Can patients shower immediately after surgery

Here’s what a recent paper published ahead of print in Annals of Surgery says:

Between May 2013 and March 2014, 222 patients were randomized to the group allowed remove their dressings and shower at 48 hours and 222 to the group permitted to shower only after the original dressing and the sutures were removed in clinic. There were 4 (1.8%) superficial surgical site infections in the early shower group and 6 (2.7%) in the late shower group, an insignificant difference with p = 0.751.

The authors concluded that clean and clean-contaminated wounds can be safely showered 48 hours after surgery, and early postoperative showering may increase patient satisfaction.

I have always been an advocate of early showering after surgery. Wounds properly closed will be bridged by epithelium within 48 hours. Tap water is relatively sterile or we couldnt drink it. Many studies have shown that even irrigating open wounds with tap water instead of sterile saline does not lead to more infections. [Links here and here.]

Much as I would like to believe the Annals study, I can’t because it is probably underpowered to show a difference between the two groups.

Here is a nice definition of statistical power from a website called effectsizeFAQ.com:

“In plain English, statistical power is the likelihood that a study will detect an effect when there is an effect there to be detected. If statistical power is high, the probability of making a Type II error, or concluding there is no effect when, in fact, there is one, goes down.”

To their credit, the authors did try to estimate the sample sizes they would need by doing a power calculation. They knew that the wound infection rate for the cases they intended to enroll was about 1%. The problem is they estimated that showering at 48 hours would result in a wound infection rate of 5%. That seems very high to me for the types of cases included in their investigation—thyroid, lung, inguinal hernia and skin tumors.

If they had hypothesized that early showering would merely triple the rate of wound infections from 1% to 3%, they would have needed at least 1536 patients in each arm of the study. Then if there was no difference, one could conclude that early showering truly does not cause more wound infections.

Even if the known incidence of wound infection was much larger, say 5%, and the rate of infection with showering was presumed to be doubled (10%), to have enough power a study would need 434 patients in each arm.

Many websites provide calculators for determining the appropriate sample sizes to detect with a reasonable degree of certainty whether one intervention is better than another. Anyone thinking about doing a prospective randomized trial should realistically estimate the expected difference and calculate the power.

Whenever you read a negative study, the first question to ask is, “Was the study adequately powered to avoid a type II error?”

Read More..

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.

Read More..

Patients can chew gum immediately before surgery I guess

A study presented at the American Society of Anesthesiologists (ASA) meeting in October of this year found that patients who chew gum in the immediate preoperative period may safely undergo surgery.

The authors, based at the University of Pennsylvania, found that gum chewing increases saliva production and the volume of fluid in the stomach, but stomach acidity was equivalent to that of non-gum chewers. An article about the study said The mean gastric volume, or total amount of liquid in the stomach, was statistically higher in patients who chewed gum before their procedure (13ml) versus those who did not (6ml). A 7 mL difference might be statistically significant, but surely is not clinically important.

The research differed from previous studies because it involved patients who underwent upper gastrointestinal endoscopy, which enabled the investigators to recover all of the fluid in the stomach for testing. Prior studies had been done using nasogastric tubes, and it was impossible to determine whether all gastric fluid was recovered when the tubes were suctioned.

The study involved 34 gum chewers who were allowed to chew any type or any amount of gum compared to 33 patients who did not chew gum.

Another article quoted its lead author.

"We found that although chewing gum before surgery increases the production of saliva and therefore the volume of stomach liquids, it does not affect the level of stomach acidity in a way that would elevate complication risks," explains Dr. Goudra.

He says patients shouldnt be encouraged to chew gum before procedures involving anesthesia, but the habit shouldnt necessitate the cancellation or delay of scheduled cases if other aspiration risk factors arent present.

There has been long-standing debate about the subject of whether using gum and hard candy should be treated the same as ingesting a regular meal.

I wrote about this on my blog back in January 2014 and pointed out that the ASA guidelines do not address the issue.

In an effort to do due diligence, I was able to locate the abstract of this paper on the ASA website. Im glad I did because the abstract came to the opposite conclusion.

When the abstract was submitted, it included fewer patients—24 who chewed gum and 23 who did not.

The average gastric volumes were 9.78 mL for the gum chewers and 24.08 mL for the non-gum chewers (p = 0.027), and pH values were not significantly different (p = 0.094). It looks like regression to the mean occurred as the number of subjects increased.

In the original abstract, the authors concluded the following: Chewing gum in the preoperative fasting period leads to significant increase in the residual gastric volumes, with no difference in pH. We recommend that patients who have inadvertently chewed gum in the fasting period should be treated as full stomach and management modified accordingly. [Emphasis added]

So what is going on here? This would not be the first time that an abstract differed from the final paper. Actually, this sort of thing happens quite frequently. However in this case, the conclusions of the two versions are diametrically opposed to each other.

The study was presented at a meeting. Lets see what happens when it is submitted to a journal for peer review.

The correct way to have done the study would have been to calculate the number of patients needed to be studied (power analysis) beforehand.

Since this was not done, I recommend we go with the conclusion of the larger number of patients studied because it agrees with my bias that chewing gum is not potentially harmful.

Read More..

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.

Read More..

