But it wasn’t always that way.  As a resident, I had a habit of finding out just how brown a white coat can be.  It was hard to tell for me, as the change was very gradual.  But a few years into a residency, I could stand next to someone with a truly white coat and the difference was, well, ghastly.  But now it is different, and while I have to give my AA credit, in truth the credit goes to my third year REI attending, Dr John Schnorr.

I started my REI rotation early in my third year.  Effectively, this meant that the two white coats I had been given at the beginning of my internship were somewhere between yellow and poo.  I walked into the Taj Mahal office, as REI offices tend to be, and presented myself to Dr Schnorr.  He gave me a funny look that I didn’t quite pick up on.  He then proceeded to go over all the rules and responsibilities for the rotation, as would be typical for the orientation.

We had a great first day.  At the end of it, I could tell he was a little uncomfortable about something.  He hesitated, then he came out with it. 

“Do you get your coats laundered?”

This was a very polite Southern way of saying  “Your coat looks like shit”

“Uh… no” 

As if I had to say it.

But then he said the greatest thing.

“Just throw your coats in our laundry bin…. our people will launder them for you.”

So I did, and was forever changed.  When I got that first laundered coat, all bleach white and starched, I never looked back.

So residents – take your coat to the cleaners from time to time… its only seven bucks, but it looks like a million.

Per the statement “If most women undergoing hysterectomy for benign conditions each year chose a vaginal or laparoscopic procedure—rather than TAH or robotic hysterectomy—performed by skilled and experienced surgeons, pain and recovery times would be reduced while providing dramatic savings to our health care system. Conversely, an estimated $960 million to $1.9 billion will be added to the health care system if robotic surgery is used for all hysterectomies each year.”

This morning a large cadre of minimally invasive surgeons released a statement of response, accusing ACOG of not being supportive of minimally invasive techniques and misinterpreting the data on robotics.

Here’s my take on the issue:

I am a surgeon that focuses on minimally invasive techniques and gets a lot of referrals for difficult cases.  I’ve been doing robotics for about two years now, and have done enough cases (over 100) that I feel like I can make a pretty objective assessment of its utility in what I do.

As Intuitive Surgical will be happy to tell anyone that listens, robotics has quite a few advantages.

The ability of the robot to move with wrist-like motions allows laparoscopic maneuvers that are difficult if not impossible with straight stick laparoscopy. This allows one to do surgery in very small delicate areas that are much harder to address traditionally.

The vision allowed by the robot is far superior to traditional laparoscopic vision, for 4 reasons: 1) image fidelity is better than most traditional equipment 2) 3D vision allows one to see relationships between structures far better 3) the screen is so close to your face that it fills your whole field of view, creating an immersive “I am the robot” experience and 4) you control the camera and don’t have to depend on your assistant to show you what you want to see.

The ability to pass energy through both primary instruments creates a surgical flow that is difficult to match with traditional instruments. The fact that one can cauterize every surface that is cut tends to lead to bloodless surgery. This can be done traditionally as well, but its a bit more difficult to achieve the same result.

Long laparoscopic surgeries require a surgeon to stand in a way that is eventually painful to the back and legs. Robotics is quite comfortable for the surgeon, as he is sitting in a ergonomically superior position.

All of this together allows one to tackle much more difficult cases than one might have tackled with straight stick, such as stage IV endometriosis with obliterated cul-de-sacs, huge uteruses, or cases that require extensive suturing. As such, robotics has the potential to turn cases that otherwise would have been abdominal cases into laparoscopic cases.

There is potential to do surgeries through a single site using the robot, which is a cosmetic advantage over multiple port surgeries.

And here is the downside:

The robot is a tremendously complicated piece of equipment that requires a very skilled team to operate efficiently.  Without that team, the use of the robot adds a huge layer of complexity to a surgery.  With that team, it still slows things down.   While one may be able to do the operative portion faster, the setup time for the room and and early part of the surgery is significant and will slow most cases down overall.   A ideal team may mitigate this completely, but such a team I have never seen in an academic center.

The robot is extremely expensive, both to buy and to maintain.  It costs between 1.5 and 2 million dollars, and several hundred thousand dollars a year for a service contract.

One usually needs more port sites to do robotics than traditional laparoscopy.

