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Saturday, March 19, 2011
Monday, October 18, 2010
What Does Dave Weigel have to do with Sermo?
Dave Weigel is a libertarian, right-leaning blogger who had been writing for the Washington Post. Although his politics veer right of center, he has no tolerance for the radical, wacky wing of the Republican Party (think Tea Partiers, Glenn Beck, Sean Hannity, etc.) Weigel was a member of the liberal-leaning listserv called JournoList (a private, by-invitation-only email group comprised of professional journalists and bloggers). JournoList provided a forum for these guys to exchange ideas with one another in an off the record fashion. Weigel, this week, in a moment of reckless writing, posted a thread on JournoList implying that the world would be a better place if Matt Drudge suddenly decided to self immolate.
Someone read the post and decided to break protocol. Ultimately, several of his off the record email posts were published for the general public on both the Daily Caller and FishbowlDC. Weigel subsequently resigned his position as a writer/blogger for the Washington Post.
The embroglio got me thinking social media and professionalism, in general. On places like Facebook and private blogs and Twitter accounts, people often present a far different characterization of themselves than the one they perhaps proffer in the office, at the hospital etc. Perhaps we sometimes trust too much that these two versions of ourselves do not overlap, that our secret rebellious, outgoing selves are secure behind passwords and restricted access walls. (This is why I don't do Twitter or Facebook--- Buckeye Surgeon is the sole source of learning about Dr Parks; no contradictions or duplicity. As long as I keep writing honestly, I don't feel any need to worry about reprisals.)
Sermo is a social network restricted to physicians (you have to give a verifiable medical license number in order to join). It's a great resource for docs. I've run cases by strangers on Sermo in real time while trying to decide upon an appropriate treatment plan for a difficult patient and have been aided immeasurably by the advice and comments I've received. But there are also posts about the political aspects of medicine and complaints about other specialties and rants about difficult patients and malpractice claims. And not everyone on Sermo chooses to be anonymous.
What if someone obtained access to Sermo for nefarious purposes? Perhaps a physician-turned-hospital administrator who went looking for dirt on a trouble-making internist. Or a malpractice attorney who used his brother-in-law's log-on ID to troll for cases.
Dave Weigel lost his job over a careless post on what he thought was a secure, private listserv. You figure it's not a question of if, but when, something similar will occur to casually flippant doc on a site like Sermo....
Someone read the post and decided to break protocol. Ultimately, several of his off the record email posts were published for the general public on both the Daily Caller and FishbowlDC. Weigel subsequently resigned his position as a writer/blogger for the Washington Post.
The embroglio got me thinking social media and professionalism, in general. On places like Facebook and private blogs and Twitter accounts, people often present a far different characterization of themselves than the one they perhaps proffer in the office, at the hospital etc. Perhaps we sometimes trust too much that these two versions of ourselves do not overlap, that our secret rebellious, outgoing selves are secure behind passwords and restricted access walls. (This is why I don't do Twitter or Facebook--- Buckeye Surgeon is the sole source of learning about Dr Parks; no contradictions or duplicity. As long as I keep writing honestly, I don't feel any need to worry about reprisals.)
Sermo is a social network restricted to physicians (you have to give a verifiable medical license number in order to join). It's a great resource for docs. I've run cases by strangers on Sermo in real time while trying to decide upon an appropriate treatment plan for a difficult patient and have been aided immeasurably by the advice and comments I've received. But there are also posts about the political aspects of medicine and complaints about other specialties and rants about difficult patients and malpractice claims. And not everyone on Sermo chooses to be anonymous.
What if someone obtained access to Sermo for nefarious purposes? Perhaps a physician-turned-hospital administrator who went looking for dirt on a trouble-making internist. Or a malpractice attorney who used his brother-in-law's log-on ID to troll for cases.
Dave Weigel lost his job over a careless post on what he thought was a secure, private listserv. You figure it's not a question of if, but when, something similar will occur to casually flippant doc on a site like Sermo....
Compromise
Glenn Greenwald has done a bang up job of exposing the cozy, compromising relationships that the elite press corps has developed with the very Washington DC politicians and insiders they are ostensibly supposed to be covering. In this era of blogging and open source media, the public doesn't necessarily have to seek political news and opinions from the old guard of mainstream media. The elites no longer have a monopoly on defining what is news and how the news ought to be interpreted. So they cling to the one thing that the bloggers will never be able to touch---their sources, connections, and inside contacts.