A paper of mine was published Did anyone read it

An orthopedist asked me if I could explain why a couple of papers of his did not generate any feedback. He wasnt even sure that anyone had read them. He enclosed PDFs for me.

Not being an orthopedist, I cannot comment on their validity.

But I think I can explain why the papers have not created much interest.

Are you familiar with the term "impact factor"? If not, here is a link explaining what it is:

A journals impact factor is an indication of how widely cited its articles are. One can also assume that it is a good indication of how popular the journal is and by inference, how many people read its papers. The impact factor has been criticized, but it is one of the few measures of a journals influence.

The two papers in question were published in Orthopaedics & Traumatology: Surgery & Research. A list of the top 40 orthopedic journals ranked by impact factor in 2013 showed that it ranked 37th with an impact factor of 1.061. That means the average number of citations for any paper published in OTSR was about 1, and 36 orthopedic journals were more widely cited than OTSR.

A paper in Physics World claims that that 90% of published papers are never cited and 50% are never read by anyone but the authors and the journals peer reviewers. I believe this is true of papers in medical journals too.

I was unable to obtain any figures regarding the number of subscribers to OTSR, but I suspect it is not large. This may also account for the lack of responses to the papers. My own experience is similar. It was very rare to receive any feedback about any of the over 90 peer-reviewed papers, editorials, or reviews that I had written.

Consider this. A blog post of mine "Appendicitis: Diagnosis, CT Scans and Reality" which I wrote 4 years ago has received over 19,600 page views and more than 100 comments. I am certain that post has been read far more than all of my published research papers combined. In fact, my 550 blog posts have recorded over 1 million page views.

What does it all mean?

Journals may have to adapt and become more like blogs. In the future, medical information may be disseminated by blogs and comments rather than journal articles and letters to the editor.

Will scientists CVs be valued more for the number of page views their papers receive than the number of peer-reviewed papers they publish?

Read More..

OR delays Whos responsible and what can be done

Every two or three years, someone, usually a hospital administrator, decides that delays in operating room turnover time need to be looked into. A committee of 20 or 30 stakeholders (love that term) is appointed and assigns someone the job of measuring the time between cases and identifying reasons for delays. In years when turnover time is not being studied, first case starting delays are on the agenda.

In my nearly 24 years as a surgical department chair, one or the other of these issues was investigated at least 10 times. We were never able to conclusively determine the exact causes of delays or solutions to the problem, and we returned to business as usual.

An article in Anesthesiology News about a paper that looked at causes of operating room delays in over 15,500 cases at a single hospital got my attention.

The number one reason for delays was that the nurses did not have the operating room ready for the patient. Nursing also was responsible for the third most common cause "preop prep (IVs, meds, etc.)."

Surgeons were the reason for the second most common problem, "notes, consent, patient marking not complete." A few more of the top 10 included surgeons running two rooms, surgeon unavailable, and my favorite, "last case ended early." I’m not sure how a case ending early causes a delay in starting the next case. Usually we are blamed for underestimating the length of time we need to do an operation.

Anesthesiologists were cited for only one of the 10 most common reasons for delays—placement of an IV line or regional block.

Not surprisingly, the study was done by anesthesiologists using data they collected.

When I expressed skepticism about this on Twitter, I was accused of implying the research was fraudulent. Not so. Some of my best friends are anesthesiologists. In fact two of my medical school roommates became anesthesiologists. Fraud is not the issue. Its a matter of perspective.

For example when the nurses investigate OR delays, the problem never seems to be nursing.

Im not saying that surgeons dont cause delays. A task force once found that one of my surgeons was late for his first case every time he operated because he had to take his kids to school.

Another surgeon would disappear between cases and was always late for his next one. No one knew where he went. Some thought he may have been calling his broker or perhaps having an affair.

Here’s what the anesthesiologist researchers may have overlooked.

In effort to avoid delays, I would often ask for an anesthesia consult on complicated inpatients booked for surgery a day or two later. On nearly every occasion, the anesthesiologist who saw the patient was not the one assigned to do the case. The consulting anesthesiologist never said a certain lab test was necessary, but in the holding room, the one who was going to put the patient to sleep said it was. A spirited discussion, phone calls, and a delay ensued.

Sometimes a day surgery patient who arrived 2 hours ahead of schedule wasnt interviewed by anesthesia until the scheduled time of the case.

Then there was my patient whose operation was postponed for 6 hours because she had a piece of hard candy in her mouth when she got to OR. The anesthesiologist said it was the equivalent of having a full stomach. Read the full story here.

Can delays be shortened by working together? A 2014 paper in the Journal of Surgical Research by a surgeon and four anesthesiologists found that “various events and organizational factors created an environment that was receptive to change.” The authors were able to decrease their general surgery OR turnaround times from 48.6 minutes to 44.8 minutes, a statistically significant (p < 0.0001) but hardly clinically important difference.

Let me hear your experiences with OR delays.

Read More..

A high school student has questions about a medical career and pathology vs surgery

A female high school student asks about pathology, surgery, and medicine in general. [Email edited for length.] See if you agree with my answers.

The field I am most interested in is pathology. I have a very logical mind and would enjoy being able to solve the complex puzzle of disease. I would also like the somewhat flexible hours compared to other more intensive specialties. However, I do have some qualms.

