Some of this diagram I agree with, and some I do not, or at least what is implied by the information contained therein.    Overall, the diagram is correct – American’s can’t afford healthcare.  At least not the kind we try to provide.  However, I don’t feel that the diagram really addresses why Americans can’t afford healthcare in an accurate way.

The diagram starts with a comparison of health care costs, showing what we know, which is that we spend more on health care per capita than any other nation.

The diagram goes on to refute ideas that the high cost of healthcare are because of demographic issues – obesity, smoking, etc..  I completely agree.

Finally, we learn why healthcare costs are so high… and here is where I think the diagram gives only part of the story.

Hospitals are overcharging…..  Well, hospitals in most cases are not terribly profitable organizations.  They charge a lot, but their costs are enormous.   Its true that American hospitals charge more than hospitals in other countries.  They are also under a level of adminstrative pressure not felt in other countries.  We have a healthcare system that does not provide care for the uninsured, which shifts the costs onto those who do have insurance, and creates obscene charges for those who had no or little insurance, yet have enough money to potentially be billed anyway.  The diagram is correct that itemized bills from hospitals can list ridiculous charges for seemingly tiny items, but in truth the hospital is just finding a way to bill for the tremendous number of costs that they cannot recoup, such as staff, insurance, and free care.

Hospitals are wasteful……  I find this a little off.  Hospitals spend a ridiculous amount of money on administration, but its hard to call compliance with government and legal regulation a wasteful expense.  I’d rather say that the regulations that our country imposes on our healthcare system demands and enormous amount of resources, which in the end provides little to no benefit for patients.   Our country chooses to tightly medicine for the benefit of patients, and to meet these regulations hospitals must spend a great deal of money.

For example, if one were to review a hospital chart from a patient hospitalized for 7 days, you would find over 1000 pieces of paper in that chart.   If one wanted to know what happened medically, which is putatively the reason the chart exists, you would only need about 20 of those pieces of paper.  The remaining 980 are composed of hyperdetailed records of nursing activities, medication administration, and protocol adherence.  These records are there for two reasons – 1) to document that the hospital met all regulations regarding the care of the patient and 2) to document the care of the patient in an infinitely detailed way in case the hospital and/or physician is sued over the care of the patient, with questionable efficacy in that goal.

So are hospitals wasteful?  Yes, but only in that they must spend a tremendous amount of money to meet ridiculous government edicts like HIPPA, and to pre-document every potential future court case.  I’d call this a problem with government regulation and lack of a proper malpractice system more than an actual problem with hospitals.

Outpatient care costs are massive…. I don’t get this part at all.  Is it better to treat a hernia in the inpatient setting?   No.   Our country has a strong system for outpatient surgery, which is a cost saving measure, not a cost growing one.

Doctors are overpaid…. I think you had an argument here in the 1980 when we have a fee for service system and doctors had a habit of billing tremendous amounts of money for their work. But not anymore.  I can spend an entire hour of office time with a patient and get paid less than two hundred dollars from their insurer.  After paying my greater than 50% overhead (partially because of ridiculous regulation), I’m getting paid less than a plumber.  Furthermore, I live in the only country that does not heavily if not completely subsidize medical education.   Current medical students are coming out of medical school with three hundred thousand dollars or more in debt.  On pure economic theory, one should not spend more for an education than one can expect to make in a year practicing in that career.  Put that way, we’re actually massively underpaid.  The country needs more primary care physicians, but in many cases students graduate with so much debt that they are nearly forced into a higher paying specialty job.  Either that, or train for eight years post-college and the live on Top Ramen.  If doctors’ educations were routinely paid for by the government through a program of public service, we would see a startlingly different distribution of medical specialties.

Insurance companies are charging too much….   Its nice to beat up on the insurers, but ultimately they base charges on what it costs to provide care for their enrollees.  And that cost is enormous.  Most insurers actually lose money on medical care, paying out more than they actually collect.  The way they make money is through investment on the money they keep in float. That’s actually how all types of insurance works in most situations.

So now that I have argued against many of these points, I must make my case for why healthcare is actually so expensive, and here it is.

We spend too much on healthcare because we have no incentives not to. 

That’s it in a nutshell.

We have a capitalist health care system, which means that each party involved ultimately has a financial stake in providing a service.   Drug companies develop wonderful new drugs because they can charge a lot for them.  Equipment manufacturers develop amazing new surgical technologies because they can charge a lot for them.  Hospitals acquire and operate expensive MRI machines because they can profit  from doing that.  And patients want all of these services at an unlimited level of access because they don’t have to pay for any of it.  And that’s ultimately it.

The people pushing the product make money, but the money being made doesn’t come from the people consuming it.  This situation will lead to unlimited consumption, pure and simple. Its doesn’t matter what we are talking about.  If gasoline were entirely free, the appropriate economic behavior would be to run your blender on the stuff.  But because it isn’t, we find a more efficient way to run the blender.  But not with healthcare.  Despite the graphics claims of medical bankruptcies, by and large healthcare decisions in this country are made entirely independent of the costs of that care.  As long as healthcare benefits people, this system will lead to infinite cost healthcare.

Politicians like to talk about rationing healthcare as if it were some kind of evil plot, when actually its exactly what we need.   In order to control healthcare costs, one has to start with the acceptance that we cannot afford to spend an infinite amount of money on any quanta of medical benefit.  We have to decide what we’re willing to spend, and then figure out some just way to distribute the costs and benefits to the citizens of the country.  We have to find a way to control the costs of new medical developments, while still promoting its development.

Personally, I support a hybrid socialist/private model of healthcare delivery.  But for any of it to work, America is going to have to stop feeling entitled to every possible treatment for every possible disease.  And we’re not there right now.

“So which one do you like better?”  I asked.

“I like them both.”

“That’s interesting, as they are two quite different fields.”

Also on my mind was that as an OB/GYN student, I thought she was average at best.  In all honesty she seemed quite bright but not at all intersted in OB/GYN.

“So OB/GYN huh?   I didn’t peg you for that.  You don’t come across as loving it.”

“Yeah, but I do like it. And my mother thinks I should do it.”

“So what about ortho?  Do you love that?”

“I like that.  My dad thinks it would be great for me to be a surgeon, and that I would make a lot of money.”

At this point it occurred to me that of the six weeks I had worked with this woman, I had only seen her truly excited on one occassion, and that moment was when she was presenting cancer cases at our tumor board conference.  She had prepared a tremendous amount of information about the cases she was presenting, and had seemed to be particularly focused on the pathology slides.  She presented all kinds of information about the slides that other students would have just ignored.  More that that, she was just beaming as she presented it.

“So…  remember when you presented those slides at path conference?  How did you feel then?  It seemed like you were really into it.”

“I love that stuff.  I love those slides, I really like looking at them and trying to figure out what it means about the patient’s disease.”

“OK…. so you want to do OB/GYN because your mom thinks it would be good, and orthopedics because your dad thinks that would be good and you would make a lot of money.  The thing is this – you don’t really love those things, but you love looking at slides.   What if I were to tell you that there is a job out there where you can look at slides like that all day, hang out with people who also love looking at slides, have great hours, never work at night, and get paid tons of money……..   

Its called being a pathologist. 

Ever think of doing that?”

Her eyes flew open, almost startled, like she had never really considered it.

She went into pathology and loved it.  Her parents were pleased she found a job she liked, because in the end, like all parents, they just wanted her to be happy.

Academic OB/GYN Podcast Episode 35 – Back From The Ashes

http://www.youtube.com/watch?v=HBnzSZU7XWs

Video embedding is temporarily problematic.  Click through to youtube to view.

The truth is that while I love doing the podcast, I have had to put it aside during my fellowship because of a lack of time.  It is quite labor intensive to prepare, record, and edit, so I decided to back burner it for now.

I really appreciate the support of all the listeners and hope to get back to it no later than this summer, if not sooner.

Regards

Nick Fogelson

Academic OB/GYN

I saw a patient today who presented with a large vaginal cancer.  I was discussing her care with my intern, and that it would make a big difference if the cancer were localized or if it had already spread to the lymph nodes.  Based on her exam, I thought there was a pretty good chance it had already spread.

“The toothpaste is already out of the tube”, said the intern.

I replied “I suppose… but usually we say ‘the horse is already out of the barn‘   After all, like cancer, the horse wants to leave the barn and run.  The toothpaste doesn’t want to leave the tube.  It will stay there forever until you squeeze it out.”

A look of understanding hit the intern’s face…. then puzzlement.

“But Dr. Fogelson, it seems like its a lot easier to put a horse back into the barn than it is to put toothpaste back into the tube.  If cancer was like the horse it would be much easier to cure once was spread.”

So there you have it.

Cancer acts like a horse at first, but then becomes toothpaste.

I am disappointed because despite all the fancy hardware and expensive software, our clinical records systems aren’t that much better than paper.  We would think that a patient could go to any doctor and present their medical records the doctor could read them, but they can’t.  We would think that it would be easy for me to get a CT scan report that was done at an outside hospital, but no.  It actually has to be printed out and faxed, requiring not only human intervention and time, but if reentered into the receiving provider’s system actually converts a digitally stored report into a picture of a piece of paper, completely breaking the idea of an electronic record system.  While information can be digital in one system, if it ever is passed on to someone working in another system, it becomes just another piece of digital paper.  The sad truth is that despite our incredible investment in EMR systems, we have only created a massive collection of information silos, and have almost no way to transfer information between them – a system little better than the paper charts we sought to eliminate.  And sadly, because these silos are hard coded and massive, innovation is stifled.

There is a very specific reason why our system operates like this, and it is that EMRs as a whole lack a common way to represent information.  Each system represents medical records in its own proprietary format, and thus lack the ability to speak to each other.  An thus no matter how wonderfully a EMR system represents information to its users, if information has to get out of the system, it can only be through pictures of pieces of paper.

So is there a solution to these problems?  I would argue yes.   But it requires a fundamental change in our paradigm – a change to a common “Model” for representing data.

To those that lack a programming background, when I say “Model” I mean something very specific.   A Model is part of a computer programming paradigm called Model-View-Controller.  This paradigm, pioneered by Steve Jobs and his team at NeXT, and continued in XCode at Apple, is based on the idea that any piece of software can be broken down into a Model, a Controller, and a View.

A Model is the part of the software that represents the data.  All it knows how to do is take data in, store it, and serve it up when asked.  By design, it has no idea who is doing the asking or who is stuffing data into it, and by design it doesn’t care.

A Controller is a piece of software that takes data from the Model and from the View, and then tells the View what to show to the User.  Most people would consider the Controller to be the “brain” of the software.  Like the Model, a Controller can potentially talk to multiple Views, and in a complex piece of software often does.

A View is the part of the software that shows the interface to the user, and organizes how user input will be presented to the Controller.

In the paradigm of a clinical record system, the View is all the windows you see and how you interact with them, the Controller is the brain of how that data is collected and how information is passed between different systems, and the Model is how it gets stored on a hard drive somewhere.

What I am proposing is that we create a single Model for representing clinical information that would be accepted across industry as the only way to represent medical information.  Every vendor would be free to represent that data on screen and interact with the user any way they like, but when they store it there is only one way – because there is only one Model.  Vendors could still fight for the best design to attract customers, or even create a wonderful custom system for only particular customer – all without destroying the portability of the data.

A move to a common model has tremendous advantages that we lack in our current systems.  The single biggest difference is that it allows a complete shift of paradigm from a system where individual providers or hospitals keep isolated medical records to a system where a single patient’s entire medical record from every provider is kept in one place.  Instead of storing records, hospitals would access the patient’s file, edit it and add to it, and then put it back where it is stored.  If the patient went to another doctor or hospital, they would be able to access those new records.  This alone would be a massive improvement in our healthcare system.  Millions if not billions of dollars are wasted every year because records cannot be easily transferred.  It is quite common for doctors to re-order expensive imaging tests or labs because they need information that already exist in another medical record system.   With a common Model, this would be eliminated.

Another advantage to a common Model is that it would foster an incredible surge in creativity among software designers.   Right now, there are only a few big players in EMR software, and it is almost impossible for a small player to get a foothold.  Hospital systems pay huge sums of money to have Cerner, GE, or EPIC manage their EMR system, and thus store their patient’s medical information in the Model defined by one of those companies.  While functional, none of these companies products have particularly great designs, all being relational databases designed by arguably unimaginative software engineers.   The sad thing about this is that there could be an wonderful young designer out there with an incredible idea on how to represent medical records, but with the way the current system is he or she would have no possibility of breaking into the market.  The current players are far too established, and the cost to switch to a new system too great.

But with a common Model, this problem is eliminated.  As all players would agree to represent medical records the same way, any number of new interfaces, or Controller/View combinations per the MVC paradigm, could penetrate the market.   If someone came up with a new system for viewing and editing records, it could be integrated into a hospital’s workflow at a low level, perhaps by only a few doctors.  If it were liked, it could  spread organically.   This is not unlike the way that new web browsers have spread out and been adopted.  They all work on the Model called HTML, and thus they each can be tried out and adopted or rejected by each potential user.  With a common Model for representing medical records, it would be entirely possible for different physicians at the same hospital to use different medical record systems to view the same records.  They could also use different hardware in different environments, such as a computer while on the ward and an iPad while walking around the hospital or in the operating room.  The advantages are tremendous, which makes the lack of a common Model painful to use all.

With a common Model, hospitals no longer permanently store medical records, but rather access records that were stored elsewhere.  Where that would be would be a question to answer, but I think the answer is that they will be stored in many places, an in most cases in multiple places simultaneously.  It is quite easy for an individual to carry enough storage on a USB stick to carry their entire life’s medical record.  That information could be mirrored to a cloud service that kept it backed up and available anywhere.  Hospitals could download a copy when a patient is admitted and intermittently back it up to the cloud.  There are of course technical issues, but they would be solved in time.  Perhaps we will even evolve as a society to the point that we would accept the idea of storage being implanted under our skin, to carry our medical records for our entire lives.  I’m just Star Trek enough to believe in such an idea.

I have discussed this idea with people in the industry, and many claim that acceptance of a common Model at this point is impossible, that there is just too much momentum to overcome.  I would argue that there are countless examples of where others have succeeded in exactly this, and there is no reason why it cannot happen in medicine as well.  For example, DVD became an accepted Model, as did MP3.  In many cases, these models were started by one company and managed to spread throughout the industry, like Sony’s creation of the DVD standard, or Apple’s creation of the FireWire standard.  The same thing can be done for medical records.  It has to be done.

The current system we have, in its many forms, is really just a digitization of a paper chart.  This just isn’t good enough.  While this was perhaps the logical first step, it cannot be the last.  We must move forward. In order to create a truly great record systems, we have to throw out the old ideas of how medical information is stored and represented, and ask ourselves how we would do it if we had no restrictions at all.   Information must be patient centric, and interfaces must be agnostic to the Models they read and write to.   Everyone could have the system they wanted, yet everyone could still communicate.  It is my true belief that if this could be accomplished it would be one of the greatest medical technology advancement in history, and perhaps contribute more to the health of humans than any new drug or surgical technique.