The robot breaks down from time to time, sometimes in the middle of a surgery.  While these problems inevitably get resolved, it is a remarkably unpleasant experience for all involved.  A two million dollar machine with a two hundred thousand dollar a year service contract should not break down at all.

The robot is sold and serviced by a company that does not have an objective view of their own technology.  They aggressively market their product directly to patients, and even more so to the robot trained surgeons.  They do not seem to see the reality of their product, which is that it is very useful for a subset of laparoscopic surgeries and a hinderance to another subset.  They prefer to think about it as an improvement to all laparoscopic surgery, which it clearly is not.

——-

My feeling is that ACOG’s statement is a response to the tremendous proliferation of robotics throughout benign gynecologic surgery without a clear evidence base to suggest that this level of use can be justified.  I agree with that part.   A lot of surgeons are using robotics to complete cases that could have been done via traditional laparoscopy or vaginal surgery, which is not right.   The entire point of the robot was to convert open surgeries to laparoscopic surgeries, but in benign gynecology it is being used for far more than that.  This drives up costs at minimal to no benefit to patients.

Some argue that robotics allows a surgeon who is not a particularly skilled laparoscopist to do more difficult laparoscopic surgeries.  I think this is true, but at the same time I am not sure that is a good thing.  Surgery is done best when it is done by people that do a lot of it.  If one does a lot of laparoscopy, one gets good at doing a lot of things with or without the robot.  At that point many mild to moderate difficulty laparoscopic surgery is most easily done without the robot.

Right now my hospital has two robots at one center and is about to buy a second at our other site.  The drive to have multiple robots is because of demand for time on the robot.  While this seems appropriate, I have to ask myself whether these marginal cases that justify a second machine actually cases that require robotics to be completed laparoscopically.   If not, then the cost is not very justifiable.

I love working with the robot, and get a real feeling of accomplishment when I am able to complete a robotic case that I know I never would have been able to do through traditional methods without a laparotomy.  I have done many of those.  But having done over 100 robotic cases, a 10 week size hysterectomy done robotically does not give me that sense of accomplishment.  I get that sense of accomplishment by doing that case vaginally or via traditional laparoscopic surgery, being out of the room in two hours and with far less expensive toys.

And then there are days when it isn’t going that way.  The anatomy is distorted and confusing.  There is bleeding that continuously distort your view.  Your assistants are struggling.  You are quickly becoming unhappy and want nothing more than for the surgery to be over and the patient to be well.

I have had many of both kinds of days.  Over the years I have been operating, I have identified a few things that tend to have happened on the latter kind of days, and hope to pass a few of those things on.   So if you find yourself struggling with laparoscopy, consider whether one of these things is going on.

1) If there is one key to a laparoscopic hysterectomy, it is proper placement of the uterine manipulator and associated obturator ring.  Whether you use the KOH or V-Care to do your TLHs, it is absolutely imperative that it is placed correctly and the ring is pushed all the way up against the cervix.   If you are struggling with the anatomy, there is a good chance the problems is that the ring is not where it should be.   When it is in correctly, it should bulge up between the insertions of the uterosacral ligaments posteriorly, and should be prominent anteriorly.  If it isn’t, it probably isn’t in right.

There are many ways the ring can be in wrong, or come out of position during the case.  With a KOH, the uterus can be pulled off the manipulator, leading the ring to no longer be up against the cervix.  This is particularly true if you are using the robot and your tenaculum is pulling up on the uterus.  It is very easy to pull so hard that you pull the uterus off the manipulator, particularly if the person on the manipulator is not careful to keep pushing.  With the new RUMI-KOH ARCH, it is possible for your assistant to push so hard than they push the slide off the arch, thus allowing the ring to become loose in the vagina and no longer surround the cervix.  One can also forget to remove the tenaculum from the cervix before pushing the manipulator in, which will keep the ring from seating correctly in the upper vagina.

If your assistant pushes hard enough on a V-Care and doesn’t have the white thumbscrew down hard, the shaft will come loose and perforate the uterus.  While this isn’t the worst thing, as you are taking out the uterus anyway, it now means that the ring is no longer pushed hard against the cervix.  So if this happens, make sure your assistant pulls the shaft back, secures the ring against the cervix, then screws that thumbscrew down hard this time.

Bottom line – if you are struggling, check that manipulator.  There’s a good chance it isn’t in right.