Im also interested in general surgery. I would love to learn how to perform all the different types of surgeries that surgeons perform. If I were to be a pathologist, would it be "knife-free"? Pathology really intrigues me, but participating in the occasional surgery sounds like it would be extremely interesting and full of learning opportunities.

There is some knife wielding in pathology. Specimens must be properly cut, and there is the occasional autopsy. However, its definitely not surgery.

What does a pathologist really do? Ive looked at various descriptions online, and none of them seem to be very specific. What would a typical day look like for a pathology resident? I was also wondering what types of skills pathologists are taught?

Pathologists spend most of their days looking at specimens, mostly microscopic slides. Here is what pathology residents at Johns Hopkins learn.

I know that medicine is constantly evolving. With new medical technology, certain fields will soon become obsolete. Do you think this will happen to pathology?

I suppose there will be some technical advances that might involve automated digital reading of pathology slides, but I believe there always will be a need for pathologists. A residency position in pathology is much easier to obtain than one in general surgery.

Since Im interested in both pathology and general surgery, I was wondering if there was a way I could do them both (in a combined program or something like that). I know this is highly unlikely.

It cant be done.

I am a very anxious person. Specifically, I have health anxiety. (Im all too aware of the irony). Do you think that the amount and intensity of the material covered during med school and residency could take a severe toll on a persons mental health?

I think every medical student at some point worries she might have a disease she just read about. Im not sure what to tell you because I am not a psychiatrist, but studying diseases for four years and having a health anxiety might be a problem.

I would also like to know whether being involved in medicine could dramatically alter a persons personality by magnifying their negative characteristics. I am very driven, hard-working, ambitious, logical, easily annoyed/frustrated, and sometimes easily distracted. Im quite anal-retentive and OCD. Some of my friends and family have described me as an emotional robot. How do you think these characteristics would be affected by a journey through medicine?

Many medical students and residents become less empathetic and more jaded as they go through medical school and residency. Except for being easily distracted, many of your traits are common in med students. Heres more about empathy and medical students.

Do you know how difficult it is for Canadian students to get into American med schools? Or do you know any medical schools abroad in English speaking countries (e.g. Scotland, England) that would be willing to admit international students? Also, would it be more difficult for a woman?

Its not easy. Here is a link to a website that has some data on Canadian applicants to US schools. I dont know much about UK schools. Ive written about Caribbean schools. Type "Caribbean" in the search field of my blog. Being a woman wont matter.

How would medicine affect interpersonal relationships? Im really close with my immediate family, and it would be difficult not being able to see them all the time, let alone during holidays or breaks. How can a person manage a serious relationship and medicine at the same time?

It can be done, but it takes some effort. I have written a few posts about so-called work-life balance.

Choosing a specialty is difficult
More about choosing a specialty
Anguish about choosing a specialty
Surgery and work/home conflict

I hope this helps. Good luck.

Read More..

The best general surgery residency programs for clinical training

Ive received a couple of emails from Doximity [A closed medical "community" of > 280,000 doctors] reminding me to complete a survey which they are sponsoring jointly with U.S. News & World Report. They are asking members, possibly only surgeons, to name the best general surgery training programs in the country.

Not mentioned in the email but stated at the beginning of the survey is that they want respondents to name the 5 best programs for clinical training.

I have a feeling that not everyone will notice the part about clinical training, and we will get a list of the usual suspects just as we do every year with the U.S. News best hospitals survey.

For several reasons, the survey is fundamentally flawed.

There are 240 general surgery residency programs in the country. Unless one is personally involved with a program, it is impossible to judge the competency of its graduates. How would I or anyone else who does not work there know whether residents training at UCLA or Baylor or Lehigh Valley are clinically competent?

There are no accepted ways to judge the clinical skills of any surgeon. Video recording of procedures with judging by peers can assess technical ability, and as shown in the recent New England Journal paper from Michigan, there is some correlation with outcomes.

The American Board of Surgery publishes first attempt board passage rates for all programs, but passing the boards does not necessarily equate to clinical skill.

Most surgeons have probably encountered only one or two graduates of any of surgical residency. Even if the ones we have seen were great, they may not represent the majority of graduates.

Ill bet I can name most of the top 5 programs right now. These are not necessarily the programs that produce the best clinically trained residents.

Here are my guesses: Massachusetts General, Johns Hopkins, Mayo Clinic-Rochester MN, New York Presbyterian-Columbia, Cleveland Clinic.

In the past, some institutions on my list were rumored to be terrible places to learn to perform surgery because the residents did a lot of watching and retracting but not much operating. Whether that is true today or was so in the past, I could not tell you.

I guarantee you that no community hospital will rank in the top 20 [maybe top 50] despite the fact that such hospitals produce many fine clinical surgeons.

I have no idea which programs produce the best clinically trained surgeons. After the Doximity-U.S. News survey results are published, you wont know either.

Read More..

Questions about antibiotics vs surgery for acute appendicitis

A study from Finland suggesting that antibiotics may be a viable alternative to surgery for acute appendicitis has created a stir. As you might have expected, I had some concerns about the paper which you can read in my blog post here.