It is my hope that true industry players will read this and consider what their role could be in this potential healthcare revolution.  If I had to single out a single player that should take the lead, I would choose Apple.  Apple has had incredible success and sponsoring and developing new Models, and has the commitment to design to create something great.

The only problem is that whatever industry heavyweight takes on this task doesn’t have all the people they are going to need.  They have brilliant Engineers… but the lack the healthcare professionals that they will need to help them design what is truly needed.

I’ll be waiting for their email.

In the eyes of many, I became an “Expert in Delayed Cord Clamping”, worth quoting to others, and even name dropped as some sort of trump card – “Well, Dr Fogelson says….”  So let me set the record straight.  I am not an expert in delayed cord clamping, if such a person even exists.   I am certainly not an activist for the idea, not am I sure that such activism could be justified in the literature.

What I am is this:

1. An educated person with access to the literature and training in interpretation of medical research.
2. A physician with intellectual expertise in maternal health, and first hand experience in its practice
3. A person with a platform where his opinion would be heard.

and

4. A person who chose to express said opinion on that platform.

And that’s it.   Does that make me an expert?  I say no.  Nonetheless, it seems that anyone that chooses to speak in a public forum will be given great respect as an expert in whatever they choose to speak about, if only because they took the effort to open their mouth and be heard.  It is this instant “respect to the one who takes the trouble to speak” that makes public speaking so powerful.  But let’s not go overboard.   I encourage anyone who has read what I have written to investigate the literature, consider the non-data driven logical and physiologic arguments, and then decide for themselves.  If you do this, you will be as great and expert as I.

So with that in mind, consider what’s new in the field.

****

Since the 2009 article, several randomized trials have been published, as well as review articles on the topic.

Andersson et al recently published work that demonstrated improved iron stores, lower prevalence of iron deficiency anemia in delayed clamped infants, without evidence of any adverse effects.  This data was interesting in that it was produced in a population with a lower prevalence of maternal iron deficiency than the population studied by Chaparro et al in Mexico.

Oh et al recently published data for a randomized groups of 33 very low birth weight infants ( < 1500 grams), which showed higher hematocrits in the delayed clamped infants.  They found non significant trends towards improved morbidity rates.  Mercer et al demonstrated improved morbidity rates with a sample size of slightly more than double the number of infants studied by Oh, suggesting that Oh may have lacked adequate power to find a difference between groups.  It is also possible that Mercer’s data represented an alpha error and overstated the actual benefit of delayed clamping, and that Oh’s data is more representative of reality.

De Paco et al looked at cord gasses from infants of delayed versus immediate clamping, and found minimal differences between the groups.

A JAMA meta-analysis concluded that delayed clamping at term had both short and long term neonatal benefits without apparent downside risk.

*****

So how are we to interpret this and previous work?  Firstly, you get to decide for yourself, as I am just one person.  Some people with similar backgrounds to myself see it differently.  But the following is how I would interpret it.

Delayed cord clamping is more akin to the natural process of birth that we have evolved towards, and to the birth process shared by all land mammals.  Immediate cord clamping clearly reduces the amount of blood in the infant in terms of volume, blood cells, and iron content.   In my mind, this action removes blood from the infant that the infant was “destined” to receive absent the intervention of immediate cord clamping.

That said, human beings born at term clearly thrive no matter what is done.  One only needs to deliver a few hundred infants, clamp their cords immediately after birth, and watch them go home apparently healthy to know this.   However, when we measure outcomes at a population level, delayed cord clamping appears to benefit infants.  These benefits appear to be clear for iron stores.  In preterm neonates, there appears to be a benefit in terms of intraventricular hemorrhage and perhaps sepsis, but we must remain conscious that these data are based on small sample sizes, and are therefore at risk for being the product of statistical error.

Most important in my mind, however, is that there is no real data to suggest that delayed cord clamping is at all harmful to an infant.   For that reason, the combination of the underlying physiologic and rational argument with the available data is compelling enough to me to support a policy of routine delayed cord clamping for term and preterm neonates.

But let’s not get ahead of ourselves with this data.  Some are supporting delaying cord clamping in an infant that is born distressed in clear need of resuscitation.  To me this seems foolish.  An infant that is bradycardic from hypoxia is going to have a hard time circulating through its cord.  It needs oxygen, and the way to deliver that is through its lungs.  If we can devise a way to do this while leaving the cord intact, so much the better, but lacking this lets just be pleased that we have wonderful pediatric staff who can deliver expert care to these infants, and let issues of the cord fall away.  Let’s not also hang on the theoretical possibility of placental ECMO, or continued neonatal gas exchange through the cord after delivery.   This idea clearly has some physiologic merit, but we have no data whatsoever that would support delaying resuscitation of a infant in jeopardy under the belief that it will self-resuscitate through the cord.  Sadly, some have quoted me in support of such a policy, so let me make it clear that I cannot support the idea outside of a research protocol.  We are so good at resuscitating infants with proper airway management and ventilation.  Let’s not impede our ability to use our strength in pursuit of naturalism.  Infants in distress deserve better.

So let’s support delayed clamping and do it whenever feasible.  It makes senses and there is data to support it.  But holding it up as the one critical moment of an infants birth is more religion that science.   And for crying out loud, an infant that is born near lifeless needs to breathe a lot more than it needs an intact umbilical cord.  We must remember that if that baby is lifeless, the cord wasn’t doing a very good job up to that point.  We’d better give it a break and take over.

Circumcision is an interesting issue because it crosses multiple boundaries.  It is a social tradition in many cultures, and in some cases considered a religious mandate.  It is also an ethical issue for many, with some feeling that it is an assault on an infant with long term negative impact on their psychosocial health.  For some it is just cosmetic.

As a young person, I always thought that my penis looked like penises were supposed to look. It looked like my father’s and my brother’s, and anyone else’s I had ever seen.  For the most part, I was blissfully unaware that a penis could look any other way, until one day in high school when my world completely changed.  I happened to see a friend’s penis we were showering after wrestling practice, and in that flash of a moment all kinds of things went through my mind.  Did he have some kind of growth on his penis?  Could he pee out of that thing?  A few other choice thoughts.  I can still remember the shock to this day.  All I had ever seen looked like mine, and in that moment what I saw was foreign, revolting even.  You see, from my frame of reference he looked like an alien.  It took me a few minutes and SNAP! it came to me like a ton of bricks – he has a foreskin.  He probably doesn’t have an alien death ray then.   I can relax about that one.

Of course now I realize that I also was born with a foreskin, and at some point in early life had it cut off.  Despite what was no doubt a anesthesia free surgical procedure, I have no memory of ever having had a foreskin, or of any trauma of it having been removed.   It never occurred to me to miss my foreskin, but apparently others do.

I hear stories from various anti-circumcision activists about how men are traumatized by their lack of foreskin, or even that some use strange devices to try to restore their foreskin in some way.   I am struck with these stories, and have one burning question – when did they start missing their foreskin?   From the moment they had the capability to store long term memories, they had no foreskin.  Being circumcised was their frame of reference; it was their ‘normal’.  The only way they could ever ‘miss’ their foreskin would be through some outside influence that convinced them of some new ‘normal’, and that they were somehow incomplete.  Some of these men express anger at their parents or doctors for circumcising them as an infant, it seems to me that this anger is misplaced.  It would make far more sense for them to be angry at the person who felt the need to drive a message into one’s head they were somehow incomplete, a message without which the feeling of loss never could have occurred.

I also hear stories of how the lack of a foreskin somehow interferes with sexual pleasure.  I just don’t understand how this can be verified.  I can say that from a personal point of view, everything down there seems to work just fine.  I also don’t notice a preponderance of Jews who do not enjoy sex.  Anecdote aside, one can only know what one has, and so again, anyone that feels that their sexual pleasure was supposed to be better than what it was got that idea from some other person, not from their personal experience.  There’s plenty of people with foreskins that feel like their sexual pleasure was supposed to be better as well.

My biggest question in all of this is just why?  Why do people care so much about this?  Its really hard to say that an infant is being victimized by the procedure.  Their frame of reference is being changed, no doubt, but as that frame is changed so early in their life there will be no sense of loss unless someone feels the need to convince them of it.

One could just as easily ask ‘why circumcise?”.  There are plenty of data to suggest that circumcision decreases horizontal transmission of some STDs and the rate of penile cancer, though these effects are small.  The anti-circumcision folks like to act like this data doesn’t exist, but this is just their ignorance.  When I first thought of writing this blog post I was going to lay all this data out, but as I now write I realize that it doesn’t really matter.   Those that believe or don’t care will see the strength in the data, those that are against will call it faulty or corrupt in some way.  So goes academia.  In the end, circumcision is a cultural practice that is done for cultural reasons, not for medical benefit.  In Jewish tradition, circumcision is done as a way of honoring the covenant between God and Abraham, a covenant which commanded that all of Abraham’s sons and male servants, and their descendants, as a mark of allegiance and agreement.  Though I have Jewish heritage, I am atheist.  Nonetheless, I would feel a cultural desire to circumcise my son when and if I have one.

Some of my comenters, of which there no doubt will be many, will call this stance unethical.  To this I say “grow up”.  We are hard pressed to find ethical principles on which all humans agree, and this is certainly not one of them.  A very large part of this world feels completely fine with male circumcision, and if one doesn’t, they certainly are under no pressure to circumcise their son.  This is one of the many things that we don’t all agree on.

Other commenters will say “I’m not against circumcision, I’m against forcing it on newborns.”  This is the same as saying that we shouldn’t do ritual circumcision at all.  That’s a perfectly fine goal if one is really against the procedure, but just state it that way. Male circumcision is a cultural rite performed on newborns.  Its pretty obvious that by 18 years old, very few boys are going to choose to have their foreskins removed.  Their frame of reference has already been set, and they are fine with who they are.  If we did that, we would be just fine, just as we are with a large part of the population circumcised.  A cultural tradition would be lost, but that would also be ok.  It just wouldn’t really matter.

Other commenters will say “they are dangerous and cause complications.”   This is a half-truth.  By in large, they are not very dangerous.  That said, like any surgical procedure, there are some small risks.  There have even been babies that have died from complications of the procedure.  Ultimately, it is very important that anyone doing circumcisions know what they are doing and doesn’t do them wrong.

In truth, its an issue that I don’t care a great deal about, and as such am vexed on why it matters so much to others.  Sometimes when someone writes a piece on the net, they are instantly labeled as an activist for that cause.  People certainly label me as an activist for delayed cord clamping, which I would deny.  I just wrote an article about the topic and lots of people read it.  They can make up their own mind.   I just wish people would treat this issue the same way.  Everyone is free to circumcise their child or not, and the boy will grow up just fine either way.

I fully expect an absolute flame war will ensue.  As I am busy in a fellowship, my activity in such a discourse may be limited.

In Freakonomics, Leavitt and Dubner posit that in all things, human beings respond to incentives.  If you want to understand human behavior, all you have to do is identify the incentives that drive them, be they emotional, financial, or social.  In that vein, I wonder what incentives drive us to spend so much money on healthcare, and to waste resources when they need not be wasted.

I found a potential answer in another book, Chris Anderson’s “Free: The Future of a Radical Price”  In this work Anderson investigates how an economy is affected when the marginal cost of production of a good approaches zero.  Specifically, he investigates the economy surround digital goods, that while costing resources to develop, have a marginal cost of zero to produce and distribute.  He proposes that in such a system, it is quite natural that the price of such goods will eventually approach zero, and if it doesn’t, the goods will be routinely stolen rather than paid for.

The corollary to this idea is the concept of optimal use of a resource when its cost is zero.  That is, if one gets a real benefit from the use of a resource but it costs nothing whatsoever to use it, what is the right way to use that resource?  Anderson suggests that the correct course is to use that resource to its maximal extent, and even to waste it without thinking despite diminishing returns.

While that sounds quite impractical, it is not so far from the system that governs equipment use in the operating room. Every time a surgeon has a task to do, there are many kinds of equipment that can be used.  One can use nondisposable metal instruments, or one can use disposable electronic devices.  One might think that these choices might affect patient outcome, but in most cases they do not.  In fact, countries that lack these fancy pieces of equipment often are able to do complex surgeries just as well as we can in America, they just do them for less money.  The difference is that by using the fancy equipment, the surgeon may be able to finish faster, and perhaps even enjoy performing the surgery more.  After all, we all like our toys.  In some cases, the expensive equipment provides a benefit to the patient, but in many cases not.  The same surgery could be done with less expensive toys.  Its just slower and less fun.

The problem here is one of incentives, and to whom the incentives apply.  Using expensive disposable equipment has only positive incentives for the surgeon.  It has negative incentives for the hospital, who must pay for these devices, but as the hospital is not making the decisions in the operating room, these incentives do not affect decision making.  As such, the surgeon finds themselves in the very situation that Anderson describes.   They have a positive incentive resource that costs nothing to use – and so the economically correct behavior is the wastage of that resource.

So in order to tackle this problem, per Freakonomics we must change the incentives.  Somehow we must create a positive incentive to saving money in the operating room.  If we can do that, surgeons will respond, and the entire system will save money.
Some would suggest that we somehow tie how much money a surgeon makes to how much of the hospital’s money is spent in the operating room.  That might work, and in hospital employed practices that use profit sharing, this in fact goes on to some extent.  The problem with the idea is that it is a bit vulgar.  Patients don’t like the idea that a physician would be rewarded for spending less money on them, and rightly so.

I would prefer to appeal to the competitive nature of surgeons everywhere.  I propose that a cheap digital toteboard be installed in every operating room in this country.   At the start of the case, that toteboard would read how many dollars have been spent on that case at that moment.  It would start with the attributable cost of opening the operating room, buying and maintaining the non-disposable equipment, and the marginal cost of the staff required to complete the surgery.  It would tick forward with the marginal costs of keeping the surgery going.   Every time a piece of disposable equipment were opened, its barcode would be scanned and the cost of that equipment would go up on the board.   At the end of the case, the surgeon would get a printout of what the case cost to perform, and where the money was spent.

The final piece of the puzzle would be internal publication of each surgeon’s average cost figures for the various surgeries that are performed.   If one surgeon is doing a laparoscopic hysterectomy for $7500 and another is doing it for $4000, we should know that.  These two surgeons should get together and figure out what is so different, and if the more expensive surgeon is doing anything differently that actually benefits the patient.

So some might ask “is measurement really an incentive?”  In some ways no, but in many ways yes.  Surgeons are by nature competitive, both with themselves and with each other.  We all want to decrease the cost of healthcare, but we don’t know how. I truly believe that given the opportunity to know exactly what they are spending, surgeons would compete to spend less wherever we could.  It could actually be good fun.