2) If the anatomy is confusing, make sure your camera is not rotated.  Cameras can rotate very slowly, so much so that may not notice it happening.  Over time your camera may be 90 degrees off horizon without you even noticing.  The only thing you notice is that everything seems wrong, and you can’t figure out why.   This can really happen when using a zero degree scope on the robot, which tends to rotate as you move the camera laterally.  I even tell my assistant to watch for rotation and point out to me if the horizon is getting off.  Its easy to tell from the assistant screen, but for the surgeon it can be very difficult to tell that rotation has occurred, despite the horizon indicator right in front of you.   Personally I think that the ability for a zero degree scope on the robot to rotate is a design flaw.  There is really no reason why you would want to rotate a zero degree scope, as it doesn’t change what is seen, it just rotates the screen, which just disorients the surgeon.  No upside, all downside.  The robot shouldn’t even allow it.  Or sound an alarm maybe.  Just sayin, Intuitive….

3) The robot gives you an incredible range of motion, far greater than you have via traditional laparoscopy – but don’t overestimate its abilities.  There are some angles you still will not be able to reach, either because of port placement or because the uterus is just getting in the way of your arms.   For example,if you are doing a robotic TLH and the uterus is huge, you may not be able to pronate the bipolar left hand enough to get the uterine artery right at the internal os where you should.  You may be tempted to push the uterus over with the arm and pronate the hand over as much as you can, burning the vessel out a little wider than you usually would.  Don’t do this.  You are asking for a thermal injury to the right ureter.  You will get away with it most of the time, but occasionally you won’t.  In this situation, just switch arms and bring the bipolar if from the right.  You will be able to get the uterine exactly where you want to.

4) When doing a robot hysterectomy on a big uterus, you have to be mellow with the third arm tenaculum.  It can really help you, but if you overuse it it can be hurt you more than it helps.  On one hand, it moves the uterus and improves exposure.  On the other hand, every time you move it you make more holes in the uterus, each one of which is going to bleed and obscure your visualization.   The bleeding is not clinically significant, but if you have enough of it you won’t be able to see well enough.  You will then be unhappy for the rest of the case, and may even end up needing to open because you can’t see.  So use the person on the manipulator first.  Or use the prograsp on the third arm instead of the tenaculum.   It doesn’t work as well, but it doesn’t tear up the uterus as much.

5) Maybe your ports are not placed well.  Bad port placement can ruin your day.  Do your best to optimize port placement from the beginning… but if you are struggling because your ports are not optimal, remember you can always place another port or move a port.  It is way better to have another 5 mm skin incision than to operate through ports that aren’t allowing you to operate efficiently or safely.

On the robot, make sure accessory ports are lateral enough.  A right sided accessory port has to be at least 5 and preferably 10 cm lateral to the rightmost robot port.  Preferably it is also inferior to the robot port.  If your accessory port is too superior relative to the right arm port, your assistant will be unable to access the right side of the pelvis because the handle of their instrument will clash with the robot arm.

One trick – you can actually put the robot arm ports far more medial than you would think.  The robot specs says they should be 10 cm lateral to the camera port, but since the camera doesn’t move laterally very much and the arms will always lean outwards instead of inwards, ports placed more medially will actually work fine.   The upside of this placement is that the accessory ports will have more room to move without being blocked by the robot arm, both internally and externally.  The only exception would be if you are doing a lymph node dissection, as medial arm placement may prevent the arms from reaching lateral enough to get obturator nodes.

6) If you are feeling really bad about a case as it is going on, you should consider opening.  That really bad feeling is your brain telling you something is going wrong.  It is your Spidey Sense.  Don’t ignore it.  Figure out what is wrong.  If you can’t, open.  Proceeding laparoscopically without being clear about the anatomy is a recipe for a complication.  There are far worse things than converting to laparotomy.  Your patient will be much more forgiving of an unexpected scar than an unexpected ureteral stent.

If you are a surgeon, let me know your tips!  If you aren’t, you probably have no idea what I am talking about.  That’s OK.   Its just doctors talking shop.

I grew up in Oregon, where no one ever wears a tie, and no one ever dresses up.  When it came to interview for medical school, I truly had no appropriate clothes.  I consulted my father, who suggested the outfit you see here:

Note the tie that is missing the material in the back to allow the tie to line up.  No problem there.. just use a paperclip.  Really.  While my father was trying to lead me in the right direction, little did I know this was the same father who fifteen years later would wear a tee shirt to my wedding.