On Twitter, many surgeons have commented on both the paper and my post. Several interesting questions come to mind.

Based on this and other similar studies, is the treatment of acute appendicitis with antibiotics now a mainstream alternative to surgery?

Should surgeons now mention the Finnish study results during their informed consent discussions with patients?

Is CT scanning accurate enough to differentiate a reasonable percentage of uncomplicated appendicitis from more complex cases? Previous papers have reported conflicting data on this topic. Will this lead to more CT scanning (if that is even possible)?

What do patients want? In an effort to avoid surgery, are they willing to take a 25-30% chance of a recurrence of appendicitis?

Will patients be able to understand the distinction between complicated and uncomplicated appendicitis?

We all agreed that ertapenem is not a first-choice antibiotic in the United States. In fact, the real questions may be is a three-day hospitalization for intravenous antibiotics really necessary, or as is the case with acute sigmoid diverticulitis, would a course of oral antibiotics as an outpatient be sufficient to deal with an attack of uncomplicated appendicitis?

How will it work if antibiotics and surgery are considered equivalent treatments? Although I am retired, I think I am qualified to say that I would not have enjoyed going to an emergency department at 10 o’clock at night to see a patient with acute appendicitis who after a discussion, chooses to be treated with antibiotics. Should these medically-treated patients be admitted to surgery or another service? Should the emergency physician have the discussion with the patient and only call the surgeon if the patient elects to have an operation?

Is it appropriate for an anonymous blogger to be questioning the methods and results of a paper published in a top-tier journal such as JAMA?

What do you think about all of these questions?

Many thanks to the following for their input. If I omitted someone, I apologize. @jdimick1, @NirajGusani, @TomVargheseJr, @ChrisFriese_RN, @LVSelbs, @NatalieBlencowe, @JBMatthews, @ehldallas, @zuckerbraun, @SarahB_MD, @docaggarwal, @aneelbhangu, @smootholdfart, @DRSoup34, @hswapnil, @qdtrinh, @TimLaheyMD, @jonessurgery, @RogueRad, @DrKathyHughes, @putrescine, @krchhabra, @Apathetic_Cynic, @SimonRBarron

Read More..

Recognition

The following is based on an actual case that occurred a long time ago in a galaxy far, far away.

A 65-year-old man arrived in the emergency department by ambulance after being found unresponsive. His respiratory rate was 40/minute, heart rate was 170/minute, and temperature was 102.2°. He did not respond to Narcan or an ampule of 50% dextrose. Blood sugar was 600 mg/dL. The diagnosis of diabetic ketoacidosis was made. IV fluids and an insulin drip were given. After some hydration he became more alert and complained of abdominal pain. On examination, his abdomen was tender to palpation. Four hours after arrival, a surgical consultant was called and diagnosed an incarcerated inguinal hernia. Before the patient could be taken to surgery, he suffered a cardiac arrest and could not be resuscitated. Review of the case revealed that although blood cultures were drawn and were eventually positive, antibiotics had not been ordered.

What happened? The possibility that this patient was septic never occurred to the doctors managing the case. I am sure that if a scenario like this appeared on a test, those doctors would have immediately chosen the right antibiotics. Some doctors are "book smart" but cant deal with a real live patient.

Although the doctors didnt do a very thorough abdominal exam at first, the real problem here was recognition.

I was reminded of this case by a recent article about a 2013 paper that appeared in a journal called Human Factors. The paper, "The Effectiveness Of Airline Pilot Training for Abnormal Events," pointed out that pilots doing their periodic training know that certain crises—stalls, low-level wind shear, engine failures on takeoff—are part of every simulator session and will occur in predictable ways.

The authors presented those situations in unexpected ways, measured pilots reactions, and found that experienced pilots responded less skillfully.

From the paper: Our control conditions demonstrate that pilots’ abilities to respond to the “schoolhouse” versions of each abnormal event were in fine fettle. The problems that arose when the abnormal events were presented outside of the familiar contexts used in training demonstrate a failure of these skills to generalize to other situations.

They suggested four ways to improve training and testing.

1) Change it up. In other words, dont practice things the same way every time.

2) Train for surprise.

3) Turn off the automation. Dont let the pilots depend on automated systems to help them recognize what is going on because if those systems fail, pilots will have trouble dealing with the situation.

4) Reevaluate the idea of teaching to the test which can "present the illusion that real learning has taken place when in fact it has not."

Item #3 is particularly relevant because of some recent interest in the negative effects that automation is having on pilots and possibly society in general. The 2009 crash of an Air France plane into the South Atlantic Ocean has been analyzed in several recent publications. (Here and here)

The cockpit voice recorder transcript is chilling. In a storm, the autopilot failed, and the plane stalled. Three pilots failed to recognize what happened and did all the wrong things.

I have been saying for years that we need to teach med students and residents how to think. Recognition of rare events would be a good area to focus on.

Read More..

My blog cited in JAMA Surgery paper Progress for bloggers

About a year and a half ago, I blogged that a medical student on Twitter used a blog post of mine as evidence. In January, the Canadian Journal of Anesthesia published an article I wrote under my pseudonym called “Why I blog and tweet.”

