m. on 9/2/15: See my next post for a clarification about causation and variation. 

The full text of the peer-reviewed JAMA Surgery paper is available here.

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Micro Gig Economy by Marc Charles

7:22 AM

Hi Gang:

Ive developed a new money making program called MicroGig Riches.

Its published and supported by Great Escape Publishing and Agora.

The reviews and testimonials are humbling :)

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Marc

---------

A new, fun (and some say crazy)
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AND fund your travel account …
in 10 minutes a day or less …

Fast Company … U.S. News … all agree. This is an innovative way to make spare cash.

MicroGig Riches 2015

Read More!

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Code Black Part II It gets worse

Last week, I reviewed the premier of the new medical television series "Code Black" and pointed out several flawed or impossible scenarios. I didnt think Id watch another episode.

But I was alerted to a rather shocking error on last weeks installment. I had to see it for myself.

On this typically chaotic day in the emergency department, a young woman was brought in after a car crash which occurred while she was in her way to the ED because of abdominal pain. A CT scan of her abdomen and pelvis was negative, but her serum lactate level was elevated. They then decided to examine her abdomen and noted tenderness. A bedside ultrasound done in the ED revealed a left ovarian torsion (twisting of the blood supply to the ovary which if not rapidly corrected, could cause irreversible damage). The patient had already had her right ovary removed. Further heightening the drama was that her husband died of lymphoma but had banked his sperm, and the patient wanted to have his baby.

She needed immediate surgery, but all of the hospitals operating rooms were busy. As the window of opportunity to correct the problem was closing, an operating room opened up. But alas, there was not a single gynecologist or surgeon available to do the case. According to the back story about Dr. Neil Hudson, hes a fully trained surgeon who decided to work in emergency medicine. One of the new ED residents begged Dr. Hudson to do the case, and he resisted for a while until it was almost too late.

Despite admitting to having no operating room privileges and surely no malpractice insurance coverage for surgery, Dr. Hudson finally acquiesced. Just before beginning the case, he explained to the OR staff what he was going to do.

Then the egregious error occurred. While scrubbed in the OR and wearing a sterile gloves and gown, he calmly reached up to pull his unsterile mask over his nose and mouth. Thats a no-no.

PS: I could find no reference mentioning an elevated lactate associated with ovarian torsion. The organ is likely too small for ischemia to have any effect on the that lab value.

Some other highlights. For a patient with multiple facial lacerations, Dr. Hudson ligated the maxillary artery—quite a feat in an emergency room without an OR light or any retraction. As you can see from the figure below, the maxillary artery is deep to the jawbone. Not shown are branches of the facial nerve which lie above the artery.

Dr. Leanne Rorich, the all-knowing equivalent of Dr. House, stopped a nosebleed by inserting Foley catheters in each nostril, a well-known trick. However she inflated the balloons with the closest liquid she had on hand—coffee, and the patients blood pressure normalized within seconds.

If the convoluted story of the woman with the ovarian torsion wasnt enough, the patient with the nosebleed happened to be a 14-year-old blind boy on Coumadin who fell while rock climbing with his father.

Stay tuned for the next episode featuring a bus that tumbles off a narrow mountain road while carrying non-compliant hemophiliacs.

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More ratings—this time its residency programs

Can you really decide which surgical residency program is right for you using Doximitys Residency Navigator?

I dont think so, and heres why.

The rankings of residency programs were obtained by surveying surgeon members of Doximity. They were asked name the five top programs for clinical surgery training. When the survey was announced in June, I predicted that most respondents would probably overlook the word "clinical" and focus on the usual famous academic institutions.

I also pointed out that anyone not intimately familiar with a program would be unable to judge whether it is good or not and suggested that reputation would be the main driver of results.

In fact, that is exactly what happened. Of the top 40 programs listed, all are based at university hospitals, as are 66 of the top 70. Back in June, I speculated about the top five programs and got the first two correct but in the wrong order.

A 2012 survey of surgical residents with over 4200 responders (an 80% response rate) found that community hospital trainees were significantly more satisfied with their operative experience and less likely to worry about practicing independently after graduation. Wouldnt you then expect a few community hospital programs to be among the top 40 hospitals for clinical surgery training?

Proof that the surveys findings are not reliable is that every one of the 253 surgical residency programs in the country was mentioned by one or more of those who responded. This included one program that has been terminated by the Residency Review Committee for Surgery. At least it appears near the bottom of the list.

The number of voters who cited the lower ranking programs must have been very few, meaning the difference between the 200th and 240th program ranks is probably not statistically significant.

Some programs that were rated are so new that very few or no residents have graduated yet. How could anyone know if they are turning out competent clinical surgeons?

Board passage rates for programs, which are available online, were omitted for some and were not clearly identified as the percentage of residents who passed both parts of the boards on the first attempt only.

The percentile rankings of alumni peer-reviewed articles, grants, and clinical trials are displayed prominently. What do those data have to do with the research question—which residency programs "offer the best clinical training"?

So whats the bottom line?

You can put the Doximity Resident Navigator in with the other misleading ratings of hospitals and doctors. Applicants considering surgical residencies should not rely on it for guidance.

It has warmed the hearts of faculty and residents at highly rated programs, but I wonder how the OR lounge discussions are going at places where programs ranked lower than expected.

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What are the chances of international medical grads matching in surgery

Anyone considering attending a Caribbean or any foreign medical school should do due diligence. An Internet search is step one. If the school does not list residency match statistics, that could be a red flag. It would not be easy to accomplish, but try to speak with some current students or recent graduates of any schools you are thinking about.

If the school wont give you any names, use caution, and remember, they are not likely to give you the names of dissatisfied students or alumni.

If a school does not require Medical College Admission Test (MCAT) scores, I would advise extreme caution. That suggests they probably take all comers.
Heres a look at some match data from offshore schools. The list of schools is by no means comprehensive as there are about 25 med schools in the Caribbean area. I attempted to find results from the 2015 match for the following schools: Ross, St. Georges, American University of the Caribbean, Caribbean Medical University, St. James University, University of Medicine and Health Sciences, and American Global University.

I used the word "placed" because that term is what one of the schools used, and I believe students who obtained positions in the Supplemental Offer and Acceptance Program (SOAP) after the main match are included.

The orthopedic results are shown to give you an idea of the chances to find a surgical position in any surgical specialty other than general.

For all of the schools that published lists, the overwhelming majority of students obtained positions in family medicine and internal medicine.

The number of unmatched students is not stated, but US schools dont publish that information either.

It is not completely hopeless because if you look at the NRMPs Advance Data for the 2015 match, you can see that 243 (20%) of the general surgery positions and 40 (5.7%) of the positions in orthopedics were filled by non-US grads.

Finally, heres a portion of an email I received last week.

I am a US-IMG who recently matched into a categorical surgery residency at a university program. I graduate in a few weeks from a school in the Middle East. I rotated in my 4th year at some really prominent institutions that many foreign grads dont have access to, and I believe this helped tremendously.

I was definitely on the high end for a foreign grad in terms of interviews in my class. I was very lucky. A lot of people told me I would have to look into other things or didnt believe in me, but in the end, I took a risk for something I love.

Unless you want to be an internist or a family doctor, you will have to decide if you want to risk not being the lucky one.

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