So basically, I walk into medical school interviews looking like this:

Note the rather ill-fitting sport jacket, Mathlete regulation length tie, and unmatched pants that are too small.  Ignore the pleats, they were actually in fashion then.

But how was I to know? I was a computer science major and a total geek.  This was dressing up big time.  I was fully expecting that when I went to interview I would be looking sharp.

Not so much.  When I arrived to my first interview at Baylor College of Medicine I found myself terribly underdressed compared to all the Brooks Brothers suits sitting next to me.   While I looked maybe all right, they looked good.  And more importantly, they all looked the same, and I looked different.

And perhaps that was my mistake, in that this was what I was actually going for.   I knew that a suit was the right thing to wear, but I had a rebellious streak in me that said ‘screw that! I don’t need to buy and wear a suit!  What matters is my brain and what I have accomplished!”  I also had a bloodstream that ran with Oregon blood, where most people respond to a person in a suit with the comment “so who died?” And so I proudly wore clothes that looked right out the closet of my University of Oregon math professor Schlomo Libeskind, who inspired my love for higher mathematics and modeled wearing beltless polyester pants up to his nipples.

Fortunately, I survived the process and indeed was accepted to medical school, though not as many as I thought I should have given my academic record.  As I was looking back in this during residency interviews, I decided that this time was not going to make the same mistake twice!  I was going to wear a suit!

And I chose this:

My mother had found it at a thrift store and extolled its beauty.  It was in fact a suit, and it was in fact from a fine Italian brand.  Furthermore, it was a suit that when new was quite expensive.

But what it was not was a suit that fit me.  It was way too big then, just as it is today.  Furthermore, being found at a thrift store, it was in fashion twenty years earlier, not at the time it was being worn.  It was also brown, which still set me aside from all the other blue and black suits that interviewed for residency with me.

I did get some “nice suit” comments followed by furtive glances to the side or floor.  As a person who now plays a lot of poker, I now realize that those comments were purely ironic.   I also heard “bless your heart” in the South a number of times, which by the third year of my residency in Charleston,SC I knew was actually an expression of kind condescension.

Fortunately, despite this suit, I got into the residency I wanted.  Apparently being the rare highly qualified male applicant to an OB/GYN residency was worth more than the ill-fitting suit cost me.   And at the end of my residency, the chairman took me to a fine men’s store with the invitation “Son… they’re having a sale.. and you need a nice suit for your faculty interview.”  ”But I have a suit!”  ”Son… you’re going to a be a faculty physician… you need more than one suit.”

* * * * *

At the time, I didn’t think this dressing up business was important, but now as a  faculty member I realize that it was.  There is no doubt that on the days that I interviewed in those clothes, the faculty were laughing about me at the applicant review sessions.   I have no doubt that at my medical school interview they were saying “how about that Fogelson guy with that sportcoat and no belt?”  And at my residency interview I’m sure it was “how ’bout that huge brown suit guy!”.  Of course, does that really hurt a person?  As a person who interviews and ranks applicants, I can say that it almost certainly does.  An applicant has only a few minutes to convince someone that on a very subjective level that they deserve to be in the medical school or residency.   In the end, you hope that your interviewer is talking about how smart and accomplished you are, and not about how you were dressed.   It seems so superficial, but that doesn’t make it not true.

So the truth is this:  When you interview for a job in medicine, your clothes should be invisible.  They should be well fitting, relatively conservative, and ordinary.  They should be neither particularly bad nor the height of fashion, leaving your interviewers nothing to comment on other that what really matters – the person wearing the clothes.

When I interviewed for medical school, I interviewed at 8 schools and was accepted at one.  I had great MCAT scores and way more medical experience than could be expected of any applicant.  If I had been dressed like this I probably would have gotten into a lot more schools:

]]> http://academicobgyn.com/2012/11/11/what-not-to-wear-med-school-interview-edition/feed/ 11 34.027609 -81.035067 34.027609 -81.035067 Nicholas Fogelson IMG_0365 IMG_0366 IMG_0368 IMG_0370 IMG_0374 http://academicobgyn.com/2012/10/17/book-review-baby-weight/ http://academicobgyn.com/2012/10/17/book-review-baby-weight/#comments Thu, 18 Oct 2012 01:49:31 +0000 Nicholas Fogelson http://academicobgyn.com/?p=1220 ]]>

Quite some time ago Micky Morrison, a physical therapist and author, send me a copy of her book Baby Weight.   I promised to give it a prompt review, and then promptly put it on my desk for about six months.  As the fans that are still aware of Academic OB/GYN know, the blog and I have been pretty quiet.  I did a fellowship, and now am building a new practice.