Last month, medical blogging took another step toward legitimacy. A JAMA Surgery Viewpoint formally cited my post critiquing the Finnish randomized trial of antibiotics versus surgery for the treatment of acute appendicitis.

Here is the first page with the portion of the piece discussing what I had written in the blog post.

Click on figure to enlarge.

Here is how citation appears in the JAMA Surgery article.

If you havent read my entire post about the randomized trial, click here.

Last year I said this: “Journals may have to adapt and become more like blogs. In the future, medical information may be disseminated by blogs and comments rather than journal articles and letters to the editor.”

We have already seen prominent publications such as the New England Journal of Medicine starting online forums and the BMJ hosting blogs (at least 36 so far) and rapid responses to published papers.

The sea change in the way medical research is disseminated may be happening sooner than I thought.

Read More..

From the trenches More about grit

The following was compiled from two comments on my recent post about grit written by a doctor who calls himself "Geronimo." It is reproduced with permission.

Grit cannot be assessed by a survey. I wholly agree. As a military physician, my firmly founded opinion is that grit is essential to the practice of medicine. Grit is the elusive characteristic that carries the clinician through the challenges that exceed ordinary capabilities. You cite a paper that argues for surgical training to borrow aspects of SEAL training. I applaud any measure that would allow senior faculty and program directors to unilaterally shape their residents’ training, whether or not it bears any resemblance to the rigors of BUD/S [Basic Underwater Demolition/SEAL training].

The 2011 loss of 30-hour call for medical students and interns was a fatal blow to residency training, in my estimation. I count myself fortunate for having a 30 hour call internship before embarking on my operational career. While downrange, it is not at all uncommon to be woken at inconvenient hours of the night to tend to the wounds of war. If you don’t know how you function cognitively, physically, psychologically, and emotionally while sleep deprived, exhausted, hungry, cold, and pissed off, you’re behind the curve. While it isn’t any fun to work in such a state, or to work with people so challenged, it is decidedly less fun to be a patient expiring for want of any medical provider, let alone a tired one. American medicine used to be in such a place in the not so recent past, to hear the story told by my forbearers.

How often does disaster visit that requires sleep be sacrificed? The headlines recount a few – Katrina, Boston Marathon, Tropical Storm Alison, 9/11. No doubt there were physicians stretched beyond their ordinary limits for each of those ordeals. How often does it occur that a physician or surgeon must work beyond their ordinary limits for a patient whose ill begot fate failed to generate the attention of the press? I’d be willing to bet it’s on a monthly basis at least.

You sir, are a senior practitioner, and physicians like you taught me the practice. You know better than I why long hours and challenging training are essential, sir. My only question, sir, is why residency training standards were diluted and degraded at the behest of nurses, OSHA, and likely other “powers that be”, when you knew it was the wrong way. Why don’t modern program directors, department chiefs, make a stand? If there exists widespread agreement that the current methods don’t meet the standard, why pretend that they do? If you are a retired PD, you have a privileged position as not having to fear retribution. Use your bully pulpit to build consensus, unify the opposition and mount the attack.

Your SEAL post had a comment from a Man’s Greatest Hospital surgery program director who lamented the demise of training standards in the same fashion. I find it demoralizing that PD’s have been rendered impotent in the face of these trends. Obviously this will require a near unanimous front of PD’s and department chiefs. If your generation matriculates from practice without this trend being reversed, I believe it will be too great a task for my generation to overcome.

And for what its worth, I enjoyed the comments of TheTracker…

The utter incompetence of your generation—killing tens of thousands of patients every year with preventable errors secondary to the irrational systems, sloppily maintained, that you and your colleagues built up and managed.

Not to be blunt, but maybe while were struggling to clean up your mess and catch up with the rest of the developed world, you could forgo your attempts to shift blame with anecdotes?

This is pure unadulterated nonsense. I really can’t figure out what he’s talking about, but would venture the guess that he is a fan of checklists, timeouts, shifts that don’t exceed 12 hours and bubble baths. I don’t live in his world, and don’t want to. I am a doctor.

All doctors faced an attrition rate that exceeded BUD/S trainees matriculation to operational SEALs. Among aspiring physicians, 80-90% or more, are weeded out through undergrad prereq’s, MCAT, and the like. It should be an arduous, stressful endeavor to become a physician, just the same as it should to become a SEAL. Lives depend on SEALs’ and physicians’ capacity to demonstrate grit. Bearing that in mind, we should demand the same high standards and control over how we bestow the privilege of practice on the next generation. As it has been said many times, it is harder to stay in Ranger Battalion/Special Forces Group/SEAL Teams than to become a Ranger/SF Soldier/SEAL. The same is doubtless true of surgery and medicine. Medical and surgical training programs should reflect that reality.

Is Geronimo right or wrong?

Read More..

Variation is not causation

I made a rookie mistake in statistics of the “correlation is causation” genre by confusing variation for causation in the recent JAMA Surgery paper referred to in my last post. I contacted Dr. Timothy M. Pawlik, the lead author of the Johns Hopkins study, who said the following:

"The model is explaining and attributing variation in readmission and not attributing readmission itself to the different domains. The model suggested that only 2.8% of the variation in readmissions was attributable to surgeons. This is different than saying that only 2.8% were the fault of surgeons. A more accurate interpretation would be that only 2.8% of the variation seen in readmissions was attributable to provider level factors. The majority of the variation in readmission was due to patient factors."

