Tuesday, June 20, 2017

Some general surgery residency graduates may not be competent to operate

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

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

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

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

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

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

Thursday, June 15, 2017

Surgical residents have lots of problems, need more time off

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

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

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

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

Thursday, June 8, 2017

More on artificial intelligence in medicine and surgery

Part 1

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

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

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

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

Part 2

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

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

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

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

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

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

Tuesday, June 6, 2017

Radiologists have an identity crisis

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

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

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

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

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

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

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

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

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

Thursday, June 1, 2017

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

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

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

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

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

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

Thursday, May 25, 2017

Are incentive spirometers useless?

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

Here's another question. Does it matter?

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

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

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

Monday, May 22, 2017

Finally, evidence clarifies the surgical caps controversy

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

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

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

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

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

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

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

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

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

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

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

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

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

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