As a result we get travesties like the Joe Biden party where reporters engage in squirt gun fights with the Vice President and other White House staffers. You get Chris Wallace "interviewing" Dick Cheney without asking a single uncomfortable question about torture and waterboarding. You get Sarah Palin running for Vice President without having to endure a single unscripted press conference. The presentation of "news" becomes merely a propaganda show where journalists and reporters subserviently regurgitate what the politician wants them to say, unchallenged. Because if they don't, guess what? No more access! No more "private sit down" sessions with Mr. VIP! And so the journalist/reporter simply stops doing the job he/she was hired for, i.e. holding governmental persons in postions of power accountable. Getting at the truth isn't so important as maintaining an open relationship.
Similarly, in medicine we often compromise ourselves for nefarious purposes, especially financial. We bitch and moan about tort reform and the insidious malpractice situation but we refuse to hold one another accountable. When another doctor makes an error, no one says anything. It's "too awkward" to say anything or "it creates an antagonistic environment" will be the explanations you hear. And of course this is true to some extent. But a larger reason has to do with the way private practice is constructed. Referral patterns are based on relationships and habit. You refer to a certain surgeon because he seems nice and the patients like him. You refer to a certain endocrinologist because she went to your medical school. Rare does it have anything to do with the quality of care delivered. And as these referral patterns and relationships ossify, it becomes harder and harder to change them. One thing that will change a referral pattern mighty quick would be "tattling" on a referring doctor for providing substandard care. Or receiving a notice in the mail from your QA committee that another physician has submitted several examples of cases where you delayed an intervention.
We specialists don't want to disrupt our profitable and essential referral patterns. So we don't say anything when an internist puts a patient on full strength lovenox 24 hours after a colon surgery. At most we perhaps off-handedly mention to the physician that maybe it would be a better idea to allow the surgeon to decide when to re start anticoagulation. The GI doc doesn't report the surgeon who always calls him for his all too frequent post-lap chole bile leaks. We don't report the internist to QA who prescribes massive doses of IV steroids to a patient with a rash (probably from morphine reaction) who was admitted with diverticulitis, who then decompensates and becomes septic with peritonitis. We just kinda, sorta mention that altering the patient's immunity with corticosteroids maybe wasn't such a great idea. Or maybe we don't say anything at all. Because it would just create an awkward situation.
As a result we get travesties like the Joe Biden party where reporters engage in squirt gun fights with the Vice President and other White House staffers. You get Chris Wallace "interviewing" Dick Cheney without asking a single uncomfortable question about torture and waterboarding. You get Sarah Palin running for Vice President without having to endure a single unscripted press conference. The presentation of "news" becomes merely a propaganda show where journalists and reporters subserviently regurgitate what the politician wants them to say, unchallenged. Because if they don't, guess what? No more access! No more "private sit down" sessions with Mr. VIP! And so the journalist/reporter simply stops doing the job he/she was hired for, i.e. holding governmental persons in postions of power accountable. Getting at the truth isn't so important as maintaining an open relationship.
Similarly, in medicine we often compromise ourselves for nefarious purposes, especially financial. We bitch and moan about tort reform and the insidious malpractice situation but we refuse to hold one another accountable. When another doctor makes an error, no one says anything. It's "too awkward" to say anything or "it creates an antagonistic environment" will be the explanations you hear. And of course this is true to some extent. But a larger reason has to do with the way private practice is constructed. Referral patterns are based on relationships and habit. You refer to a certain surgeon because he seems nice and the patients like him. You refer to a certain endocrinologist because she went to your medical school. Rare does it have anything to do with the quality of care delivered. And as these referral patterns and relationships ossify, it becomes harder and harder to change them. One thing that will change a referral pattern mighty quick would be "tattling" on a referring doctor for providing substandard care. Or receiving a notice in the mail from your QA committee that another physician has submitted several examples of cases where you delayed an intervention.
We specialists don't want to disrupt our profitable and essential referral patterns. So we don't say anything when an internist puts a patient on full strength lovenox 24 hours after a colon surgery. At most we perhaps off-handedly mention to the physician that maybe it would be a better idea to allow the surgeon to decide when to re start anticoagulation. The GI doc doesn't report the surgeon who always calls him for his all too frequent post-lap chole bile leaks. We don't report the internist to QA who prescribes massive doses of IV steroids to a patient with a rash (probably from morphine reaction) who was admitted with diverticulitis, who then decompensates and becomes septic with peritonitis. We just kinda, sorta mention that altering the patient's immunity with corticosteroids maybe wasn't such a great idea. Or maybe we don't say anything at all. Because it would just create an awkward situation.
The Increasingly Unacceptable Negative Appendectomy
When I was a medical student (really, not that long ago), we were taught on our surgical rotations that one can expect to take out a significant number of normal appendixes during a career. Specifically, a 15-20% negative appendectomy rate was considered appropriate, if not the standard of care. The rationale went like this: you don't want to miss appendicitis, delayed diagnosis leads to complicated outcomes, therefore, it's worth the morbidity of an operation to remove a few normal worms along the way.