He added that some of the 82.8% variation in readmissions attributable (note: attributable doesn’t mean it’s the patient’s fault) to the patient could be modified by better medically managing patients comorbidities or not operating on some of these patients.

That readmissions can be explained by a single domain or a single person is simplistic. Dr. Pawliks clarification confirms my original concern that attributing differences in patient outcomes solely to differences in technical quality of surgeons is probably inaccurate, statistically speaking.

Variation is not causation but variation is still a call to action. Regardless of who is to blame for unfavorable outcomes, surgery is a team sport. The incision is just as important as the community care. In this regard, I am certain that ProPublica and I are on the same side. Let’s work together so that we see the whole story behind the numbers.

Read More..

More on activity restrictions after surgery

In early January, I blogged about the dearth of evidence about activity restrictions after surgery.

A number of people commented and most agreed that there is little basis for most of the activity restrictions surgeons currently use.

An anonymous reader told me about a 2008 study from Creighton University that generated some interesting data about intra-abdominal pressures associated with some common activities. Here’s a summary of the paper.

The authors managed to find 10 healthy volunteers all of whom could bench press at least 100 pounds and were willing to have nasogastric manometry catheters placed and Foley catheters inserted into their urinary bladders.

Intra-abdominal pressures were recorded as each subject coughed 10 times as hard as possible, bench pressed varying amounts of weight from 26 to 114 pounds, and vomited after receiving ipecac syrup and drinking about 500 mL of water.

Pressures in the stomach and bladder correlated fairly well. To keep things simple, let’s look at gastric pressures only.

The highest mean and maximum pressures were found during vomiting. Coughing produced similar pressures. Most interestingly, intragastric pressures during weightlifting were significantly lower with a mean of 2 mmHg and a maximum of 52 mmHg, p <0 .001.="" br="">The authors mentioned that another group had found similar intra-abdominal pressures with subjects bench pressing 25 pounds.

Another unexpected finding was that although the differences were not significant, the mean intragastric pressures were inversely proportional to the amount of weight lifted.

Maybe we should tell postoperative patients not lift less than 26 lbs.

The authors were focused on measuring pressures that would disrupt a gastric anastomosis. They calculated that an intragastric pressure of 290 mmHg generated by vomiting was about 1/50 of the 20N [Newton] force that would disrupt a gastric suture line in a porcine model as demonstrated by other investigators.

The effect of repetitive stress such as found in patients with a chronic cough were unknown, but they said “the intra-abdominal pressures generated in our study alone do not appear to be responsible for hernia formation.”

The Creighton study authors concluded, "The common postoperative lifting restriction, although logical, has little evidence to support it." They called for more research in this area.

Unfortunately, their call has not been answered.

Read More..

Antibiotics vs surgery for appendicitis Its time for a randomized trial

Maybe youve heard that there is a growing debate about whether antibiotics are as good or better than surgery for treating appendicitis.

So far there have been several studies from Europe showing that antibiotics may be safely used to treat appendicitis in many cases. However, the studies have involved small numbers of patients and have exhibited some flaws in their methods. A few studies from the US have been published, but they were not randomized or prospective.

I have blogged about some of these studies on three occasions. If you would like to read these posts, click on their titles.

Antibiotics instead of surgery for appendicitis? Im still not convinced

Antibiotics instead of surgery for appendicitis? No way

Antibiotics instead of surgery for appendicitis? I don’t think so.

A group of surgeons in Washington State are putting together what will be the first randomized prospective trial of antibiotics vs. surgery for appendicitis in the United States. In order to obtain a grant from the Patient-Centered Outcomes Research Institute to help fund the project, the investigators must demonstrate that people in this country would be willing to participate in such a study.

To help determine the level of interest, they have written a brief explanation of why this study is being proposed. It parallels my thinking on the subject.

At the end of their post is a link to survey involving one question:

If you had appendicitis, would you be willing to join a study that would randomize you (a 50% chance, or flip of a coin) to “surgery ” or “antibiotics?”

You dont have to read the Washington researchers post to take the survey.

You may click here to answer that question. Thanks.

Read More..

What about activity restrictions after surgery

Although, uncommon, bleeding after surgery is the most common potential post-operative complication. To minimize the chances of this occurring, patients are advised to be as minimally active after surgery as possible. This includes activity restrictions such as:
No bending or heavy lifting
No rigorous exercise or exertion
Do not make important plans in the days immediately following your surgery

The above instructions appear on the website of a medical school department. The operation in question is

A. Cholecystectomy
B. Partial mastectomy
C. Inguinal hernia repair
D. All of the above
E. None of the above

Answer: E. None of the above. While all three of the operations mentioned could have been the subject of these activity restrictions, they were taken from a dermatology services description of the aftercare of Mohs surgery, which is a way of exercising skin cancers—not exactly major surgery.

This topic was suggested to me by a Twitter follower.



I told him that as far as I knew, there is no evidence basis for any of the activity restrictions we tell patients.

