Thursday, February 28, 2013

Cost Not-So-Conundrum

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

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

Friday, February 22, 2013

Robotic Hysterectomy: Everybody's Doing It!

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

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

Thursday, February 21, 2013

Buckeye Eviscerated on KevinMD

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

To wit, from the comment section:

Roger Goodell: Marlboro Man

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

Remind me again why anyone would possibly doubt Mr Goodell's sincerity when he says that his primary concern is the safety and well being of NFL players?  Remember his quote from the Bob Schieffer interview:
In fact, we’re all learning more about brain injuries, and the NFL has led the way,” he declared. “We started a concussion committee back in the mid-90s with the players’ association to study these issues and advance science. We’re obviously now learning more and more, and we’re investing more and more. And I think that’s going to lead to answers, even outside of brain injury, even to brain disease.”

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

It's truly astounding. 

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

Wednesday, February 20, 2013


This retrospective review from the Archives sheds some light on every surgeon's worst nightmare when it comes to rectal surgery: the anastomotic leak.    This study is a retrospective review of over 70,000 low anterior resections, nationwide, from the years 2006-2009. 
Results The AL rate was 13.68%. The AL group had higher mortality vs the non-AL group (1.78% vs 0.74%). Hospital length of stay and cost were significantly higher in the AL group. Laparoscopic and open resections with a diverting stoma had a higher incidence of AL than those without a stoma (15.97% vs 13.25%). Multivariate analysis revealed that weight loss and malnutrition, fluid and electrolyte disorders, male sex, and stoma placement were associated with a higher risk of AL. The use of laparoscopy was associated with a lower risk of AL. Postoperative ileus, wound infection, respiratory/renal failure, urinary tract infection, pneumonia, deep vein thrombosis, and myocardial infarction were independently associated with AL.

Sunday, February 17, 2013

Student Loan Bubble, Continued

From Salon, a stinging rebuke of the student loan racket that threatens to set off another credit-fueled systemic financial crisis:
In effect, the system allows any 22-year-old American University chooses to admit to borrow a sum equal to the average home mortgage, but without a single one of the actuarial controls that are supposed to minimize the risk that homeowners will borrow too much money.

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

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

Chris Christie: Very Sensitive

Former White House physician Connie Mariano M.D. set off a firestorm recently by stating the patently obvious fact that New Jersey governor Christ Christie ought to address his morbid obesity prior to entertaining thoughts of running for the Presidency in 2016. 
“It’s almost like a time bomb waiting to happen unless he addresses those issues before he runs for office,” Mariano told CNN, saying she's concerned Christie could suffer a heart attack or stroke.
The short-fused Christie unloaded on the good doctor in typically fiery fashion:
“People who have a medical license, who have the privilege of having a medical license, should in my view conduct themselves more responsibly than that.  If she wants to get on a plane and come here to New Jersey and ask me if she wants to examine me and review my medical history, I’ll have a conversation with her about that. Until that time, she should shut up." 
Well then. 

Sunday, February 10, 2013

Dash 22

The consult came in around 3:30 on a Friday.  The surgeon wasn't on call but his partner was tied up and he, the surgeon, felt obligated to see the new patient before it got too late.  To do otherwise is known as a "dick move" in the world of small private surgical practice.  The computer record outlined the picture of a man in his late seventies with an unremarkable medical history.  He only took something for gout and various other over the counter vitamins.  He took something called Life-X 3000.  The consult request was "evaluate for gallbladder disease".  The patient had been admitted three days prior.  That was interesting.  The admitting diagnosis was "diarrhea".  The surgeon perused the completed  blood work and imaging.  Mildly elevated liver function tests.  White blood count (WBC) over 20,000.  The CT report had the surgeon logging out of the terminal and brisk walking to the other side of the hospital--- severe cholecystitis, possible malignancy vs liver abscess. 

Thursday, February 7, 2013

I want to ask them

What's it like to be old and afraid like this (if you are in fact afraid I apologize if I am leaping to conclusions because you look like it, you have this terrified look on your face, a face with a caved in gash where a mouth should be and black horrifying eyes, like they are trying to leap out of your head, to escape somewhere) in a mechanized complexly caterpillared hospital bed and are you worried that everything you thought was true until now you are starting to doubt and maybe it's not true it's all a comforting lie or delusion and you worry you dont have the energy or zest or whatever you call it life force to find something else, lunge forward, seek, seeking, think of something else, latch onto something else there's always time, like the way you used to think when you were younger and full of spirit and confidence and limitless possibilities, or are you just tired and you don't care anymore and that's what happens (physiologically, evolutionarily as a solution to existential angst) when you start to actually d.i.e. and oh my god what if that's what really happens you just get tired and burn out stop grinding stop burning for answers and reasons, you just stop.  Are you sad.  Are you angry, disillusioned?   Are you cranky lying there alone and half nude because you are dwelling internally on the possibility that this is the end and it's like I'm not even here you're not even really there disembodied sort of like floating above and everything irrelevant and distracting.   Dont be afraid I would say if you asked.  But I dont really know, do I?  What am I, some sort of Christ doppelganger?   I have nothing to offer anymore.  You know better.  You look at me like I am a robin pecking the grass in spring.  A waterfall.  Tree branches soughing in a June breeze.  Inanimate.  If you want to talk about it now. Talk to me. I am here going through the motions of listening to your heart and mindlessly ripping off gauze and cloth tape and performing and I am a doctor it is important, from an identity perspective, that I play this role while you lie here and I have done all I can and the numbers look bad and I do not know a rale from a rhonchi, definitionally, but whatever it is that I hear is no good and the nurses have stopped paying attention to you I want to say I am sorry and when I try to hold your hand it is like dry leaves and limp and I have lost you.  If only you would say one thing.  Talk to me one last time.   