This dogma dominated surgical thought right up until the Era of the Ubiquitous CT Scan came into being. Today's scanners are quick and highly sensitive for intra-abdominal pathology. An inflamed appendix rarely eludes its watchful eye. As a result, given the highly litigious environment of 21st century medicine, it's rare for a patient presenting to an ER with belly pain to go home without a scan. Personally, I like the CT scan, even in the so-called no-brainer cases (20 year old male with focal RLQ abdominal pain). For one thing, it helps me plan the surgery better--- is there an abscess in the pelvis needing drained, is it retrocecal, should I place my ports in a certain configuration, etc. For another, I'm a self-described ace when it comes to reading a scan for appendicitis. If I don't see the hallmarks of appendicitis while scrolling through the images, then I'm pretty hesitant to rush the patient to the OR. Finally, I just hate the concept of doing a surgery for no reason. Taking out a normal appendix is a highly unsatisfying endeavor. The only two truly negative appendectomies I've done in my career so far were on pregnant patients who chose not to undergo pre-operative CT scanning but had suggestive clinical histories.
It's funny, in the recent past, a surgeon with such a low negative appendectomy rate would raise suspicions from his local QA committee. It suggested that he/she was "not being aggressive enough" in treating ER patients in abdominal pain. The tide has turned however. A recent article from Radiology demonstrates a decrease in negative appies from 23% to 1.7% over the past 18 years, again directly attributable to the old CT scan. Also, from Surgery, a group at a New York hospital describes a decrease in negative appendectomy rates to around 5%. And that sounds about right to me.
Nowadays, a surgeon who regularly takes out normal appendices is going to come under fire. On one of my QA committees, we "keep an eye on" surgeons who have negative appy rates over 15%. With modern CT scanners, it's hard to justify the old dogma. Of course, someone will probably write up some groundbreaking finding about how all these CT scans lead irrevocably to a higher incidence of cancer---- which will reverse the tide again and we'll be once more teaching residents the value of "laying on of hands" and clinical judgement.
This dogma dominated surgical thought right up until the Era of the Ubiquitous CT Scan came into being. Today's scanners are quick and highly sensitive for intra-abdominal pathology. An inflamed appendix rarely eludes its watchful eye. As a result, given the highly litigious environment of 21st century medicine, it's rare for a patient presenting to an ER with belly pain to go home without a scan. Personally, I like the CT scan, even in the so-called no-brainer cases (20 year old male with focal RLQ abdominal pain). For one thing, it helps me plan the surgery better--- is there an abscess in the pelvis needing drained, is it retrocecal, should I place my ports in a certain configuration, etc. For another, I'm a self-described ace when it comes to reading a scan for appendicitis. If I don't see the hallmarks of appendicitis while scrolling through the images, then I'm pretty hesitant to rush the patient to the OR. Finally, I just hate the concept of doing a surgery for no reason. Taking out a normal appendix is a highly unsatisfying endeavor. The only two truly negative appendectomies I've done in my career so far were on pregnant patients who chose not to undergo pre-operative CT scanning but had suggestive clinical histories.
It's funny, in the recent past, a surgeon with such a low negative appendectomy rate would raise suspicions from his local QA committee. It suggested that he/she was "not being aggressive enough" in treating ER patients in abdominal pain. The tide has turned however. A recent article from Radiology demonstrates a decrease in negative appies from 23% to 1.7% over the past 18 years, again directly attributable to the old CT scan. Also, from Surgery, a group at a New York hospital describes a decrease in negative appendectomy rates to around 5%. And that sounds about right to me.
Nowadays, a surgeon who regularly takes out normal appendices is going to come under fire. On one of my QA committees, we "keep an eye on" surgeons who have negative appy rates over 15%. With modern CT scanners, it's hard to justify the old dogma. Of course, someone will probably write up some groundbreaking finding about how all these CT scans lead irrevocably to a higher incidence of cancer---- which will reverse the tide again and we'll be once more teaching residents the value of "laying on of hands" and clinical judgement.
Doctors or Technicians?
Interesting article recently from Health Affairs (via WSJ blog) about the clinical equivalence between the care provided by anesthesiologists and CRNAs. The article concludes by advocating that CRNAs be given permission to practice anethesiology without physician supervision. It's more cost effective. And there is no compromise to the quality of care delivered to patients.
We recommend CMS return to its original intention of allowing nurse anesthetists to work independently of surgeon or anesthesiologist supervision without requiring state governments to formally petition for an exemption,” they conclude. “This would free surgeons from the legal responsibilities for anesthesia services provided by other professionals. It would also lead to more cost-effective care as the solo practice of certified registered nurse anesthetists increases.” The study was funded by the American Association of Nurse Anesthetists.