When I was a resident in the early 1970s, we kept patients who underwent inguinal herniorrhaphy in bed for no fewer than five days, and nephrectomy patients were bedbound for a week.

For the former, the theory was that early activity might disrupt the repair—implying that many repairs were tenuous in those days. Regarding nephrectomy, the prevailing wisdom was that the tie or ties on the renal vein could be dislodged by increased pressure in the inferior vena cava from something as trivial as a Valsalva maneuver. Following this logic, we should have prevented nephrectomy patients from coughing or having bowel movements too.

Since then, progress has been made. Hernia patients are discharged on the day of surgery, and nephrectomies are not kept in bed.

What is the definition of "heavy lifting"? It is usually described as lifting more than 10 lbs. Where did that come from? Other than 10 being a nice round number, I cant think of another reason.

A far-from-exhaustive literature search revealed no evidence-based studies and nothing at all pertaining to general surgery.

A 2008 opinion paper suggested that cardiac surgery patients who have excessive limitations on their activities might suffer excessive anxiety and depression leading to poor outcomes. They recommended that patients be given "personalized activity guidelines developed by an exercise specialist to help them resume their presurgical lives."

Activity restrictions after gynecologic surgery are also not evidence-based. A review from the University of Utah found no studies relating postoperative activity and surgical success. A previous survey had found "Depending on the surgery, 88-99% of surgeons restricted lifting for mean of 5–7 weeks (range 1–26 weeks and up to forever [?] after vaginal hysterectomy with vaginal repairs)."

In 2011, an expert panel said patients undergoing laparoscopic supracervical hysterectomy should avoid lifting more than 10 kg, bicycle riding, and vacuum cleaning [?] for two weeks.

At the other extreme is the story of Ryan Callahan, a forward for the Tampa Bay Lightning of the National Hockey League. Last May, he began practicing three days after a laparoscopic appendectomy and played in a playoff game two days later.

To put it mildly, the topic of postoperative activity restrictions is long overdue for prospective study.

Read More..

Applicant worries about the future of surgery

On my "Ask Skeptical Scalpel" blog, a medical student who is applying to general surgery programs is concerned about "The rise of the two Ms—machines and mid-levels."

I talk him off the ledge. You can read the post here.

Read More..

The Surgeon Scorecard My analysis

Ive got nothing against ProPublica. If a valid way to rate surgeons is ever discovered, I would support it completely. However, ProPublicas Surgeon Scorecard is not the answer.

I keep hearing its defenders say, "Some data is better than no data at all." I disagree strongly with that. To me, bad data is worse than no data at all. People with much more statistical sophistication than I have pointed out the flaws in the scorecard.

Digression: Having written many posts about statistics, I can tell you that the mere mention of the word drives readers away about as fast as if you were to yell "Fire" in a crowded theater.

I want to focus on a different area. The scorecard has created a lot of chatter on Twitter, and just about everyone I know has blogged about it.

This reminds me of a couple of posts I wrote back in 2011. [Links here and here.] I pointed out that Twitter might not be as important as those of us who use it think it is.

While we were busy arguing about the merits of the scorecard on Twitter, Im not so sure what the general public was doing.

For example, ProPublica says the Surgeon Scorecard has had over 1 million visitors since its launch. That sounds like a lot until you consider that the current population of the United States is estimated at 321 million. So 1 million people would be 0.3%. We do not know how many of those 1 million were unique visitors. It could be that many of them were doctors looking for their own statistics and bloggers looking for ideas.

That the public may not care was reinforced by a rather tepid response to the ProPublica AMA (Ask Me Anything) on Reddit today.

By 1:00 PM EDT, which was two hours into the AMA, there were 80 comments, 31 of which were by ProPublica staff or the spine surgeon who had consulted on the scorecards methods.

Just to give you some perspective, an AMA last year by a guy with two penises drew 17,134 comments.

Because the demographic is skewed toward younger people, perhaps Reddit may not have been the right venue. Although Reddit boasts 169 million unique visitors per month, the most recent figures show that 33% of the Reddit users are mostly men between 18 and 49 years old. Those under 18 are not counted but represent "a substantial percentage of Reddit users."

My two favorite questions asked of ProPublica were "How can I tell if my doctor is capable of making an error?" and "Do you fix the leg which is broken completely?" [Did the question refer to a leg that was completely broken, or did it mean should the leg be completely fixed?]

What have we learned here? Its hard to say.

If you want to read a measured critique of the scorecard, go to Dr. John Mandrolas piece on Medscape.

Read More..

Cool Business Opportunities by Marc Charles

Cool Business Opportunities in 2014

7:04 AM

Dear Entrepreneur:

I discovered three opportunities with “over the top” profit potential.

I’ll give you the details in a second.

I usually focus on one opportunity each week…so consider this a Happy New Year present!

But know this……Ive been identifying great business opportunities for more than 30 years.

I’m referred to as “King of Business Opportunities” for good reason. 

Here’s what R.F. said about me recently:

“Marc has an uncanny ability for spotting profitable trends and creating simple profitable businesses around them.  There are a ton of people selling push-button “sit by the pool” type programs which claim to make a million dollars instantly. That’s not what Marc Charles does. He’s a simple guy, making a ton of money in simple ways.  If you have a chance to meet Marc in person you will be a richer person, guaranteed”

I’m not tooting my own horn! I just want you to know identifying “legitimate” business opportunities is in my blood.  I’ll be doing this until they find me found face down on my keyboard!