Wednesday, February 6, 2013

Roger Goodell: A Modern RJ Reynolds Spokesman

Roger Goodell's interview last Sunday with Bob Schieffer about the link between football-related head trauma and long term cognitive impairment (CTE) was a a sickening display of arrogant obfuscation and denial.  This line, when asked if he would ever allow his own son to play football, is especially revealing:
  “Absolutely,” the NFL commissioner insisted. “I have twin daughters just like the president, and I’m concerned when they play any sport. The second-highest incidents of concussions is actually girls soccer. So what you have to do is to make sure the game is as safe as possible. In the NFL, we’re changing the rules, we’re making sure the equipment is the best possible equipment, we’re investing in research to make sure we can address concussions, not just to make football safer at the NFL level, but all levels in other sports.”
Surely the Rog knows that CTE has little to do with concussions, right ?  Surely he knows that current scientific research indicates that  CTE is a neurological degenerative process that evolves over time, as a result of a lifetime of accumulated sub-concussive blows?  So why bring up the thing about girls soccer?  It's a distracting non-sequitor. 

And then this line:

Tuesday, February 5, 2013

Bush Redux: The Obama Assassination Memos

Michael Isikoff from NBC News was granted  had leaked to him a 16 page "white paper" last night, carefully prepared by the Obama Department of Justice (DOJ).  This paper was a summation of the arguments made in an official Office of Legal Council (OLC) memo (which itself inexplicably remains a top-secret document) used to justify the due process-free, unilaterally-determined assassination of American citizens by Presidential decree.

Libertarians like Glenn Greenwald, Marcy Wheeler, Connor Friedersdorf and Adam Serwer have elegantly deconstructed the absurdity of it all (with special emphases on the redefinition of "imminent threats", the idea that "Al Qaeda-affiliated" is so broad a phrase as to include, potentially, anyone who may harbor sentiments or thoughts that could be construed as "anti-American", and the frightening implications of a permanent Global Battlefield)  with far more expertise and eloquence than I could ever muster.  Please read them all. 

But the bottom line is this:

Sunday, February 3, 2013

Suicide Docs

From the Economist in October 2012 was an article on physician assisted suicide.  In the United States, terminally ill patients can apply for permission to end their lives with the guidance of a doctor in Oregon and Washington state.  Several safeguards are in place to prevent this from becoming the default death pathway (only 0.2% of total Oregonian deaths).  Also, I had no idea that Holland, Switzerland, and Belgium allow assisted suicide even in non-terminally ill citizens.  So you can be suffering from, say, severe acne vulgaris, in the Netherlands and be within your rights to seek immediate death from a certified death-administering professional.  Revelatory, indeed.  And heartwarming to read about on a Sunday. 

My main interest is in the doctors who are contracted to carry out these ghoulish deeds.  By physician assisted, I think what everyone has in mind is some sort of benign, humane, minimally invasive practitioner of life sapping.  You lie on a table.  Calming eastern mystic yoga music plays softly in the background.  The room smells of lilac and aloe.  A soothing voice whispers in your ear, "it's going to be alright, peace and love await you".  And then a white robed man with a Francis of Assisian face of compassion slowly injects painless sedatives until you pass out and then the final killing agent is administered while you are in a state of blanked nothingness. 

Single Port Appy?

First off, I am rather dubious of this whole "single port" business as a new tool in the laparoscopic armamentarium.  Several reasons. 

One, given the two dimensional aspect to today's instrumentation, there is a high premium on the concept of "triangulation" of your ports.  In other words, being able to approach a target from angled positions on the abdominal wall augments the efficiency and usefulness of right and left handed instrument control.  Approaching a target with instruments originating from a zero degree position is awkward at best, and hemorrhagic stroke inducing at worst.  Ultimately, in perhaps the most stinging rebuke, it lacks elegance.  Any surgeon worth a darn, from a technical perspective, will always seek the Way of Elegance when performing an operation.  (As an aside, relative absence of elegance is directly correlated with overall OR mood and surgeon/ancillary staff relationships.)   Until the instrumentation improves (i.e. articulating capabilities, curved shafts, ect) then any and all attempts at zero degree single port laparoscopy will be efforts in frustration. 

Saturday, February 2, 2013

Contingent Healthcare: Birth Control

The Obama Administration announced yesterday a compromise plan to appease opposition from religious organizations (i.e the Catholic church) regarding the coverage of birth control under the auspices of Obamacare.  Under the compromise, employees of churches and non-profit religious organizations will receive free oral contraceptives through a separate healthcare plan, to be paid for by health insurance companies. 

The litigants are not satisfied.
But Kyle Duncan, the general counsel of the Becket Fund for Religious Liberty in Washington, which is representing employers in eight lawsuits, said the litigation would continue. “Today’s proposed rule does nothing to protect the religious freedom of millions of Americans,” Mr. Duncan said.

Religious groups dissatisfied with the new proposal want a broader, more explicit exemption for religious organizations and protection for secular businesses owned by people with religious objections to contraceptive coverage.