So is this practical?  Perhaps its a little ambitious to think we’re going to have digital toteboards in every OR, but just like countries that do advanced surgery with minimal tools, its entirely possible to implement the spirit of this idea with far less technology.  To start, the surgeon could get a list of each disposable they used and what they cost the hospital.  Some hospitals keep this data already – they just fail to make an incentive out of it.  And by failing in that regard, they make wastage the common behavior.
It is said that everything we measure we will improve.  So let’s start measuring.

In most cases, what religion a person subscribes to has little to no impact on their clinical outcome.  We have an exception, however, when it comes to a Jehovah’s Witness with cancer.  JHW patients to a rule will not accept blood products of any kind, which greatly limits their ability to be effectively treated for cancer.  In some cases they cannot have surgery the surgery they need is unsafe without the possibility of blood transfusion.  In some cases they cannot take chemotherapy because blood transfusion is required to survive the associated myelosuppression.  As surgery and chemotherapy are our two best treatment, they are at a major disadvantage.

When I was a resident, I had a pretty hard opinion about this.  I heard a lot of different view on the topic, but the position of one of my attendings resonated best with me.  He felt that his job as a physician was to protect the health of his patients, and that if a JHW was dying in front of him he was going to transfuse them whether they liked it or not.  He was quite clear about this upfront, and told JHW patients that if they were not happy about this they should find another doctor.  He even arranged for attending coverage for emergent issues if need be.  He felt that the preventable death of a patient was an emotional trauma he didn’t want to be exposed to, almost as if the patient, through refusal of blood, was exposing him to unnecessary emotional violence.  While this was a very hard line, I respected the boldness of  it, and that he was being true to his internal values.  I held a similar feeling for the first few years of my attendinghood, though I never had to test it until my third year out of residency.

The test came when a JHW presented to our hospital in Hawaii with severe vaginal bleeding, and had a hemoglobin of only 4 (normal being about 15).  We did everything we could medically, but she continued to bleed off an on.  She was utterly saveable with a blood transfusion and a subsequent hysterectomy.  It would have been fairly routine.  But in her case it wasn’t routine, because she would not take blood.  We tried a number of approaches, but nothing really worked.  There were so many things we could do with blood, but without it she was too unstable for us to act without killing her.  And so she slowly declined until she was in high output heart failure.  I had never seen someone’s hemoglobin drop so low, and was amazed that she didn’t actually die until she was down to 0.6, with blood so clear you could read the paper through it.  I had previously stood with my hard line attending, but being put to the test I found myself more respectful of the patient’s wishes, and helped the team care for her the best we could until her death.

Since that time I’ve taken care of a few similar patients, some of which could be saved and some not.  I was recently in a surgery where we were discussing whether or not Hespan was acceptable or not.   As my patient was bleeding I was thinking that authors of the Bible didn’t know what Hespan was, that the whole things was a bit ridiculous.  We gave the Hespan.  Another recent patient had recurrent cancer and cannot be effectively treated because of her low hemoglobin, and will eventually find her life cut very much shorter than it would have been if she took blood.

What’s interesting to me is that unlike my hardline attending, I have found very little emotional distress in these situations.  While I would love for these people to have good outcomes, I didn’t make them sick. I don’t share their religion, but I am pretty sure that robbing them of their faith and security would do far more harm to their personhood than a few pints of blood could ever heal.  Everyone must die eventually, and it seems better for them to go on their own terms than to live on in fear that they have damaged their potential in eternity.  I don’t know whether their religion has an accurate view of the long term consequences of taking blood or not.  But that doesn’t matter.  Making it matter wouldn’t be good doctoring.

There is a saying that a physician must strive to have great sympathy, but to do what they can to avoid empathy.  The distinction is lost on many.   Sympathy is when you care about how your patient is feeling, but empathy is when you feel it yourself.  Empathy, in other words, is taking it personally.  While some argue that such closeness with patients is a positive physician trait, I would argue that these people haven’t well considered the difference between sympathy and empathy, and the results of the execution of each.   Patients appreciate their physician’s sympathy, but in the end depend on the physician’s lack of empathy.  Without that, it is very difficult for the physician for the physician to give objective medical advice, and if need be to respect a patient’s right to refuse that advice.  While it saddens me to some extent that a JHW might die for lack of blood, I feel enough sympathy for their decision to place their religious belief above their self preservation that I can ignore my empathic need for them to take blood.  Its not my life after all.

I think back to my attending that had the hard line, and think perhaps he had a little too much of his own ego involved.  He was deeply invested in his patient’s outcomes, and therefore would be personally injured if his patient died a death that he thought was preventable.  I used to see this as noble, but in the end it was not the most effective physicianhood.  His patients would have been better served if it he didn’t take their outcome so personally.

I wish I could say that when I’m done doing a little impromptu lecture on pelvic anatomy that there is something on paper worth saving, but well, there isn’t.  Wish you could have been there.

Academic OB/GYN Podcast 34 – Journals for June through August 2011

Recently in Oregon there have been some deaths during attempted breech deliveries at home, all attended by various home midwives of varying skill.  Following this there was a discussion in the legislature about whether or not licensed midwives should be completely banned from intentionally attending breech births at home.  Joanie wrote a passionate letter about the topic.  She shared this letter with me, and to my surprise the letter was not in support of breech birth at home, but rather a plea that the legislature ban breech homebirth.  She felt that too may midwives believed that they understood how to deliver breeches, not because they had experience, but because they were just ignorant of the potential risks and the techniques required to succeed.  I some cases they just “believed in birth” and felt that the baby would deliver if one would just stand by and watch.

I have always felt that the more one knows the more one realizes what one does not know.  I can say from personal experience that as I grow in experience, my knowledge of what I lack becomes only more clear.  Joni is the most experienced midwife I know, and in her great experience clearly feels that she cannot safely deliver a breech at home, and chooses not to offer that service.

Here I republish Joni Dawning’s letter to the Oregon State Legislature for review and comment.  Joni may be able to respond to comments as well.

***

“I am a lay midwife practicing for more than twenty-five years in Eugene. Recently, I received an email urging me to submit comments on proposed protocol changes.  I tell you honestly that it has been an emotionally agonizing process to arrive at the decision to compose and send this letter.  I wish to voice my support for placing breech delivery in the category of absolute risk.

We all enter midwifery with a profound sense of awe of the powerful natural forces of birth. Along with that awe is a sense that the medicalization of birth has detracted from the spiritual, emotional, and physical experience of childbirth for mother, baby, family, community and care provider.  I will not argue with that.

I acknowledge that it is clearly possible for vaginal breech birth to occur safely, indeed serenely, and I grieve the inevitable loss of those birth experiences to protocol.  I am however, aware of four infant deaths directly attributable to attempted home birth of breech babies.  Anecdotally these births have apparently been associated with mistaken beliefs on the part of the midwives and their clients that these births were “normal”.  The attending midwives reportedly either did not recognize or did not respond to early indicators of impending complications such as cord compression, footling presentation, and sacrum posterior position in such a way as to prevent these sad outcomes.
Though I believe deeply in parents’ rights of choice regarding both care provider and setting for the births of their children, I also believe that midwives have a core responsibility for self-identifying our own limitations in training, experience and skill as care providers for higher risk pregnancies.

In the mid-1980’s when I was younger and less experienced as a midwife, licensure was touted in discussion as legitimizing our profession.  Legislators were told that passage of a licensure bill would mean assuring consumers of care that licensed midwives met knowledge, education, training, experience and safety criteria and thus, should be reimbursed by third party payers.  Many of us felt concerned then that, along with licensure, would come protocols restrictive of birthing women’s choices of care.

Though I still believe wholeheartedly in choice, my experiences of more than a quarter century of practice have confirmed for me that it is a midwife’s responsibility not only to assist prospective homebirth clients in making fully informed, knowledge-based choices but also, just as importantly, to acknowledge the limitations of the care she can provide.

Prospective clients often ask a standard set of questions that includes “do you do breeches?”  My response is that I believe it is my job as a midwife both to patiently safeguard normalcy and to identify and respond to known risks in such a way as to facilitate transfer of care to a setting where risks might be better addressed if they occur. Though midwives study the mechanism of breech birth in texts, workshops, and lectures to enable us to respond to an undiagnosed and rapid breech birth, it is important to recognize that because breech occurs so infrequently, supervised hands-on training in skills necessary to facilitate such births is not commonly available.  I have safely delivered only two “surprise” breech babies whose mothers’ labors were so efficient that they were well progressed through late stage labor when the babies’ frank breech positions were discovered.  I have transferred care before labor or transported during labor at least three times that number.

I have come to believe that midwifery and obstetrics are complementary callings and I practice with confidence knowing that I can facilitate my clients’ access to medical consultation or transfer their care in the interest of safety for a mother or baby. I believe that the local medical community trusts that I will endeavor to identify risks, inform and educate my clients, and respond to those identified risks before they become disasters.

Physicians in our community are currently willing to assist homebirth clients by providing ultrasound confirmation of breech position, offering external version when appropriate, and accepting third trimester transfer of care in the event of a persistent or late identified breech. Rarely has the experience of seeking consultative care, transfer or transport been anything other than welcoming and respectful of my clients, their desires for a holistic childbirth experience, and the sometimes difficult choices they have made to enter the medical system.

I am clear with my clients that current local standard of practice is delivery of breech babies by cesarean section; and that the standard is based upon a large cohort study that demonstrated increased morbidity and mortality rates for breech babies delivered vaginally. In contrast to the information I provide, one particular licensed midwife in the community reportedly says “they’ll just cut you!”

I trust that most midwives’ practices are self-governed by a commitment to provide care that is within our scope of experience, education and skill and I am profoundly saddened to have arrived at the point of advocating absolute restriction of practice in order to proactively assure that the disastrous behavior of a few individuals is prevented.

Respectfully,

Joni Dawning”

***

If you’re a radical homebirth supporter, I hope this provides a little perspective.  If you’re a physician who thinks that all homebirths are dangerous, consider what is possible with the kind of midwife that knows what she is doing, and knows what she does not know.  There is a happy medium, and in that medium great things can happen.

So things are getting separated:

If you want to hear about things related to the blog, the podcast, and other things of medical interest, continue to follow @academicobgyn.

If you want to hear from me on a more personal level, follow @nickfogelson.

Or follow both.

In all this moving, there hasn’t been a lot of time to write blog posts or do podcasts, but I’ll be coming back soon with lots of good stuff.  Atlanta is perhaps the best city I have ever lived in.  I’ve been here a week and love it already.  If any fans or friends live in ATL please let me know so we can meet up!

My move to Atlanta comes as a sabbatical from attendinghood, returning to the learning side of it all in an Advanced Pelvic Surgery Fellowship in the department of Gynecologic Oncology at Emory University.  I hope to get some great material for surgical videos, though Emory’s policies for posting may be a bit restrictive – more research is warranted.

One of the great things about Atlanta is the incredible music scene.  Every big act plays here.  I just saw Idina Menzel tonight – just awesome.  She played Chastain Amphitheater and there was daylight for the first 2/3 of the show.  She kept saying it was making her nervous seeing all the audience watching her.  Even virtuosos get nervous.

We also discussed the risks.   “You could have bleeding during the surgery, potentially enough to need a blood transfusion before or after surgery.  You could get a communicable disease from a blood transfusion.  You could develop a wound  infection or abscess, which sometimes is easy to treat and other times quite complicated.  Anything in the abdomen could be damaged during the surgery, such as the bowel, bladder, ureters (“which carry urine from the kidneys to the bladder” I always say), blood vessels, or other structures.  Anything damaged can be fixed at the time by myself or a consultant.  There is a possibility something could be damaged but we do not recognize it at the time, or that there is a delayed injury.  If this occurs you might need further surgery, antibiotics, or hospitalization.  Though extremely rare, you could die or be injured from an unforeseen surgical complication or complication of anesthesia.”

At this point she looked white as a sheet, as usual, and then I tempered with “but all of this is extremely unlikely, less than 1% of cases for major issues, and I have to explain it all for legal reasons.  I am well trained to do this surgery and will do my absolute best for you.”  I answered her questions, the consent is signed, and we had our pre-op.

While this consent process is quite standard, it just seems a little ridiculous to me.  Its a bit like asking your neighbor bring your son home from school, and having her say “we may get hit by another car, I might run a red light, we may run out of gas on a train track, there might be a meteor that hits the car and kills us all…. but don’t worry I am a good driver and your son will be fine.”

The fundamental reason we do these consents is that we believe that in some way they will protect us in a lawsuit if something bad happens.    For example, let’s say somehow I transect a ureter in my patient’s hysterectomy, I can say “See – I said this was a risk of the surgery… it wasn’t my fault!”

But isn’t that a bit ridiculous?  Is telling somebody that something bad could happen actually a defense if that bad thing does happen?  In some cases a problem is truly random, such as the development of a pelvic abscess after a hysterectomy, but in other cases it is not.  There is almost no situation in which I could cause a ureteral injury and have it not be a surgical error.  If it happens, I did it – and it was a mistake.  Ureters are damaged in about 1% of hysterectomies, but its not like they magically get injured in 1% of cases.  In 1% of cases the surgeon makes an error.

When I was a resident I worked with one attending that thought along these lines as well, and had a very different consent process.

“We are doing X surgery because of X.  I’m a good surgeon, and think I can do this surgery without a problem.  You need to sign this paper or the hospital won’t let me operate.  I think it will go well, but anything can happen, and if it does and you think its my fault you can still sue me.”

This all seemed very glib the first time I heard it, but I have to say I have always had a lot of respect for that attending’s honesty.  He was telling it like it really was, even though it wasn’t necessarily the smoothest way to go about it.   He was indeed a very good surgeon.  His partners thought he was a bit nuts, though.

The trouble with the standard consent process is that it doesn’t deal with the real issue; errors do occur, and physicians cannot be perfect.  By naming error-driven events as statistical occurrences, the process supports an expectation that surgeons will never make errors, and thus the corollary that any surgical error is a de facto breach of physician’s fiduciary duty.

Every time I do a standard consent process, I think about doing it differently.  Perhaps something like this:

“We are doing X surgery because of X problem.  I am well trained to do this surgery, and think I can give you a great chance at an good outcome.  Your surgery is something I know I can do well, but I cannot guarantee that you will not have a problem.  I can only guarantee that when I do your surgery I will be well rested and that my team and I will do our best.

Sometimes when bad things happen during or after surgery it is a random event.  There are certain things we can do to reduce these events, and we will do those things.  Another kind problem can be because  a member of my team or I makes a technical error.  While I do my best to operate perfectly, it is possible that I could make a mistake.  I have occasionally done so in the past, and will no doubt do so again in the future.  As I have always learned a great deal from these rare mistakes,  I hope to think I will never make the same error twice.  Fortunately, almost every error is recoverable, and I know how to make those recoveries.  If we have a problem, I will be there to fix that problem and help you through whatever recovery is necessary.  I will explain the problem to you, and if I know, I will explain how it happened.