“Yeah….But What Have You Done For Me Today”?

There hundreds of magazines, newsletters, websites, podcasts, newspapers, TV and radio shows devoted to exploring business opportunities today.

But most of the opportunities people are talking today about are history - nada, toast!

My focus is on business opportunities which capitalize on rising trends right now!

And listen…..I’ve watched entrepreneurs lose millions on “sure things” such vending routes, franchises, restaurants, flipping real estate, nightclubs, discount clubs, software, MLM, kiosks, airport gift shops and “life changing” inventions.

My approach is pretty simple…I don’t want align myself with obsolete products, businesses or dying trends.

On top of that, you don’t want to risk a boatload of cash either.

 

My preference….although it’s not always available….are businesses that don’t require a ton of employees, inventory, paperwork, lawyers, regulation or physical assets.  

My columns are for entrepreneurs who want the gut-wrenching truth about legitimate business opportunities. 

Most of the opportunities I research are not a good fit for readers because the cost of entry is too high.

For example, a typical Subway “franchise” will set you back $100,000 - $250,000 - and that’s just for starters. 

The real money pit for any restaurant (and especially a franchise like Subway) is the operating capital. 

On top of that, most franchises require you to cough up a percentage of the profits every month in the form of royalties too. 

But that’s not all…..there’s more downside risk

Most franchise businesses are required to buy food, supplies and equipment from the parent corporation. Wow! If you do a search in Google News on Stone Cold Creamery you’ll see what I mean.

Twenty-five years ago a Burger King franchise was considered one of the best opportunities around. 

But today, you can’t unload a Burger King franchise fast enough. 

There’s even a group of franchisees suing the company because they
“can’t get out”!

The trend of owning a MacDonald’s or Burger King franchise for a start up entrepreneur is over for most entrepreneurs. Not to mention sales are down big time at these places.

Granted, restaurants can be profitable. 

If you’re completely out of your mind and still decide to open one – my suggestion would be to partner with a rising brand such as Johnny Rockets, Baja Fresh or Famous Dave’s BBQ. For higher end restaurant franchise consider KEO Japanese or Morton’s Steak House.

You can go it alone – and try to copy the formula of a rising franchise brand – but the odds are against you.

There are hundreds of business opportunities in the world today that don’t require massive capital, employees, buildings, inventories, accountants, lawyers or huge learning curves.

Three Cool Opportunities for 2014 (and beyond) 

1)    Internet Direct Response

Internet ecommerce continues to climb and there’s no end in sight.

Internet direct response businesses which provide “over the top” service and reasonable prices should perform well – even in a downturn.

Internet direct response businesses would include selling products on eBay, Yahoo! Marketplace and Amazon.com.

This also includes selling information and digital products.

ClickBank.com is a wildly successful digital marketplace for small entrepreneurs. 

2)    Self-Storage Real Estate (in Select Areas)

The self-storage business generates more revenue per square foot than any other real estate investment. I know it’s hard to believe - but it’s true.

Granted, the 70s and 80s were the boom time for the self-storage industry.

In 2010 there was a consolidation in the market and a pull back in the trend.

But in my opinion the trend is back. This market presents some great opportunities for entrepreneurs of every size.

The downside is the capitol required. But you’ll find hundreds of self storage properties for sale and many with owner financing.

Or you can build your own facility.

The one thing I like about this business….(and I know it better than most)…is the multiple streams of income.

You can generate income from unit rentals, ancillary products, insurance, truck rentals, late fees and self storage auctions.

The key to success in a self storage business is marketing, which includes capuring drive by traffic.

I’m not convinced the new trend in portable self-storage units or “pods” is a hit rising trend. I know they’re gaining popularity. But the “numbers” I’ve seen do not compare with traditional self storage operations or self storage REITs.

3)    Import Export Businesses

There’s a misconception regarding most import and export businesses.

You can start this business on a shoestring, and even become a middleman or finder and profit this way.

Importing and exporting is a rising trend. You can run successful import export business from anywhere in the world.

One of the hottest sites on the Internet for helping import/export entrepreneurs is Alibaba and AliExpress

eBay and Amazon.com will continue to play a role in helping import and export entrepreneurs too.

I’ve developed an exciting new program called China Wholesale Trader. It’s designed to help entrepreneurs make money quickly and easily in the import market.

There you have it!

I’ve shown you three new “over the top” business opportunities for 2011 and beyond.

I’m interested in hearing what you think…..not only regarding these opportunities but my weekly articles for The League of Power.

Drop me a note or post your comments on the forum.

Until next week!

Your Humble Host,

Marc Charles

******Valuable Resources *******

Internet Direct Response Gurus:

Bob Bly

Frank Kern

Ken Envoy

Joe Vitale

Allan Gardyne

Self-Storage Real Estate Gurus

The New Real Estate Riches Seminar

B. Wayne Hughes

Import Export Gurus

China Wholesale Trader (Yours Truly)

Ty Hicks

Read More..