A couple of caveats. One, the study was conducted by the American Association for Nurse Anesthetists (sort of like a study claiming that Jeff Parks is the smartest man on earth being conducted by "friends and family and hired sycophants of Dr. Parks"). Also, the study admits that CRNA's tend to work on less complex cases than MD anesthesiologists.
The main thrust of papers like this is to delve into the essence of what it means to be a "doctor". Are all doctors alike? Is the orthopod who replaces 350 knees a year the same as the internist cranking through 30 patients a day with complex medical problems? Is it fair or unfair to further categorize the various specialities according to some sort of intellectual hierarchy? Do some specialties verge perilously close to being mere technicians, thereby inviting the sort of turf war salvo sounded by the above referenced paper?
In reality, I think it goes beyond anesthesiology (although anesthesiologists are an arguably easier target). Most of the work done by a family practitioner can probably be adequately performed by a NP or PA without adverse effects. If you trained a physically gifted person to take out gallbladders and that's all he did, day after day, I bet you would be able to find a paper demonstrating that the non-MD surgeon has a similar complication rate as a formally trained general surgeon. But then what is that automaton going to do when he encounters a cholecysto-colonic fistula or when the cholangiogram shows he has cut the common bile duct? What is the NP going to do when she has to manage a patient with diabetes, heart disease, peripheral vascular disease, and obesity who comes into the office with abdominal pain? Would any CRNA accept the responsibility and stress of running a CABG solo?
The bottom line is, most of the time you don't need a doctor until you really need one. But you never know when that day is going to be. You never know when that seemingly normal patient who walks into the ER ends up turning into a complete disaster. My advice to these non-doctors seeking legitimacy and complete autonomy: be careful of what you wish for.
We recommend CMS return to its original intention of allowing nurse anesthetists to work independently of surgeon or anesthesiologist supervision without requiring state governments to formally petition for an exemption,” they conclude. “This would free surgeons from the legal responsibilities for anesthesia services provided by other professionals. It would also lead to more cost-effective care as the solo practice of certified registered nurse anesthetists increases.” The study was funded by the American Association of Nurse Anesthetists.
A couple of caveats. One, the study was conducted by the American Association for Nurse Anesthetists (sort of like a study claiming that Jeff Parks is the smartest man on earth being conducted by "friends and family and hired sycophants of Dr. Parks"). Also, the study admits that CRNA's tend to work on less complex cases than MD anesthesiologists.
The main thrust of papers like this is to delve into the essence of what it means to be a "doctor". Are all doctors alike? Is the orthopod who replaces 350 knees a year the same as the internist cranking through 30 patients a day with complex medical problems? Is it fair or unfair to further categorize the various specialities according to some sort of intellectual hierarchy? Do some specialties verge perilously close to being mere technicians, thereby inviting the sort of turf war salvo sounded by the above referenced paper?
In reality, I think it goes beyond anesthesiology (although anesthesiologists are an arguably easier target). Most of the work done by a family practitioner can probably be adequately performed by a NP or PA without adverse effects. If you trained a physically gifted person to take out gallbladders and that's all he did, day after day, I bet you would be able to find a paper demonstrating that the non-MD surgeon has a similar complication rate as a formally trained general surgeon. But then what is that automaton going to do when he encounters a cholecysto-colonic fistula or when the cholangiogram shows he has cut the common bile duct? What is the NP going to do when she has to manage a patient with diabetes, heart disease, peripheral vascular disease, and obesity who comes into the office with abdominal pain? Would any CRNA accept the responsibility and stress of running a CABG solo?
The bottom line is, most of the time you don't need a doctor until you really need one. But you never know when that day is going to be. You never know when that seemingly normal patient who walks into the ER ends up turning into a complete disaster. My advice to these non-doctors seeking legitimacy and complete autonomy: be careful of what you wish for.
Horseshoe Abscess
These cases are sometimes a little tricky. The patient had been suffering from severe butt pain for over a week. He couldn't even sit upright in a chair. He was feverish and had an elevated WBC count upon arrival in the ER. But on exam, you couldn't actually see any of the typical findings of perianal sepsis---no erythema, induration, or fluctuance. But it hurt him like hell when you tried to do a rectal exam. So we got the pelvic scan as seen above to help clarify the diagnosis.
What you see is a circumferential abscess/phlegmon, ringing the low rectum. You can't just lance these things at bedside like you can most abscesses. So I took him to the OR and made a couple of counter incisions to help effectuate complete drainage of the deeper pelvic sepsis. Then I like to leave a Penrose drain in situ, connecting the two incisions. It comes out in the office usually in a week.
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