(now sign this paper or the hospital won’t let me operate )”

I often wonder if the common legalese consent process we go through actually protects us.   Ultimately, we are bound to meet the goal of “The Standard of Care”, and we don’t get to define that standard on our consent form.  Lawyers love to say that this standard is readily viewable in any textbook, but in reality its pretty grey.  The exact definition changes from state to state, but usually is defined as what another reasonably practicing physician of similar training and situation would have done in the same situation.  Fortunately, reasonably practicing physicians of similar training and situation also make mistakes from time to time, and usually lawyers and juries recognize that.  As long as one recognizes the mistake and does the right thing from there forward, usually one has a reasonable defense.

So let’s just say that up front.  We are well trained, and we do our best.  If we screw up, we’ll let you know that, and we’ll fix it.   Now sign here.

Robotics is an exciting new area of surgery, and is of great use in gynecologic surgery.  Robotics can be used in most any laparoscopic surgery, and makes many minimally invasive cases possible that otherwise would have to be open cases.

Presenting patients is a skill that takes a great deal of time to master.  Each student is taught the basic form of a medical presentation at an early ‘age’ – Subjective, Objective, Assessment, and Plan.  Each of these bits can be broken down into many subareas, such a Past Medical History or Social History (part of the subjective usually), Chest Exam or Labs (parts of the objective), or individually listed problems (each parts of the assessment and plan.)

This sort of structure is both an aid to great presenting and a hinderance.  It helps because it gives the presentation a structure that is easy to follow, and over the years of hearing such presentations the listener has created little boxes in their mind, and had developed the expectation that these boxes will be filled in a specific order.  By following this structure, the student fills those boxes and thus creates a structured narrative that fits the listener’s expectations.  This can be very functional and efficient.  The downside is that if the student follows that structure too tightly, the presentation sounds stilted, like a person reading a spreadsheet.  This creates a presentation that is technically correct, but lacks grace.

When I was a student, I heard experienced attendings talking to other attendings about patients and noticed that they presented a bit differently.  It seemed to me that they were just telling stories, in the same way that one might tell any story.  For a bit of time I became convinced that all of this structured presentation was just a thing we did in medical school and residency, but that once we were more experienced we drop it.  Eventually I realized that the story telling is not a different style of presentation, but rather the final evolution of the structured presentation.

If one listens to a great presenter, it’s not a stilted structured presentation.  It flows from beginning to end.  They setup the presentation with a narrative of how the patient came to be ill or in the hospital.  Then, without verbal header, they weave in the bits of their past that are truly relevant to the case.  Eventually we move onto the vital signs and objective findings.  Finishing that we get to what the presenter thinks is wrong, and what we need to do about it.  No headers, no stilt – just a story.  But a story with structure.  Its like a paper mache sculpture built on a frame.  From the outside its a beautiful piece of art, but in its construction there are spars and frames holding each piece together, and each of structural members are placed according to the laws we learned from the beginning.

When I was learning one thing I noticed about such presentations is that the traditional order of things sometimes gets intentionally messed up.  Initially this seems wrong, but over time one realizes that strategic reordering of the elements can greatly improve the presentation.  For example, consider the two following openings:

“The patient is a 45 year old man who presented with chest pain in the central chest that was worse after he ate a fried oyster sandwich..he gets this often when he eats….Past medical history: he has a history of coronary artery disease with two prior bypass surgeries.”

or

“The patient is a 45 year old man with a history of coronary artery disease with two prior bypass surgeries and a high fat diet who developed crushing substernal chest pain while eating.”

The information is the same, but in the first we are leading the listener to an assessment that the pain is GI in origin, and the second we are leading the listener to believe that the patient is having angina.  

In this reordering we see the key to a great presentation – foreshadowing.  One’s goal is to tell the story of the patient in such as way that the listener is already thinking what the assessment is going to be before the presenter gets there.  It is one’s hope that the listener comes to the conclusion that the patient has X at the exact moment that the presenter says that the patient has X.  Such timing can be difficult, but the best presenters do it often.  As an attending, hearing the end of such a presentation is like getting to the end of a great thriller and having one’s suspicions confirmed.  Having a conclusion that is not what one expected can also be fun, but only if one can look back over the presentation and realize that all the pieces were there.  Ending a presentation with a conclusion that wasn’t supported up front at all is just jarring, and ultimately doesn’t work.  Its like ending Harry Potter 2 with the bad guy actually being Scabbers the Rat.  Huh?  How were we to guess that?  Not satisfying.

Another important element is the use of notes.  In the beginning, notes can be necessary to keep information that needs to be reproduced during a presentation.  However, any presenter needs to endeavour to remove this crutch as soon as possible.  Reading off a paper is never a great presentation.  Its functional at best, but never great.  Some seem overwhelmed by the idea of memorizing all these little facts and reproducing them, but I ask this?   Do you find it hard to retell an interesting story that you know?  Are you struggling to remember each part of the story?  The answer of course is no, and therein lies the answer.   Move from regurgitating quanta of data to telling the patient’s story and remembering the details is no longer difficult.  If its hard at first, practice.   A student that never jettisons the note cards will never be an effective presenter.

So if you are a student, work hard on your presentations.  Start with structure, but work on making that structure the underpinings of a great story.  Once you can do that, you’ll find presenting easier, and you might even make honors.

Academic OB/GYN Podcast Episode 33 – Journals for April and May 2011

We were trying to hit a certain launch characteristic – about 2400 RPM of backspin with about 12 degrees of launch angle. The kicker was the variation in any given swing could produce quite a bit of difference, at least 500 RPM of spin and 1-1.5 degrees of launch. Being a stats geek I immediately realized that with this amount of variance in the sample groups, there was no way that 1-2 samples (swings) could really identify a true difference between clubs. Sure, I might really nail one with one particular club, but without a big series of shots that would only be an anecdote, not real data. By the end, we had settled on a particular shaft and head, and it did seems to launch the ball quite a bit further and higher than my previous club. But in the end, I wasn’t really sure if despite all the technology and experience involved in this process, we had really done anything more advanced than picking a bunch of different clubs off the rack and seeing which one felt best. Unless we hit enough with each club to overcome the variance in individual swings, all the radar was doing is putting a number on what I could already feel. It better described the anecdotal experience, but wasn’t actually identifying a real pattern. I pointed this issue out to the clubfitter, but he claimed he could tell the difference after just one swing. It seemed more to me that he was cherrypicking the few swings that he thought represented his conception of truth more than the rest.

In a lot of ways, we do the same thing with our medical experiences.

Docs worry about uterine ruptures in VBACs even though they are very rare. Midwives seem to hate misoprostol despite scads of data to suggest no increase in adverse outcomes. Despite the data, we fixate on the few anecdotal experiences that had an emotional impact on us.

We all like to think that we are evidence based, but how often are we really? I often find myself defending my points based on studies that agree with me, and tending to avoid the studies that don’t. I see the same behavior in my colleagues. Oftentimes we attack the methodology of the studies that have results we don’t like, and feel more academic for doing so. We even chortle at how foolish some researcher was for putting together a study so poorly, coming up with an answer that seemed so obviously wrong (listen to the AO podcast and you’ll hear Paul and I do exactly that on a regular basis.) But would we have attacked the study as hard if the answer had agreed with what we already thought?

Sometimes I even see two docs fighting over a point, using the same study to prove completely opposite points. Each one takes a small piece of a study and claims that bit is the most important piece.

While at some point this is all natural, and perhaps part of the scientific process, at times it gives me pause about evidence based medicine in general. I find myself asking whether or not all this research really advances what we do if people are just going to re-interpret the data based on what they already believe. I also find myself thinking about the most potent learning experiences of my career and realizing that to a one these were not the discovery of new data, but poignant anecdotes involving sick patients, difficult surgeries, or great teachers. Each such experience was an N of 1, and yet those series of N1 experiences have contributed far more to who I am as a physician than hundreds of the N1000 studies I have read.

I’ve tried to be completely evidence based at certain points, but always eventually run into a situation where the evidence just doesn’t seem to fit. At that point I’ve been faced with the choice – go with what the data says is right, or go what seems correct in the specific case. I think the latter is often the more correct path. Given the way that statistical mathematics eliminates outlying datapoints, one would expect that there would be individual clinical situations that do not follow the data. Understanding this, it behooves one to try to see those situations where the data isn’t going to fit, and when ones anecdotal experience might better direct one’s course. Sometimes these deviations are heralded by an alarm bell in one’s mind that seems to scream “SOMETHING IS DIFFERENT”. I think one has to listen to such alarms.

Ultimately, we respond to the experiences of our past. Some disparage this, and attack those that do as not being scientists. There is some truth to this, and some do take this too far. Some ignore clear directions in the data because of their personal experiences, and are probably missing out on a better way of practicing. But for the most docs, a large catalogue of anecdotal experiences is one of their greatest strengths.

Strict adherence to evidence based medicine seems a good idea in the sterile field of a thought experiment, but doesn’t really seem to work in practice. There are too many times when the data doesn’t fit. There are too many outliers that have been systematically eliminated from the data.

But can one take this too far? Some docs are so experienced that they no longer consider data at all. It isn’t that they don’t believe in data. Its that they truly have seen almost everything, and have something personal to draw upon in nearly any situation. I have worked with several docs like this, and they are quite impressive. One liked to say that his actions were justified by his decades of “unpublished data.” Us younglings like to snicker at how oblivious these greyhairs are to the literature and how out of touch they seem to be, but if we’re in a bind they are the ones we call for advice – and usually they know just what to do.

Despite his obliviousness to the statistical insignificance of his observations, my master clubfitter made me a driver that was better than anything I had ever hit. In the end, performance is what matters – and oftentimes a deviation from or even ignorance of the data is what we need to get there.

Academic OB/GYN Podcast Episode 32 – Journals for February and March 2011

The March of Dimes has been a positive organization for decades, and generally does a lot of good work.  This one really blew up in their face.  MOD was a major player in pushing the FDA to give orphan drug status to 17-OHP, paving the way for KV to bring Makena to market.   Jennifer Howse, PhD, president of MOD, has stated that the MOD had no idea of the planned pricing structure, and I believe her.  Nonetheless, the MOD has suffered a great deal of bad press and in some cases decreased donations because of their association with KV and Makena.

Today the March of Dimes delivered a letter to KV Pharmaceuticals, saying a lot of the things that we have been saying.  It must have been a tough letter to write, given the amount of financial support KV has given to MOD, and the potential for that to end.  While I don’t think the letter was perfect, I think it was pretty good for a major organization that has a lot of difference issues to keep in balance.  Here it is:

March 23, 2011
Greg Divis, President
 Ther-Rx Corporation
One Corporate Woods

Bridgeton, MO 63044

Dear Mr. Divis:
Thank you for your letter of March 17th. I am pleased to learn that you are ‘listening carefully to stakeholder concerns about list price, patient access, and cost to payers’. Thank you for considering additional steps to ensure that Makena is available to all eligible women, and for convening stakeholders from the March of Dimes, the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and the Society for Maternal Fetal Medicine next week.
In advance of that meeting, I want to go on record that March of Dimes expects Ther-Rx to come to the table with substantive commitments including:

1)      A significant reduction in the list price of Makena.

2)      Adjustments to the patient assistance program to ensure adequate coverage of all patients, insured, uninsured and underinsured.

3)      A method for reporting on a regular basis to stakeholders on the patient assistance program to ensure that it is meeting needs in a timely and adequate way.

4)      A justification or rationale for your pricing based on your investment in the product, savings to the health care system, or other appropriate methodology, which you are prepared to make public.

Without these elements, I do not believe that Makena can succeed in the current marketplace environment, and as a result, at-risk women will be denied access to a safe and effective treatment to reduce preterm delivery. Therefore if you are unable to make a clear commitment to significantly address the above issues at the meeting, the March of Dimes will need to pursue alternative strategies for ensuring that this proven intervention to prevent preterm birth is made available to all medically eligible pregnant women, and we will step away from our longstanding and productive corporate relationship with Ther-Rx. Thank you for your consideration of this critical matter.

Sincerely,
Jennifer L. Howse, PhD 
President

While some folks on the internet have been critical of this letter as not strong enough, I feel like it is a pretty strong statement.  MOD has had a financial relationship with KV for some time, and they are threatening to end that if KV does not address these issues.   Their threat of “pursuing alternative strategies” certainly reads as endorsement of continued use of a compounded product.  For an organization as large as the MOD, I think this is as close to a smackdown as they could get.  For that I say bravo.

The only concern I have is the idea of KV being asked to “justify their pricing rationale” based on “savings to the health care system”, as any comparison to the cost of preterm birth is completely spurious.  Health care needs to become less expensive.   Fixing something that costs 100 with something that costs 90 is not a savings when the previous fix only cost 1.  Claiming that it does is a ridiculous assertion – yet there is no doubt that KV will continue to make such claims.

I also think that some have been a little hard on MOD.   I am concerned about their previous financial relationship with KV, but they have such a strong track record of positive contributions to pregnant women that I am willing to give them the benefit of the doubt, particularly after this letter.  KV, on the other hand, has a track record of unethical  behavior for which they are still paying fines.

While I appreciate MOD’s letter, in the end it doesn’t change my feeling towards the situation at all.   No matter what the outcome, KV is deserving of a total boycott of Makena.  They have behaved in a completely unethical manner, and deserve to go bankrupt for it.  They have attempted to mug the women of this country, aiming to force the healthcare system to pay them billions of dollars a year for nothing that they didn’t already have.   No matter how they respond to this issue, it will not change the fact that they are corporate muggers.

If somebody tries to mug you in an alley and you catch them in the act, they don’t get off the hook just because they gave you your money back.

Please join me in a total boycott of Makena.  Companies like KV do not deserve to stay in business.

While this is the first FDA approved product for this indication, this very compound has been available on the market for many years, generated by compounding pharmacies nationwide for as little as $9 a dose.  One major supplier, Wedgewood Pharmaceuticals, provides the product in vials every bit as professional looking as anything you would get from a major Pharma manufacturer.

The big problem, as most already know, is that KV Pharmaceuticals has decided to price their drug at approximately $1500 a week.  Furthermore, they are extending legal power to prevent compounding pharmacies from creating any more of the drug.

This is outrageous.  This is a well studied drug, already having gained acceptance in the community based on the landmark 17-OHP trial published in 2003.  Millions of doses have been given nationwide without adverse effect.   The fact that it has become FDA approved has done nothing for women or infants.  The only effect has been that KV now has legal protection to price the drug at 200 times the previous price and block out competitors who previously had been providing the same drug at a tiny fraction of the cost. 