But now I have finally got to the book.  And it is BABY WEIGHT!

Ok… less dramatically, its called Baby Weight, by Micky Morrison, PT, ICPFE.  Ms Morrison is a women’s health physical therapist who has focused on therapy for women during and after pregnancy for the last 15 years. She practices both in Guatemala and in Florida, where she teaches courses on prenatal and postnatal exercise.

After reading the book, I am happy to say that Baby Weight is an excellent book for any mother hoping to keep fit during her pregnancy and return to form after her birth.  The book starts with coverage of typical changes in the maternal body during the pregnancy and puerperium.  It then goes into theory on appropriate diet and exercise during and after pregnancy.

The exercises are presented under the label “CoreMama”, which to the non-physical therapist OB/GYN appears to be mostly yoga, with the weight of baby added in for added resistance in some cases.  In other words, its is very good stuff to be doing for one’s core and flexibility, and it also keeps a mother interacting with her spawn in a very fun and productive way.

I have no doubt that if one followed the exercise program described in Baby Weight, one would be quickly on their way to improved fitness and flexibility both during and after pregnancy.  I congratulate Ms Morrison on this publication, which no doubt will be a help to the women who read the book.  Having delved too deeply into surgery to ever recover, I sadly no longer practice obstetrics.  But if I did,  I would have no reservation recommending this book to my pregnant patients.  The important thing is exercise, and the material presented in Baby Weight serves to motivate women towards that goal.

Baby Weight is available at Amazon for $16.95 in physical edition, or $9.99 for Kindle.

As a physician, I occasionally encounter patients who feel like they know a great deal more about medicine than they actually do.  Sometimes its a family member of a patient.     Occasionally they are right, in that they have a particular cache of knowledge about a particular condition that surpasses me.  In those circumstances, such patients or family members are able to augment their care.   Far more often, however, their expertise is far less than they think.

For example, I once cared for someone who clearly needed a blood transfusion.  A family member was in strong opposition, mostly because that family member was Jehovah Witness, even though the patient was not.   That family member presented all kinds of information about alternatives to blood transfusion, and clearly right from a pamphlet they had read.  At a fundamental level, said family member believed that there was always an alternative to blood transfusion and it was never actually necessary.

I was benefited in this situation by seeing in my patient’s face that she found her own family member to be a little overbearing and ridiculous.  Armed by that knowledge, I smiled and said “So lets be real here… you don’t have any real background in what you are talking about, right?”  I got a smile back, so I continued “so let me explain what everything you just told me actually means, and then why it doesn’t apply in this situation.”  Ultimately the family member was satisfied, and the blood continued to run.

This situation was an example of a common rule of knowledge, and a person’s self perception of that knowledge.   That rule is this:

The less you know, the more you think you know.

And the corollary:

The more you know, the more you realize how little you know.

The family member had read a pamphlet from the church on why the do not accept blood, and all the things that can be done to prevent blood transfusion.  So having read that, but having no real knowledge to give that information context, she developed a very inflated concept of her knowledge.

This idea has been shown among college students as well.   In a psychology experiment, students are asked to take a test on a subject.  Before they take said test, they are asked to self assess how much they know about said topic.  The results invariably come out showing this:

People that know nothing realize they know nothing.

People that know just a little think they know a great deal.

People that have a medium amount of knowledge tend to know their knowledge is medium.

People that have a high amount of knowledge believe they are average to below average.

And perhaps in the perfect inverse, those that have extreme knowledge realize they have extreme knowledge.

So why is this?  I have a theory.

I think that we assess our own knowledge by comparing what we actually know to what we believe is knowable.   If we know everything that we think is knowable, then by our own assessment we are expert.  If we know what we know but also know that there is an incredible amount of information out there that we do not know, then we realize that we know very little.