An article was recently written in the New England Journal decrying this usurious pricing scheme.  In their analysis, they write “For every dollar spent for compounded 17OHP, $8 to $12 in health care costs related to pematurity are saved.. by contrast,  Makena will require $8 to $12 in drug spending for every dollar in such prematurity costs avoided.”  Further editorials have been published in both print and digital media, such as this, this, and this.  My friend @drjengunter weighs in here

KV has responded to the criticism, pointing out that they have a patient assistance program.  To be fair, they are willing to give the drug for free to uninsured women making less than 60,000 a year, and at a small copay for women making less than 100,000.  But to be fair to women and the world, this isn’t nearly enough.  No matter what individuals are paying for the drug, the medical system will be paying billions of dollars for something that used to cost a few million a year. 

Positive spin on Makena has promoted it as the first drug to decrease the rate of preterm delivery. This is an agregious mistruth. The drug has been on the market for over 50 years, and has been used for the indication for almost a decade in the United States.

At the core, KV Pharmacueticals is a leech on the blood of our society.  They are providing nothing of value, but through our bureacratic process have been guaranteed that they can extract billions of dollars a year from our healthcare system – all to get a benefit we already had.  They didn’t even have to do the research; it was done for them and published in 2003 (with compounded drug.)  The idea that their particular FDA approved product is somehow better or safer than the compounded product is completely theoretical, cannot be justified by any data.  Furthermore, the underlying efficacy of the drug KV claims has immeasurable benefit is worthy of some skepticim despite the 2003 trial, as since it went into widespread use the preterm birth rate has risen from 12.3% to 12.7%.

So what are we to do about this.   I am doing this.

I will not write a single dose of Makena, and I call for you to do the same.

If I can, I will continue to use compounded 17-OHP.  If I can’t, I will recommend daily vaginal prometrium, which very likely will have the same effect as 17-OHP.  Its off label, but so was 17-OHP before KV got ahold of it.  If a patient asks, I will politely explain that I refuse to give in to KV Pharmaceuticals and their piracy.  The cost of healthcare is destroying this country, and this is an area in which we cannot afford to give in.  Patients need to understand that these are the kinds of decisions that drive the cost of healthcare, and that we are all responsible for protecting our country’s healthcare future.

I encourage everyone over which I have any influence to refuse to write Makena for any reason, and to pass this message on to anyone who will listen.

Thank you for being there for patients around the world, fixing and cleaning their teeth and gums.  Thank you for your training and your wonderful set of skills which we all need.

But today I have a bone to pick with you.

For the one thousandth time today I was asked to write a note for a patient with an obviously infected tooth, giving my permission for you to treat her.  For the one thousandth time, I sat before my suffering patient, cursing your name, and wrote this ridiculous note.  And now my patient can go back to you, and now you can do the job you should have done when she first came to you with her painful tooth.

As an obstetrician, I am expected to be expert in all things pregnancy.  Not only that, but I am expected to understand how all things not pregnancy affect all things pregnancy.  It was for this that I went to medical school and trained long in my field.

You are much the same.

As a dentist, you are expected to know all things oral cavity, and furthermore how all things not oral cavity affect all things oral cavity.  It was for this that you went to dental school and trained long in your field.

And in this training, you no doubt learned something about the dental care of pregnant women.  You probably learned that local anesthetics are not harmful to a pregnancy, and that the narcotics you prescribe for pain and the penicillin based antibiotics you use for infection are also safe.  You probably learned that the millirads of radiation your oral films use are trivial compared the amount of radiation it would take to harm a fetus, and if you’re really on it you might even know that an obstetrician would do a 3 rad cat scan right through the fetus if he or she thought it was important enough.  At the least, you know that the big lead apron you use is going to block anything that might get to the fetus anyway.  You might have read that obstetricians are actually quite interested in oral health, and that we think that chronic oral disease may ironically be a contributing factor to the preterm labor you hope to avoid involvement with by refusing to treat oral disease in pregnancy women.

At the very least, you know that a fetus is kept in the uterine cavity, not in the oral cavity.

Since you already know these things, really what is going on is that you want your ass covered if under some strange coincidence something bad happens to a pregnancy after you treat a patient.

This is nonsense, and I am tired of it.

So forever more, here is a note for all the pregnant ladies of the world.

1. There is nothing you can do under local anesthesia that will hurt a fetus.

2. Penicillin antibiotics are safe in pregnancy

3. Local anesthetics are safe in pregnancy.

4. Narcotics are safe in pregnancy.

5. Oral xrays are safe in pregnancy.  Shield the baby like you would any patient.

If after reading this you ever again send away a pregnant patient in pain because they need a note from their obstetrician, I have only this to say:

Grow a pair.  You are doing your patient a disservice. Excercise the wonderful skills you spent years cultivating, and help your patient.

Academic OB/GYN Podcast Episode 31 – Delayed Cord Clamping

Academic OB/GYN Episode 30 – Articles for January 2011

Academic OB/GYN Podcast Episode 29 – REI Update

Academic OB/GYN was featured on the web’s Medical Grand Rounds for January 4 2011.  Lots of good stuff worth checking out.

This is a nice photo of a diamniotic/dichorionic placenta, part of a pregnancy involving two separate embryos in the same uterus.

Note the thick intervening membrane and lack of blood vessels traveling between the two placental discs, both characteristic of a di/di placenta.

Academic OB/GYN Podcast Episode 28 – Journals for December 2010

All of these things amaze me.  But to be honest, they also make the practice of obstetrics and gynecology more difficult.   We have advanced our understanding to level that is impossible to explain to patients who lack a strong background in science, forcing us to accept simplistic explanations over explanations of how it really works. Let’s use HPV as an example.

When I started my residency, explaining an abnormal pap smear to a patient was fairly simple, and that explanation could be understood by just about every patient.

“Your pap smear indicates that you have some cells on your cervix that are at risk for becoming cervical cancer.  These might get better on their own, or they may get worse.  We need to look closer at the cervix and take some biopsies so that we know how far along in this change these cells are, and to know if we need to do anything further.  If the cells are far enough along the path to becoming cancer, we can remove them so that you don’t get cancer.”

Patients understand this.  Its fairly basic, and makes some sense.  It can even be illustrated fairly easily on the back of a piece of paper, drawing a prototypical normal cell, a cancer cell, and several cells in between.   You just draw them, point to one of the cells in between a normal and cancer cell, and say that they likely have some cells like this and they need to be observed or treated.   When patient would ask why their cells get like this, we just shrugged and said “It just happens sometimes… we don’t know why.”  Patients accepted that, and we went on with whatever needed to be done.

But now we know more, and it has become much more complicated.

We can still explain what a dysplastic cell is, but now when patients ask why its much harder to explain.

ME – “Well, your cells are like this because you contracted a virus called Human Papilloma Virus, which you got from a sexual partner”

Patient – “WHAT??!?! I have a sexually transmitted disease?”

ME – “Technically, yes, but not really.  HPV is extremely common.  The only way to reliably avoid it is to never have sex, which nobody does, so really you can’t avoid getting it.  So its not really an STD like that.”

In most cases this leads to a divergence in the force, completely depending on who the patient is.   If the patient has taken some college biology, we might be able to continue with a fairly in depth discussion, leading to some understanding of how HPV could technically be an STD but not really like Gonorrhea of Chlamydia, and how one can’t really blame their partner for giving them HPV.

But unfortunately, many patients don’t have the technical background to follow you down that line of explanation.  Many are stuck on “virus”, not really knowing what that is in any specific sense, and how that might differ from a bacterial infection that one gets from sex with an infected partner.   It also now becomes extremely difficult to provide an adequate explanation why HPV infection does not really imply any infidelity in the relationship, as understanding that would require an understanding of how viruses differ from bacteria, and how viruses can be around for years without causing any problems.

Patient – “But how do I get rid of it?”

Me – “Well, if you stop being exposed to it your body will likely clear it over time, like it clears other viruses.”

More potential areas of misunderstanding.  Patients with minimal science background don’t understand the idea of a virus being killed off over time, especially when they know that a Herpesvirus doesn’t ever go away.

Patient – “So if I leave my partner it will go away?” – a logical idea, but not really a good idea.  The truth is that when patient has normal paps for years and then suddenly starts having abnormals, there is almost always a new partner in the mix.  They have a new strain of HPV.  But getting into this with patients usually leads nowhere good, and even suggesting that a change of partners might resolve recurrent abnormal pap smears, while possibly true, can be very damaging to a healthy relationship.

Me – “If you like your partner, this is no reason to change that.  HPV is so common that making relationship decisions based on who you got it from is not the right thing to do.  Unless you decide to never have sex again, you will always be at risk to be exposed to HPV, and there is really nothing you can do to change that.  Ten years ago we didn’t even know that HPV existed, and we would just be talking about an abnormal pap smear, and not about a sexually transmitted disease”

Patient “Its a sexually transmitted disease?!!?!!”

ME – “(grrr…) yes… but not really like other STDs!”

Patient “Can’t I get that Gardasil injection and fix it?”

ME – “You can get it, but it only protects you from a virus you haven’t been exposed to.  Your tests indicate you are already carry the HPV virus, so it won’t have as much benefit for you.”

Patient – “So if you treat the bad cells, it will be gone?”

ME – “Not really.  The cells will be gone but the virus will still be there.”

Patient – “Then what good is it to treat it?”
ME – “AAAGGH!”

At times like this, it makes me think that sometimes all this knowledge really hurts us sometimes.  It feels wrong to revert to a totally simplistic (and actually ignorant) understanding of cervical dysplasia, but many patients lack the scientific background to understand an explanation of what is really going on.  I love to explain the underlying disease to a patient and help them to decide how they want to go about treating it, but the complexity of our understanding forces me to be the paternalistic doctor that I hate.

Patient – “How did I get this abnormal pap smear”

ME – “I could try to explain it to you if you like, but its really complicated, and probably easier to just think of it as cells on their way to becoming cancer and leaving it a that.  We just need to treat this so you don’t get cancer.”

Patient – “OK”.

And they’re actually satisfied. But I’m not.

First blonde one for me.   Gotta catch ‘em all!

So here’s an answer to that (nonsense).

Typically, home health services are provided because the patient cannot leave their home to obtain those services, but lactation consultation is a different issue.  Lactation services are either provided in the hospital while the patient is inpatient, or in the home after discharge.  Most communities do not have facility to provide lactation consultation on an outpatient basis, other than through various licensed or unlicensed practitioners  such as doulas or (some) midwives. As such, once a patient has left the hospital home health is the best option for this service, for most patients.

Furthermore, the provided policy does not specifically address lactation consultation specifically as either being a skilled service or a custodial service.  If it were a skilled service and medically necessary, it would be covered.

While lactation consultation is not specifically addressed in plan policy, skilled services are defined as:
“A health service is determined to be skilled based upon whether or not clinical training is necessary for the service to be delivered safely and effectively and on the need for physician-directed medical care. Examples of clinical training include registered nurse, licensed practical nurse, respiratory therapist, physical therapist, occupational therapist, and speech therapist. This list is not all-inclusive.”

Based on this definition, lactation consultation would be skilled.  Lactation consultation requires a specific certification, typically given along with RN, CNM, or LPN licensure.  It cannot be provided by relatively untrained people such as certified nursing assistants.

Custodial care is defined as :
* Non-health-related services, such as assistance in activities of daily living (examples
include feeding, dressing, bathing, transferring and ambulating) – this is not the case here.  The specific activity at hand is breastfeeding, which is not an activity of daily living for the patient.  “feeding” in the policy refers to the patient feeding herself, not her infan.
* Health-related services which do not seek to cure, or which are provided during
periods when the medical condition of the patient who requires the service is not
changing. – This service does seek to “cure” a problem, in this case the problem being inability to breastfeed.
* Services that do not require continued administration by trained medical personnel in
order to be delivered safely and effectively. – This service does require trained medical personnel, with specific education on lactation education.

As such, lactation consultation is not custodial care.

Medical necessity of breastfeeding is clearly established, as while bottle feeding is an option, breastfeeding has been shown to be of substantial benefit to the infant, both in physical (growth, neural development, immune development) and psychological (mother-infant bonding) areas.

Based on plan coverage documents the requested 2 visits should be covered as a skilled service for this patient, under the provided coverage Documents.

Academic OB/GYN Podcast Episode 27 – Journals for November 2010

Prior to going into the lab, I spent many hours going through Netter’s atlas to brush up on the anatomy so I could accurately help the medical students.  Its amazing what one can learn reviewing what one used to know.  Here’s a few examples:

1. The small vessels we like to cut at cesarean have names, and we can avoid them.

Everybody that does cesarean deliveries knows that there are small vessels in the path of entry that sometimes get cut, but not everyone knows what they are called.  So for the record, the small vessels in the subcutaneous fat that get cut are superficial epigastrics (most people know this one) and the vessels that sometimes go during the lateral extension of the fascial incision are ascending branches of the deep circumflex iliac artery.  One can see that these ascending branches lie between above the transversalis muscle but beneath the obliques, which explains why sometimes taking the fascial layers separately allows one to miss them.  I’ve always felt that the routine sacrificing of these vessels was a surgical faux pas, and knowing this anatomy helps one to avoid it.

2. The small nerves we like to cut at cesarean have names, and we can avoid them.

Most patients that have cesareans notice a area of numbness above their incision that can last for months or even a year.  This is because there are several nerve cutaneous nerve branches that are often violated during a Pfanenstiel entry (the preferred method for a cesarean delivery.)  These nerves can be injured in two different parts of the entry.  During the extension of the fascial incision laterally, the anterior cutaneous branch of the iliohypogastric is in the strike zone, and if the incision is low enough, the ilioinguinal nerve is also in danger.  During the separation of the fascia from the rectus midline, the anterior branch of iliohypogastric is again in danger, but this time as a vertical band that goes from the belly of the rectus to the underside of the fascia.  Similarly, the cutaneous branch of T12 is in danger, but closer to the midline.

The non-surgeon audience may be horrified that these structures get damaged during a cesarean, but the surgeons know that small cutaneous nerves are often severed in surgical entry despite the best of intentions.  That said, understanding the anatomy allows one to avoid them with greater frequency.  For example, note how the anterior branch of iliohypogastric runs between the fascia of the external and internal obliques before it perforates the rectus fascia, and that it is running at the interface between the internal oblique muscle and its aponeurosis.  Even though the fascia may be opened wide enough to get to this nerve, with a little care one can visualize it and avoid it.  Similarly, if one takes care as the rectus fascia is dissected up off the midline one can preserve the neurovascular bundles of the distal iliohypogastric and T12.  If all these nerves are preserved, there should be no postoperative incisional numbness.  Its doable more often than not if you try.

3. The path of the arcus tendineous fascia pelvis

Every OB/GYN knows that this part of the anatomy is pretty confusing, and that the magic of urogynecologists is that they really understand it.  This is one of those things that I just really had confused.   The arcus is actually the aponeurosis of the levator ani (puborectalis, pubococcygeus, and iliococcygeus) and the obturator internus muscle.  The levators travel down off the arcus around the rectum and back up to the other side, while obturator internus comes down off the inside of the pelvis, bounces off the backside of the arcus, and then down and out onto the femur.  Arcus is the center of the connection of three structures – the obturator internus and its fascia, the levator ani, and the anterior vaginal wall.  Understanding this finally led me to better understand the idea of a paravaginal defect, which is that it is a separation of the anterior vaginal wall off the arcus.  Effectively, if there is a paravaginal defect, one could put a hole through the lateral vaginal mucosa and put a finger through that hole until they hit the pelvic peritoneum.  With the paravaginal connection to the arcus intact, a lateral dissection would run into the arcus before it got to the pelvic peritoneum.  We can also see how the arcus ends in the ischial spine, giving one a better idea of where the end of the paravaginal defect will be.  Oh, you urogyns get to have so much fun.

4. The medial umbilical ligament ends at the anterior hypogastric artery

Every OB/GYN dreads the day that they have so much bleeding at a cesarean that they have to consider a hypogastric artery ligation.  Some have even decided ahead of time they they aren’t comfortable enough with the retroperitoneal anatomy to do it, and if they are in that situation they are going to do a hysterectomy.   I was kind of in between until recently, but dissecting a pelvis really got me back into a comfort zone that would let me do that hypogastric dissection if I needed to.  One of the big pieces was the realization that the medial umbilical ligament running down the anterior abdominal wall is going to end in the hypogastric artery.    This structure is actually an obliterated umbilical artery, and in fetal life it coursed with blood, running deoxygenated blood from the fetus to the placenta.   Before this vessel obliterates, it gives off one or more superior vesicle artery branches to the bladder.

Ultimately this means you can open the retroperitoneum deep to the round ligament, identify the median umbilical on the anterior wall, and bluntly dissect with your fingers down this path to the hypogastric.  From there, one only needs to get distal to the posterior division and ligate, passing ones ligature lateral to medial.  Understanding this anatomy and being able to keep intraperitoneal bleeding out of the dissection, the hypogastric ligation is quite doable.  Its one of those things that most OB/GYNs think of as extremely difficult, but that people who know how to do it don’t think is so hard.  As the adage goes, “everything’s hard until you know how to do it”

5. Don’t F with the pancreas

Ok, I already knew this.  But looking at the amount of connections the pancreas has to its surrounding structures, it absolutely blows my mind that there are general surgeons that can remove this structure.  The uterus just has a few vessels and ligaments attached to it.  Easy peasy.   But the pancreas is serious invested in everything around it.   It has almost no free borders, many arterial connections, is attached to vascular supply of the spleen, and has a duct system that cannot be disconnected from the duodenum without removing a bunch of of the bowel and rerouting to restore some semblance of function (A Whipple).

Knowing this, it makes the following video all the more impressive.  In fact I can hardly believe it happening right in front of me.   A Whipple through a laparoscope, with every anastamosis hand sewn and intracorporeally tied.  Incredible.

Academic OB/GYN Podcast Episode 26 – Journals for October 2010

Coverage requests get rejected when the requested service does not fit within an insurance company’s initial guidelines for approval.  This happens for a number of reasons, but usually it comes down to poor documentation or inappropriate care, or in some cases care that is appropriate but can’t be supported in the literature.  When a denial occurs, the physician or patient has several opportunities to appeal this decision.  The first appeal is about proving that your case does meet the insurance guidelines and that it was incorrectly rejected.  The second appeal is about proving that the request should be accepted outside of the coverage guidelines.  Sometimes there is another level that looks at whether the care is experimental.

The job of the reviewer is to look at the data provided and determine if the case meets insurance guidelines, or if the review is outside of guidelines, to determine if the requested service is supported by peer reviewed medical literature.  The reviewer is a physician with a busy practice, and only has a certain amount of time that can be dedicated to the review (usually less than an hour.)  Anything you can do to make this job easier will help your appeal be successful, and anything you do to make this job harder may hurt your appeal.

The following are things you should do or not do when writing an appeal to maximize your chance of approval.  In fact, if you nail these things, every appeal will be accepted.

THINGS YOU SHOULD DO
Write a summary letter - The reviewer is trying to look through your medical records and figure out what you are trying to do.   If they have to look through piles of semi-illegible notes and try to put it all together, they may come up with the wrong idea.  It behooves you to write a letter that summarizes the care of the patient, including presenting symptoms, workup performed so far, previous treatments done and response to those treatments, current diagnosis, and what is planned.  Do not make the reviewer put this all together on their own.

Answer the phone! – If a peer reviewer calls you, for god sakes please answer the phone.  Tell your staff that they should get you for these calls.  The person calling you is a doctor who is probably trying to call you between patients.  They have a limited amount of time to turn the review over, and if they need information and can’t get it, you are going to be rejected.  You must assume that if a reviewer is trying to call you, they didn’t have enough information in the provided records to approve the case.  If the call doesn’t happen, the appeal is going to get rejected.

Be a good documenter - It goes without saying that if your notes are crap, its very tough to win an appeal with them.  If you aren’t a good documenter and are losing appeals, this is probably why.   This doesn’t mean you have to write a novel.  It just means you have to include important information and justify what you want to do.  “Patient has heavy bleeding for two years and has fibroids. Plan: hysterectomy” NO!  “46 year old with menorraghia and anemia for 2 years, 16 week size fibroids uterus.  We discussed various therapies including medical and conservative surgical options, and she would like a hysterectomy” – YES!  That’s all you have to say.  It is this reviewer’s sadness that too many physicians don’t take the time to write even this much.  Corollary: if you are appealing and realize your notes are crap, write a really good letter, which makes the notes unimportant.

Practice Evidence Based Medicine - If you are trying to do something that can’t be supported in evidence, its going to be hard to win an appeal.  A good example is a subcutaneous terbutaline pump.  Its nearly impossible to win an appeal for this, because the reviewer can’t quote any literature that would support an approval, even if the reviewer thinks they work.  The corollary to this is that if you are doing something that is somewhat controversial and are appealing a rejection, it really behooves you address that controversy in your appeal letter, preferably with peer reviewed sources to justify your point of view.  If you make a good sourced argument, there is little to keep the reviewer from just using your argument and your sources to approve the case.  This may seem onerous, but in reality it is a good thing to be doing anyway for your own doctorhood.   If something is getting rejected, and you sit down and try to justify it and find that you can’t, perhaps what you are doing wasn’t right in the first place.

Limit what you send in - It is far better to send in the 20 pieces of paper that justify your case than 200 pieces of paper that mostly consists of irrelevant documentation.  Include your letter, your clinical notes _about the condition at hand_, labs, and path and imaging reports.

THINGS YOU SHOULD NOT DO

Don’t be a jerk - My god, how many doctors don’t get this!  Some doctors think that by berating the reviewer they are going to get approved.  Oppositeland, people.  If a reviewer calls you, its because your chart didn’t have enough information to approve the case, or they didn’t understand what you are doing.  If the you get on the phone and decide to unload on the reviewer about what you thinks of the insurance company / the reviewer / the patient / how medicine is going to hell…  it really hurts the case.  The reviewer is a doc that is probably trying to fit this call between patients.  They just want the facts, doc.  In my experience, being berated by a doc doesn’t really affect the review directly, but it really gets in the way of getting the information.  “DO YOU WANT TO SEE MY PATIENT AND TELL ME I’M WRONG!!! IS THAT WHAT YOU WANT!!! TELL IT TO MY FACE!!”.  Not productive.

Check your ego at the door - And by this I mean, don’t assume that medical necessity is defined strictly by what you think is medically necessary.   I read so many appeal letters that say “Jill needs X because it is medically necessary for her condition.”   This is worthless.  The appeal is not a note from the doctor getting Jane out of work for the day.  If the fact that there exists a doctor that thinks that X is medically necessary were sufficient, nothing would ever get rejected and there would be no need for an appeals system.  Maybe some doctors would like this, but it is a recipe for a bankrupt medical system.

Insurance companies ration care.  Its what they do (see part 1.)  They do not assume that just because you think it is necessary that it actually is, and perhaps more imporant to understand, they do they allow reviewers to make arguments on that basis.  Your appeal letter must describe and defend your case.   Don’t take it personally, its just the way the appeals process works.

Don’t write illegibly - And if you do, type or dictate your notes.  A pile of illegible papers does not a good appeal make.

Don’t quit after one appeal - If you get rejected once but you really believe in the issue, appeal again.  Remember, its not until a second appeal that the case gets considered outside of insurance guidelines, or when something that could be considered experimental might get approved.  If you always quit after one attempt, lots of things that might get approved don’t.  Is this system designed to approve fewer things?  Maybe.   But if you want to win, you have to do it twice.    If you write a good appeal letter the first time, there is no reason you can’t just send in the same appeal again.  If what you want to do is a little grey, your justification of what you want to do may not even get considered until the second appeal, because the first review is just about guidelines.  A good example would be using a novel chemotherapeutic for recurrent ovarian cancer. If it doesn’t fit the guidelines (which are still pretty good documents – see part 1), it probably won’t go through on the first appeal.

Don’t have your patients write appeals - While patients write passionate appeal letters, they almost never have useful information in them.   The kinds of things that patients write have almost nothing to do with the appeals process.  The fact that they paid their premiums for years and are super pissed that X was not paid for is completely irrelevant.  The only thing a patient can do that is helpful is to describe the case better than it was described in the medical records.  If your records are good, this shouldn’t be an issue, and usually patients have a hard time describing the case in an objective way.  A patient can almost never actually defend the medical care, which is usually what is needed, because they don’t have the background to do it.

And if you really want to be a master of winning appeals, become a peer reviewer.  In the four years that I have been doing this, not only have I made extra money, but I have learned this system inside and out.  It has given me a better understanding of what it takes to really justify what one is doing, and in doing so has made me a better doctor.  I have a much better idea of what will go through and what will be scrutinized, and can explain those things to patients in a way that makes sense.  It has also forced me to keep up on the literature in my field, even in areas that I might not typically read in.

When good doctors become peer reviewers, they help the system work the way it should.  Maybe you should do it too!

One thing that many residents do not know is that there are more benefits to becoming a board certified physician than just that plaque on the wall.   One of these benefits is that ability to pick up a few extra hours of work here and there doing consulting for the multitude of companies that would like the opinion or expertise of a physician.

In some cases this consulting can be about products under development.  Sometimes it is reviewing the work that another physician has done, perhaps for a hospital quality care committee.  There is also work for some reviewing legal cases.   But probably the biggest area of this work is insurance work – usually in the area of appeals.

When I became board certified, I did a few google searches and ended up signing up with a number of insurance companies to become a third party peer reviewer.  Through this work, I have learned a huge amount about how insurance companies work, and actually developed a far greater respect for what they do than I had previously.   I have also learned the ins and outs of the insurance appeal system, which a third party reviewer is invariably involved in, and in doing so have gained a skill set that allows my insurance appeals to be invariably accepted.  For that reason, I recommend that every young physician review charts – if not for the money, for the education.

But for those who don’t, let me pass on some of the pearls I have gained from this work, that perhaps when your patients are being denied services you think they should have, you will have a better idea of how to have a successful appeal.

In this post, I am going to talk about how the system works and why things get rejected. In the next post, I will discuss a few things you can do to win appeals.

Any time an insurance company receives a claim, it goes through an automated process that determines if it will be automatically approved.  This is typically based on a comparison between what was requested and the ICD9 codes used to justify that request.  As long as these codes match and the service is not major, approval will likely happen right there.  In some cases, likely with more costly or rare services, the case will be manually compared with the written coverage guidelines for the patient’s plan.  In some cases records will have to be provided, which will be reviewed against plan guidelines.   If the case meets guidelines, based on the review of a (potentially non-physician) employee of the insurance or review company, it will be approved right away.

If something is rejected, there is now an opportunity for an appeal, initiated either by physician or patient.   In this process, the appealing provider provides notes that clearly document what was done (or is proposed to be done), usually with intention to prove that it was needed.  This is different than the initial gathering of documents, where usually one just provides medical records but doesn’t really do anything to otherwise justify the request.  These documents are now again compared to plan coverage provisions, to see if the case meets guidelines.  Usually this comparison will be done by a physician working for the insurance company, or third party reviewer at a contracted review company (like me.)  At this level of appeal, the question is whether or not the case meets the guidelines, not whether an exception to guideline should be made.  If the case does not meet guidelines, it will again get rejected.

If this second rejection occurs, the appealing party now has a opportunity for a second appeal.  In the second appeal, documents are again provided (or are re-reviewed), but now the possibility exists that the case might be considered outside of the standard guidelines.  This level of appeal is almost always done by a third party physician with expertise in the specific field at hand.   It is at this level of review that a therapy that is still experimental might be evaluated as still being medically necessary, and thus being covered despite a policy against coverage of experimental procedures and treatments (ie a novel chemotherapeutic regimen after traditional therapy has failed.) These reviews are usually done based on industry standard definitions of medical necessity or experimental/investigational (see appendix).  In this stage, the appeal documentation of the appealing physician is crucial, particularly if they provide a thoughtful letter justifying the request.

To some, this process seems ungainly and complicated, or even downright evil.  Physicians bristle at the idea that an insurance company would ever deign to tell them how to practice medicine, even with the help of a unbiased third party (like me.)  I have had these feelings myself at times – but these feelings are unjustified.

There is a near-unlimited amount of medical care that could potentially be delivered for patients in this country, but the amount of funds is relatively fixed.  As such, it is absolutely imperative that there is some system of rationing involved that will work towards using those limited funds where they will be most useful.  Weeding out requests for therapies that are medically unnecessary or unproven is part of that.  While it can be frustrating, we have given insurance companies this job.  We can argue that they shouldn’t make so much money doing it, but its hard to argue that it doesn’t need to be done.

Before I started doing this type of reviewing, I generally thought that insurance companies rejected payment for sport (and profit), with little justification or reason.   Now I realize that the system is actually quite just.  Basically, all that is required for something to get approved is that the therapy requested is reasonably within the standard of care and can be supported by current evidence.  In other words, it should be good medicine.   Occasionally appropriate therapy will have to go through the appeals process to get approved, but if what one is doing is appropriate, it will almost always get through.

I have been consistently impressed with the thoroughness and timeliness of insurance company guidelines, which read like well sourced peer reviewed review articles.  They are generally very up to date, and very well thought out, and often were written by experts in the field.

So why do things get rejected?  Here’s an ordered list.

1 – Poor documentation.  Of every 10 charts I review, 6 were rejected because the physician did not document what they were doing and why they were doing it.   When we are residents, we are taught to thoroughly document what we do, and the thought process involved.   Some doctors in private practice have gotten so far from this that their charts have almost no useful information in them.   If that chart is being used to justify an expensive therapy, there is almost certainly going to be a problem.  Physicians have to expect that someone else may read their chart in an effort to justify their actions.  If it doesn’t tell the story or is illegible, rejection is on the way.