The nature of education is such that we are exposed to a tremendous amount of potential knowledge, but actually only learn a subset of that knowledge.  In fact, I would estimate that for every quanta of knowledge that we gain, we become aware of perhaps ten times as many quanta that we do not actually gain.  For example, as a physician I have significant mastery of the area in which I specialize, but through the course of reaching that mastery I have been exposed to orders of magnitude more information over which I did not attain mastery.  Therefore, as we learn, our ratio of knowledge to our awareness of potential knowledge is constantly decreasing, and thus our assessment of our own expertise is actually falling as we become more expert.

Sometimes this inverse relationship goes in cycles.  I experienced this myself over the course of my medical education.  While in college, I studied as an Emergency Medical Technician, and eventually reached the middle grade of EMT-Intermediate.  I worked in the emergency department for several years during that time, and indeed picked up a tremendous amount of medical information through that experience.  To my great self-embarrassment, however, I can honestly say that it occurred to me at that time that if there had been no emergency physician present, I could have run that emergency department.   I now know, however, that at that time in my life I knew almost nothing.  My mind at that time was filled with a lot of little facts and little relationships, but I had no real idea how those facts connected together.   While I might have been able to deal with certain situations, I had no way to deal with a new situation or work out something complex.  I simply lacked the education to realize how little I actually knew

Upon entering medical school, it took me about 24 hours to figure this out.  I was overwhelmed with potential knowledge, and once again felt completely ignorant.  But over the four years of medical school, my self assessment again started to rise.  I had learned a tremendous amount about a wide variety of medical topics, and had started to mine the depths of my view of the medical world.  I was again an expert.

Then I became an intern, and now faced with the depths of my specialty, which previously I had only learned at a superficial level, once again I realized I knew very little.  By the time I was a chief resident, full of knowledge but lacking ultimate responsibility, I was pretty sure of my self once again.

As a young attending, I was pretty sure I could handle anything that came my way.  And I did indeed have substantial expertise.  But by six years later, continuing to grow and learn, I knew I didn’t know enough, and that I wasn’t as good a surgeon as I wanted to be.  This ultimately led me to fellowship, where I not only learned but again expanded my awareness of what I did not know.

And now, with four years of medical school, four years of residency, six years of practice, and a year of fellowship, I have a lot of expertise.  But I’m also aware of how much there is out there that I don’t understand.

But this is good.  It keeps me reading, and hopefully keeps me humble, which some may said would be difficult.  And I have no doubt that in ten years I will be able to look back on my current self and muse on how little I actually knew, and how I thought I knew so much.

And so, to the lady that wants to teach me all about blood transfusion from the pamphlet her church gave her, I can only laugh.    I too once thought I knew it all, but it was only because I knew almost nothing.

****

To those who have not experienced the wonder that is Game of Thrones, both in book and television form, Jon Snow was a man who grew up in the North of Westeros, and per his ancestry was descendent of the original people of The North.  Upon actually coming north of The Wall, he meets a woman who had lived there her entire life.   She constantly reminds him that he only knows enough about The North to think he knows far more than he actually does.

This video demonstrates techniques for resecting infiltrating endometriosis, including dissection of bilateral ureters and pararectal spaces.

For consultation with Dr Fogelson please call Emory University at (404) 778-4416
Copyright 2012 Nicholas Fogelson and http://www.academicobgyn.com

This video shows a particularly difficult robotic hysterectomy, complicated by severe inflammatory adhesive disease of the left paravesical space. This case demonstrates retroperitoneal anatomy and key strategies for dealing with complicated hysterectomies.

For consultation with Dr Fogelson please call Emory University at (404) 778-4416
Copyright 2012 Nicholas Fogelson and http://www.academicobgyn.com

These are signs that your manuscript may not be fit for publication:

1) Your manuscript has been rejected so many times that the impact factor of the journal your are now submitting to is lower than the p value of your results.

2)  You were just accepted for publication, but the editors have asked that prior to publication the manuscript be translated into Urdu.

3) Your last rejection letter included a suggestion that your manuscript be changed from a description of a randomized controlled trial to an comedic editorial.

4) You receive a solicitation for publication by The Journal of Irreproducible Results

5) You are now submitting to a journal that is peer reviewed by chimpanzees.

6) They have rejected your manuscript for insufficient banana content.

7) Instead of a form letter thanking your for your effort and desire to publish, the editors write you to tell you that your submissions are no longer welcome.

8) Unless they include bananas.

9) You are considering submitting  to Cat Fancy.

10) You have decided that it’s far easier to publish via blog post.

There’s always Southern Medical Journal.

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!