2 – Bad medicine.  Of every 10 charts I review, in at least 3 the physician is asking for something that shouldn’t be done, such as a hysterectomy in a  30 year old woman with a normal uterus, without any real attempt to treat her conservatively.  The physician may  get mad about the case getting rejected, but in truth they are practicing bad medicine.  The insurance company is right to reject them.  My experience is that the level of anger that physicians experience in these cases is directly proportional to the bogosity of the treatment they are recommending.  Sometimes a physician requests something that he/she knows is bad, but the patient is requesting, and even writes “we’ll see if insurance will approve this”.  These almost always get rejected (for good reason), and the physician is usually happy to tell the patient that the evil insurance company won’t pay for what they want.  Insurance companies are happy to be the bad cop in these situations.  I have spoken to docs in this situation and heard a sigh of relief when I said that the case doesn’t meet the guidelines.

3 – Industry acceptance of something that cannot be supported in the literature.  Breast MRI is a great example.  Radiologists love to recommend a breast MRI when they have an ‘indeterminate’ mammogram, but this use of breast MRI cannot be supported in the literature, and may actually be harmful.  Doctors freak when the insurance company rejects these, but in truth these doctors are not familiar enough with the literature to realize that what they are asking for is experimental, and possibly harmful.  Another example would be something like compounded bioidentical hormones or salivary hormone testing.  Lots of people believe in them, yet there is no real literature to support their efficacy, safety, and usefulness.   This leads to appropriate insurance rejection, and failed appeals.

4 – Industry introduction of new technology that has yet to be adequately studied.  It is common for industry to try to get their new technology into the standard of care before a study can prove it to lack efficacy.  Short armed retropubic/obturator slings are a great example.  They were on the market for years before any data proved their efficacy, and we are now finding that they aren’t as good as longer ones (what a surprise!).  This is the kind of thing that an insurance company might reject, and rightly so.  MRI guided focused ultrasound for fibroids is another good example of this.  Its a new technology, and data to show comparable efficacy to traditional therapies just isn’t there, nor for cost effectiveness.

5 – Failure to attempt reasonable treatments that are less expensive prior to going to expensive treatments.  Docs hate this, but they really should try less expensive things first.  In most cases, generic drugs are as good as brand, and it does behoove use to spend less money when we can.  Trying some birth control pills for dysfunctional uterine bleeding prior to going to hysterectomy is not only cost effective, it is good medicine.  As docs in general are often not worrying too much about cost, insurance companies worry about it for us.  It is the job we have asked them to do when we decided to create the insurance system about 30 years ago (blame Nixon.)

In my time working with this stuff, I have been genuinely impressed with a consistent desire to cover evidence based and efficacious care from every insurance official I have spoken to.  While the company as a whole may be profit driven, the guidelines they use to ration care seem completely appropriate and up to date.  As physicians, there will be times that we are forced to justify what we do, but this should not be an undue burden.  Throughout residency we are forced to justify what we do, and it makes us better doctors.   Applying the same skills to creating a rational and well sourced argument for our actions continues to be necessary, and helps us to stay thoughtful and current.  Embrace the opportunity to put real words on paper that really describes the course of care.  It will make you a better doctor, and will get your therapies approved along the way.

In part 2 of this article, I will discuss how to successfully appeal an insurance rejection.  If you are practicing good medicine, its not hard to be successful.

APPENDIX

** Standard industry language for medical necessity

1. Supported by credible scientific evidence published in peer-reviewed medical literature and recognized by the relevant medical community.
2. Clinically appropriate in terms of type, frequency, extent, site, and duration, and considered effective for the condition in question.
3. Not primarily for the convenience of the patient or health care provider.
4. Not more costly than alternative services at least as likely to produce the desired result.

APPENDIX
** Standard industry language for experimental/investigational -

1. Does the requested service have final approval from the appropriate government regulatory bodies for this member’s particular condition (respond only if applicable)?
2. Is the requested service of proven benefit according to published peer-reviewed medical literature for the diagnosis or treatment of the member’s particular condition?\
3. Is the requested service generally recognized by the medical community as reflected in the published peer-reviewed medical literature as effective or appropriate for the member’s particular condition?

4. Is there proof as reflected in the published peer-reviewed medical literature that the requested service is at least as effective in improving health outcomes as the established alternatives for the member’s particular condition?

5.Is there demonstrated evidence as reflected in the published peer-reviewed medical literature that, over time, the requested service leads to improvement in health outcomes, for this member’s particular condition; i.e. the beneficial effects outweigh any harmful effects?

Academic OB/GYN Podcast Episode 25 – Journals for August and September 2010

Once a student becomes  a resident, things start to change.  As residents are physicians, they have the power to write orders and have them executed without anyone else approving of them.  In the beginning, this is a scary power for the resident, as they are terrified they will hurt someone.  At the same time, it a welcome reward after years of having to ask someone’s permission to do anything at all.

Beyond the ability to just write orders is the idea of resident autonomy.  Autonomy is more than just orders, it is the freedom a resident has to make judgements and act on those judgements without asking someone’s permission.  Autonomy is more complex than just orders, because there are many fewer rules that govern where the edge of autonomy lies, and because over time, that edge moves.   A resident that is very junior may be afforded very little autonomy, but as they become more senior they are expected to take more and more independent authority to make decisions, a transition that is gradually defined not by written rules but in slow changes in the hundreds of interactions with their attending physicians.  In the beginning, a resident could be criticized for being too autonomous, and later in their training, for not being autonomous enough!  They have a difficult job in this regard.

From the outside, some patients may feel that residents should be afforded no autonomy at all.  After all, they are not fully trained, why should they be allowed to execute their decisions without direct supervision?  While this makes sense at some point, it is a misunderstanding of what residency is.  Residency is not being a student doctor.  That’s being a medical student.  Residency is being an apprentice doctor.  Just like the blacksmith’s apprentice that is allowed to forge a sword unsupervised at times, the resident must practice medicine at times without direct supervision.  If residents are never allowed any autonomy, they will graduate board eligible in their field never having made any decisions on their own, making them wholly unprepared for the practice ahead.  If they are given too much autonomy before they are ready, they can be dangerous.

Understanding that too little autonomy can stunt a resident’s development, and too much can potentially lead to significant errors, and attending physician must continously evaluate each resident and do his or her best to figure out just how much autonomy can be given.  This may very well be the most difficult task an attending physician has.  As the adage says, the residents “needs enough rope to hang themselves, just not enough to hang the patient”.

From a resident’s perspective, this struggle for autonomy takes on a different perspective.  In many cases, it is a mixture of the joy of having the power to commit medicine without asking permission with a sense of fear that one might make a terrible mistake.  The answer to this struggle is always to seek supervision when there is any question of the appropriateness of a particular action.  Residents who are well grounded do this often and are appreciated for it.  Others fail to seek the right amount of supervision when they need it, which frustrates attendings, and through iteration of the supervision process leads to decreased autonomy for a period of time.

The typical path of resident autonomy is that of a sine wave.   Initially, a resident seeks supervision for appropriate issues.  Over time, they find more and more than the plans they propose are being approved.  As confidence grows, supervision is sought less and less.  Eventually, this lack of seeking supervision leads the resident to make an error.  The resident then gets yelled at and feels bad.  Confidence is crushed, and now the residents seeks supervision for every little move for a period of time.  The cycle now starts again.

This cycle is mirrored for the attending physician, who may allow more and more autonomy as a resident demonstrates more and more competence, until one day there is a problem, initiating a short period of yelling or other expression of consternation, followed by a period of decreased resident autonomy.  While increased resident autonomy may relieve the attending of some physical work, it also comes at the cost of increased vigilance, as one needs to expend great energy to make sure that things are going well even while allowing others to make decisions with less supervision.

And this is the nature of things, and it has worked for a long time in training to residents become autonomous physicians.

And so now we come to the yelling -

When residents make mistakes, sometimes they get yelled at.  In truth, it is usually more of verbal dressing down, but ‘being yelled at’ is common vernacular for any manner of such treatment.  Some residents complain about this, feeling that they are being treated badly, or are being unnecessarily made to feed bad or have hurt feelings.  And to this I have this to say -

Suck it up.   Residents have a choice to make, and that choice is between autonomy and supervision.  Any resident can completely eliminate any possibility of being yelled at by seeking supervision for anything they do.  While this is a fairy miserable way to train, at least no attending will be justified in taking them to task.  On the other hand, a resident can choose to do some things without asking permission, which after a certain amount of training is a far more satisfying (and efficient) way to go through residency.  BUT – any resident that chooses to do this (and almost all do), MUST accept that with this freedom comes the possibility that they may get taken to task for a mistake.  This is the price of their freedom.

But is it too much to ask that attending physician just always be nice and provide perfectly constructive criticism and never really get mad?  Yes is is.   Supervising residents is an emotionally taxing task.  The attending physician is ultimately responsible for everything the residents do, and in turn all of the medical care delivered under their supervision.  Attendings know that allowing resident autonomy will occasionally lead to an error, but to not allow it is to squelch resident growth, and create a job that is physically impossible to accomplish.  But what about the patients?  Does allowing this resident autonomy endanger them?   As long as it is done right, it does not.  Because there are so many checks and balances in the system, it is very difficult for any one person to make a mistake that injures a patient.  Medical errors that injure patients usually involve many people, not just one.   So giving the residents some rope is OK.  But it is stressful, and when residents make mistakes, they have to be redirected, and sometimes attendings aren’t super nice about it.

So to all the residents out there that are reading this, give your attendings a break.  The autonomy they give you is a gift that is difficult to give.  Choose to accept that gift, and you have to accept the criticisms that may come with it.  If you can’t take it, you can always choose to ask permission for everything.  But if you really want to learn, and to enjoy your residency, just grow some skin and get out there and do it.

Celebration is a fascinating place.  In some ways it is bizarre – assuming that one has never seen a town where every lawn is mowed on the same day, there is not a speck of flaking paint, the shrubbery is all perfectly trimmed, and everything is 50% more expensive than it should be.  But in other ways, it is an amazing accomplishment – a community truly in the image of the Disney idea.  A community Onstage.  Particularly at its hospital.

Celebration Health is in some ways like every other community hospital:  about 110 beds, operating rooms, a cafeteria, an ER, and hospital wards.   But in other ways, it is nothing like other hospitals – because its a Disney hospital.

Anyone that has ever been to a Disney themepark has probably noticed that everything they see around them is just about perfect.  From the lack of rubbish to the perfectly painted surfaces to the overestimated wait times in the lines, Disney creates a world that seems too good to be true.  We know it isn’t real, but the effect is good enough that for the time we are in the park disbelief is suspended and we and our families just enjoy the experience.
At the same time, Disney parks have a backside to them.  For every Snow White white there is a seamstress wearing normal clothes working in some back area.   For every Space Mountain ride attendant dressed in a perfectly creased, slightly but not too futuristic outfit, there is a normally dressed and normally greasy mechanic that makes sure the ride is running safely.

Disney has a name for this dichotomy – “Onstage” vs “Backstage”.    Onstage is anything a “guest” might ever see, whereas Backstage is everything they will never see.   And they do mean never.   Backstage is completely inaccessible to the guests, and for that reason the illusion is never broken.  Even behind the scenes tours are really just illusions of Backstage, because they’re really Onstage experiences.

Onstage means more than just a physical location.  Its also an attitude taught to everyone that works there.   When any employee walks Onstage they are taught that they are no longer an employee, they are a Castmember, critical parts of creating the experience of Onstage.  Whatever is going on in their lives, for those hours they are part of the illusion – more than anything else, it is that illusion that makes Disney what it is.

While Celebration Health is not technically a Disney Property, it is clearly designed that way.  To start, the hospital looks nothing like a hospital.  If anything, it looks like some kind of performing arts center.  When one walks in the front door (Onstage) you are greeted not by a normal hospital lobby, but by a huge atrium with windows on nearly all sides.  The entire front of the hospital is walled with huge windows, bringing natural light into every space.  One one end of major front hall are outpatient offices, but they don’t really look like offices.  Not only are the materials much better than anything one would see in most hospitals, but the waiting areas outside the offices feel more like what one would see outside a french bistro than your typical hospital based doctor’s office.

At the end of the hall is an entrance to a massive gym and spa, that is open to the public of Celebration, and serves as the community’s health club, and at the same time the place for all patient rehabilitation and physical therapy.  The idea behind this is twofold.   First, the spa brings the entire community to the hospital on a regular basis, emphasizing its role as a place of health rather than a place of sickness.  Second, it serves as the hospital’s physical therapy and rehabilitation center, comingling patients having directed therapy with community members doing there regular excercise.  The entire idea is to make patients and guests feel like they are not in a hospital – and it works.

Beyond the patio like outpatient waiting areas and the huge health center, the Onstage front of Celebration Health has one huge difference from every other hospital I have ever been in – a complete lack of sick patients.   In fact, Onstage I did not see a single patient in a wheelchair or a single gurney.  I thought that maybe it was just the time I came in, but my guide assured me that it was by design.   It turns out that the entire hospital was designed such that the Onstage experience rarely had anyone sick in it.   For example, all the elevators that area likely to be ridden by visitors (“Guests”) open up to Onstage areas, and while they feel spacious, they conveniently are of just the right size such that the hospital’s gurneys do not fit in them.  So that experience of going up the elevator with a guy on a ventilator?  Not at Celebration Health.  And hallways that have doors opening up into radiology reading rooms and big red flashing signs that say “X-RAY IN USE”?  Not at Celebration Health, at least not Onstage.

Backstage at Celebration Health is not quite is different as other hospitals, except that its just really nice.   But it also has a few features that show its Disney style.

One of the things that Disney always does is to try to force its Guests to do the things that will make the environment great, without ever letting them know they are being directed.  They also always try to underpromise and overdeliver, like the waiting time estimates at the rides, where 40 minutes estimated wait times are actually about 25 minutes.  This type of social engineering is in full effect Backstage at Celebration Health.

For example, patients room don’t look like patient rooms, despite the fact that they have everything in them that is needed for emergencies.   For example, oxygen, suction, and IV poles are all hidden behind trick headboards, such that they are invisible when they are not needed.   Monitoring equipment is similarly hidden, except when immediate use requires.  They also engineer the way the halls in the wards feel, by putting comfortable open waiting areas all over the place.   When a patient needs private time with their physician or nurse, any family that leaves the room is naturally going to go sit down in one of these areas rather than loiter in the halls. Unlike the labor and delivery in my hospital, these halls are always clear, even without any explicit policy about family standing around in the halls.

Radiology, unlike the relatively dark and dingy radiology departments one sees in most hospitals, is a trip.  Like many areas in the hospital, has a theme, and in this case it is a Trip to the Beach.   The entire area is decorated as such – and not a few pictures of sailboats and some beachy posters decorated, but Disney decorated.  From the ocean smell coming through the ventilation to the barium served in beach martini glasses, its a complete illusion.  The patients are even given beach tee shirts and board shorts instead of gowns when they go in for their exams.   The little workup rooms have beach chairs and chaise lounges instead of gurneys.

Nuclear Medicine is themed after Going to the Movies.  The lobby feels like the lobby of a theater, and is dominated by a large screen similar to what one might get if they spent a hundred grand on a home theater system – complete with a popcorn maker.  Since nuclear medicine studies often take hours to do, patients are encouraged to watch a movie while they are waiting, and even to finish watching it after their study is completed if they like.

While these themes in some ways seem a little hokey, in a lot of ways they make the relatively anxious experience of having radiologic studies pretty fun.  And lest that seem kind of pointless, Celebration Health has the lowest refusal rate for MRIs in the country, with less than 2% of the patients leaving without their study being completed.

At the same time, the hospital has some of the most advanced surgical suites in the world, including quite a bit of what I am interested in – DaVinci robots.  They have six of them in use, and more than that in their training center.

****

So with all of this fancy stuff, one would think that Celebration Health would be inaccessible to most patients.  I was suprised to find out that this wasn’t the case – they take all insurance including Medicaid.  And because they provide an value added experience to their services, they are very popular.   So popular, in fact, that they area tripling their bed count over the next 10 years.

While Celebration Health is in some ways an odd hospital, it is a great thing to see.   Like the Patch Adams’ Gesundheit Institute (still to be built), it is a testament to the idea that there is more than one way to build a hospital.

I was super impressed with my visit there, and want to thank Dr Arnold Advincula and his partners and staff at their Center for Advanced Gynecologic Surgery for showing me around.   So impressed, that maybe I’ll end up working there.

But the people doing this are not physicians – they are the healers of various cultures.  Throughout the world there are practitioners who claim to divinate illness through feeling a person’s pulse for several minutes.  This is particularly prominent in Asia.  They describe using the rate, strength, and character of the pulse to make all manner of determinations.   This practice is fairly laughable to physicians, as it seems crazy to get so much meaning from feeling someone’s pulse.

But is this so much different than EFM?  In fact its quite similar.   Given that traditional healers are probably hit and miss with their diagnoses, its no surprise that EFM technology is similarly lacking.

Beyond the fundamental issues of divining information from a single vital sign, EFM also suffers from great interobserver variability.  Just as a different mystic might think different things from feeling one’s pulse, different practitioners may interpret the same strip differently.  In test performance terms, EFM has a small Kappa, where the larger a Kappa is the more the observers agree.

Not only do different practitioners interpret strips differently, they describe them differently as well.   Some people call a late deceleration purely based on position relative to the contraction, while some consider a variable looking decel post contraction to still be a variable.  Some people infer meaning from the variability during a deceleration, while others think this is inappropriate.

Recognizing these issues, the NICHD issued a new set of guidelines in 2008, defining how we should all describe our strips.   Finally, we have a clear direction on how we should interpret strips!  Or do we?

The NICHD guidelines categorizes strips into three categories, which basically boil down to:

Category I – strip’s fine

Category III – strip’s really really bad

Category II – everything else.

More specifically the categories (importantly, in the same order) are:

Category I:

Rate: 110-160
Variability: moderate
Late or variable decelerations: absent
Early decelerations: present or absent
Accelerations: present or absent.

Category III:

Variability: absent
and at least one of:
Late decelerations: present and recurrent
Variable decelerations: present and recurrent
Fetal bradycardia

OR

Sinusoidal pattern.

Category II:  everything that is not Cat 1 or Cat 3:

Rate: bradycardia but without absent variability  OR tachycardia
Variability: Minimal, absent but without decelerations, or marked variability
Accelerations: Absence of induced accelerations after fetal stimulation
Decelerations:
Recurrent variable decelerations accompanied by minimal or moderate variability
Prolonged deceleration >= 2 minutes but < 10 minutes
Recurrent late decelerations with moderate baseline variability
Variable decelerations with other characteristics, such as slow return to baseline, “overshoots” and “shoulders”

So how does this help us?

On the good side, it does help us to be more clear on our documentation, and helps us to be in more agreement on how we are going to categorize strips.   We should all be able to agree what is a Cat 1, Cat 2, or Cat 3.

But other that that, its not terrible helpful.   This is because Cat 1 is such a good strip that we all would have called it good, and Cat 3 is such a horrible strip that we all would have done an urgent cesarean delivery.   The problems is that everything else is Cat 2.

Just about any strip can be Cat 2, from a baby that is just sleeping to one that is having recurrent hypoxic events that just haven’t decompensated yet.   Ultimately, Cat 2 is just about any strip that we would disagree about.  Some Cat 2s are clearly benign, and some are clearly precursors to Cat 3 strips, but most are somewhere in the middle.

So while the NICHD criteria makes it easier to document, it doesn’t really tell us what to do, because all the indecision is in that big category II.

So is there a better future to our electronic Indian Healer machine?

Probably, but its more likely to be a new technology than a new way to interpret what we have now.     This new technology may be STAN monitoring, or ST segment interpretation of the fetal EKG.   Like a full EKG, STAN not only looks at the heart rate but also at the movement of the electricity waveform in the fetal heart.  STAN does computer analysis of the ST segment, in the same way that we look at ST segments in adults with concern for heart attacks.   So far, the technology has been very promising in early trials in Europe, and in one study the center that implemented the technology cesarean rates for abnormal strips had decreased cesarean deliveries and a decreased number of infants born with cord pH < 7.05.  However, the jury is still out, and there are a number of issues to still work out.

Like all things, the US is far behind in getting this technology.  For better or for worse, the FDA requires a great deal more data than is required in Europe before this can be put into play.   If STAN works out in Europe, likely we will see it in use in the US in the next 3-7 years.  If STAN is a bust, as fetal pulse oximetry was in the 2000s, we may never see it here.

Either way, we’ll just keep reading the fetal heart rate tea leaves.

Academic OB/GYN Podcast Episode 24 – The Preemie Primer and Reproductive Infectious Disease Part 2

One thing I have learned by being active in the obstetrics and birthing blogosphere is that there are a whole lot of people out there that think that most cesarean deliveries are unnecessary. While most of them will admit that some cesareans are medically required, its pretty rare that the ones that have had a cesarean looks at their cesarean that way.

A popular term bandied about is “Unnecesarean”, a catchy little phrase that implies the underlying belief that most cesareans are unnecessary. Frequently, commenters state that they had a cesarean that they didn’t want, and that at some point later in their life someone let them in on the secret that their cesarean wasn’t really necessary, and this is completely accepted as fact. In some cases, people believe that they were robbed of the vaginal birth they were destined to have, or even that they were somehow raped by the their physician.

Frankly, I am tired of it.

Anyone that has followed my writing knows that I am not a big fan of cesareans, and believe that a fair number of the cesareans we do might be avoided. I have discussed the relationship between sensitivity and specificity for identifying abnormal labor and heart rate tracings, and how where we put our thresholds will effect how many cesareans we do. I have discussed how the Friedman curve is too strict, and that to hold women to this curve is to place the label of abnormal on a huge number of women who area laboring normally, potentially leading to avoidable cesareans. I have even talked about how VBAC access needs to improve, and that we should be encouraging more women to attempt VBAC.

That all being said, I have never seen an unnecessary cesarean delivery(*). In fact, no one has.

What some members of the blogosphere likes to call “unnecessary” cesareans are misnamed. They are misnamed because the word necessary implies something that cannot be applied to this situation. As was noted in the introduction, necessary means something that is essential, indispensable, or requisite. Specifically to cesarean, necessary would imply that the procedure is required in order to have a favorable outcome for the fetus or mother. The problem with the term is that we don’t know what would have happened if we hadn’t done the cesarean, and as such we have no idea if the cesarean was necessary. If fact, the true necessity of any cesarean can never be determined, as we will never know what the outcome of the alternative decision would have been. As such, it is completely unjustified to label any particular cesarean unnecessary, and with apology to Jill, the term “Unnecesarean” isn’t fair.

So assuming that there are some cesareans going on that might have been avoided, how should we talk about them? How about using the correct terminology: indicated vs unindicated. When something is indicated, it means that given the current state of practice and knowledge, the proposed procedure should be done. Unindicated means that it shouldn’t be done. Unlike “necessary”, these terms can be used prospectively. They do not claim that the choice they lead to is absolutely the correct choice – they only mean that with the best information we have at the time, it is the most appropriate course of action.

So here are indications for cesarean:

• nonreasurring fetal heart rate tracing remote from delivery. In most cases, this means a NICHD Category III tracing that cannot be resolved through medical treatment or expedious vaginal delivery.
• An elective repeat cesarean in a woman who after appropriate counseling chooses one.
• Arrest of dilatation
• Arrest of descent
• Previous uterine surgery with high risk of uterine rupture
• Maternal pelvic reconstructive surgery with a desire to preserve the repair
• Malpresentation of a singleton pregnancy
• Malpresentation of a subsequent baby in a multiple pregnancy, when breech delivery of the second twin is not feasible.
• Maternal request

Are these indications absolute?  Of course not. They just mean that when these indications are present, we think that a cesarean in in the best interest of mother and/or baby. Does that mean that to not do the cesarean would absolutely injure either party? No. It just means that the risk/benefit of pursuing vaginal delivery is no longer in favor of it, to the best of our knowledge.

So lets not call cesareans unnecessary. Lets just say that maybe a particular cesarean was not indicated. We can all have a great intellectual discussion about what it means to truly have an arrest of dilatation, or whether or not a breech singleton can be safely delivered vaginally. We can argue about that risk/benefit analysis, and even retrospectively argue that the risk/benefit of a particular situation was prospectively misinterpreted. We should pursue these arguments, because dialogue helps us to develop our knowledge. But arguing that a cesarean was unnecessary because one believes that they were going to go on to have a healthy vaginal delivery without it is fallacious. It implies something that just isn’t true, and is ultimately unfair to all parties involved.

* At least not by my definition of the word unnecessary.  As the commenters have pointed out, it depends on how you use the word (added 7/28/10)

Academic OB/GYN Podcast Episode 23 – Journals for June and July 2010

The point of the article was to look at a large retrospective cohort of emergent cesarean deliveries, stratify them by vertical or transverse skin incision, and then look at operative times and patient and fetal outcomes.  This dataset was drawn from recorded data from many different centers, as part of the MFMU Network system of studies.

The study looked at 3,525 emergent cesarean deliveries performed in 1999 and 2000 at the study centers.  Of these deliveries 2,498 (70.9%) were done with transverse abdominal incisions and 1,027 (29.1%) were done with vertical incisions.

The two groups were similar in age, but differed in BMI, with patients having vertical incisions being more likely to have larger BMIs (31.5 v 32.4, p = 0.02).  There was also significant differences in rare between groups, with vertical incision patients being more likely to be Hispanic than transverse incision patients (Transverse – white 37%  AA 47%  Hispanic 11%; Vertical 16% white 41% AA  Hispanic 40%, p < 0.001.)  Transverse incision patients were also more likely to be nulliparous (49% vs 43% p = 0.002.)

The groups also differed in number with previous cesarean deliveries, with the vertical incision group being somewhat more likely to have had previous cesareans.

Surgeries with vertical incisions were done more quickly than transverse incisions, with median incision-to-delivery intervals of 5.5 minutes with transverse versus only 3.5 for vertical for primaries, and 6.8 minutes vs 5.1 minutes for repeat cesareans.   The incision to closure interval was longer for vertical incisions, 50 minutes vs 46 minutes in transverse incisions in primary sections, 67 vs 56 minutes in repeat cesareans.

Contrary to what one might think, there was no differences in maternal injury with the two groups, with intraoperative injury occurring in 0.7% of each group.  Postpartum endometritis was more common in the vertical group 15% vs 11%, p = 0.006.  Wound infection, hematoma, ileus were similar between groups.  The vertical group had more need for transfusion, 7% vs 5%, p = 0.01.

Low umbilical artery pH < 7.0 was  more common in the vertical group 10% vs 7%, p = 0.02.  Frequency of hypoxic encephalopathy was greater in the vertical group 3% vs 1%, p < 0.001. Babies born via vertical incision were more likely to need intubation in the delivery room, 17% vs 13% p = 0.001. There were no differences in  need for infant CPR, neonatal death, or 5 minute apgar scores (though there was as trend towards lower apgars for the vertical group, 5% vs 4% p = 0.06.)

OK – so what does this all mean?

This is what I get out of it:

1. In a very large set of data, gathered at teaching centers where residents are doing the operating, surgeons seem to be able to get babies out a bit quicker with vertical incisions than with transverse incisions.

2. Contrary to what I would have thought, there did not seem to be a greater number of maternal injuries with the vertical incisions.  This is surprising to me as the worst bladder injury I have seen came from an overzealous vertical incision during a crash cesarean.  Perhaps I am just mentally scarred from one event.

3. The fetal outcomes data is not worthwhile.  The data is quite biased by the indication for the crash cesareans.   People already have a pre-existing thought that a vertical incision can lead to a quicker delivery, and so it makes sense that they would have done more verticals in more severe cases where it was felt that every second counted.  As such, it is not surprising that the vertical incision babies had worse gases, were more likely to be intubated, and had a higher frequency of neonatal encephalopathy.  To me, this says nothing about the effect of the incision, especially given that the group with the worse outcomes had quicker delivery times.

But here’s the thing:  It seems very odd to me to aggregate some huge dataset to try to describe something that is so individual from surgeon to surgeon.  Each surgeon has a pretty good idea of what they can do quicker, and a large data set that describes thousands of different surgeons doesn’t really imply anything about each individual.   I can say without question that in a primary section I can reliably deliver an infant through a transverse skin incision in less than 60 seconds.  Perhaps I could do it a little faster with a vertical, but to me those few seconds don’t seem worth it.  Does this mean that everybody else should do the same thing as I?  Of course not – we are all different surgeons and some people might be able to do a vertical much quicker than they could do a transverse incision.   There are factors that might change our mind for each patient as well, such as previous surgeries, or even previous vertical incisions.  But ultimately, each surgeon knows more about their individual performance than any paper can tell them about themselves.  And for that reason, I don’t find this data all that helpful.

To me, the thing that will be quickest is usually what one knows the best.   Most gynecologists have done hundreds if not thousands of transverse entries, and if need be they can do them very quickly.  Most gynecologists, especially residents (who were described in this case), have not done as many vertical incisions, and likely can accelerate a technique they already know better than they can try to rush something they are not as comfortable with.  That being said, the data did show than on the average (or on the median), verticals were faster.  Go figure.

So what do you all do?

Comparison of transverse and vertical skin incision for emergency cesarean delivery.   Wylie BJ, Gilbert S, Landon MB, Spong CY, Rouse DJ, Leveno KJ, Varner MW, Caritis SN, Meis PJ, Wapner RJ, Sorokin Y, Miodovnik M, O’Sullivan MJ, Sibai BM, Langer O; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units Network (MFMU). Obstet Gynecol. 2010 Jun;115(6):1134-40.