Today I had the displeasure of sitting in judgment before a modern inquisition at one of the hospitals I attend. Although the grand inquisitor lacked the trappings of a monsignor or bishop, and without a physical executioner in the room, I was subjected to round after round of questions regarding my apparent disregard for system wide medical and post surgical protocols. Such protocols have been adopted by CMS (which oversees Medicare) and a large amount of money is tied to their proper implementation.
There are protocols pertaining to prevention of venous thromboembolism (VTE), antibiotic use in surgical patients, removal of urinary catheters along with a few others which rarely are an issue for me. The principal point of concern for the Inquisitors was my use (or apparent lack of use) of pharmacologic agents for VTE prophylaxis. Specifically, I had not used Lovenox in 3 patients who had undergone major surgical procedures.
One of the patients had a re-do open hiatal hernia repair with a tiny nick in the spleen, another was an elderly lady with a complex medical history and carcinoma of the colon who underwent a laparoscopic right colon resection and the third had exploratory laparotomy for a small bowel perforation with generalized peritonitis and systemic sepsis four days after laparoscopic hysterectomy. In each of these cases I determined that there was more than the usual risk for bleeding and that anticoagulation, even with low dose Lovenox, increased this risk. Each patient was treated with sequential compression devices (SCDs) and none developed a deep venous thrombosis (DVT) or any other complication.
Before going before the inquisition I reviewed some of the literature on VTE prophylaxis in the general surgery patient. The incidence of DVT in this population is reported to be in the range of 6-7% without any prophylaxis. Using sequential compression devices alone reduces the incidence to about 3% and pharmacologic prophylaxis with subcutaneous Lovenox, heparin or something similar reduces it to around 1%. The tradeoff with the anticoagulants is an increased incidence of bleeding complications. In each of the three cases cited I made a medical decision to accept a slightly higher risk of developing a DVT while minimizing the possibility of post-operative bleeding.
At this point I should point out that I cannot remember the last time I had a patient develop a DVT. My standard approach to DVT prevention is to use sequential compression devices on nearly all my patients intraoperatively and post operatively. Pharmacologic agents are used whenever the risk is acceptable. Aggressive early ambulation is also employed. The last DVT I can recall was in a patient who had an uneventful laparoscopic cholecystectomy with a surgery time of about thirty minutes, discharge on the same day as the procedure, but readmission five days later with a DVT which involved the superficial femoral vein, but did not extend to the common femoral or iliac veins. This patient would not have needed any VTE prophylaxis under the current protocol, although he was treated with SCD’s during surgery.
Armed with my research I entered the arena to face a grim panel of inquisitors. Memories of my fraternity initiation passed through my mind as I took my seat near the head table.
“Do you have anything to say about the cases under review before judgment is passed?” the grand inquisitor queried. I must add that the “committee” had reviewed the cases under question the previous month, in my absence (I was unable to go to the meeting because I was in surgery). It was only after I protested their arbitrary ratings, particularly a level 4 (worst rating possible) for the patient with peritonitis and small bowel perforation, that the chairman of the committee invited me to address the eminent council.
“Yes, your eminence” I started. “I take great exception to your scoring, particularly on the first case …” I then went through each case and explained my reasoning behind the medical decisions which were made.
“You are living dangerously,” the grand inquisitor admonished.
“You’re careening down the highway out of control and will undoubtedly crash,” counseled another inquisitor. “Patients must have Lovenox or they are doomed … doomed.”
“It is heresy and blasphemy,” shouted the grand inquisitor, pounding his fist on the table and tearing his clothes. (Not really, but it would not have surprised me if these words had been uttered.)
I don’t know what the outcome of this inquisition will be. I’m sure a certified letter will arrive in the near future and I will be commanded to do 10 hours of penance by taking some sort of CME in surgical care improvement project (SCIP) and write “I will use Lovenox” a thousand times on a blackboard as part of SCIP detention.
But should it be that way? Shouldn’t I, as surgeon on a case, be the best individual to decide the risks and benefits of each therapeutic intervention, particularly in the immediate postoperative time period? It should come down to judgment, weighing the risk of bleeding relative to the risk of DVT or pulmonary embolus for each particular patient.
“Which would you rather have, bleeding or pulmonary embolus?” was one of the questions I was asked.
Of course, the answer is neither. But, it was presented as if it had to be one or the other, a flawed statement according to the laws of logic, but that is a whole different subject.
And, if my judgment regarding the risks of different therapies is not necessary, then why do my Medical consultants constantly write orders such as “Lovenox 40 mg SQ daily, if OK with Dr. Gelber?”
And, in the bigger picture, why am I chastised for attending to a very ill, septic, complicated patient on a Saturday afternoon, operating on her, and saving her life?
I have nothing against pharmacologic anticoagulants. The committee cited three cases out of hundreds of surgeries I had performed at that facility over the months. The cases “fell out”. All three were fairly complex cases. Certainly, in the myriad other operations I have performed I have ordered Lovenox when appropriate.
I know the answer to the questions I raise above. The answer is money. These “core measures” are tied to Medicare reimbursement. If the hospital is not compliant then it loses money. Thus, the nursing staff lives in terror lest one of them forget to contact the doctor to have him or her comply. Excellent nurses have been fired for failure to make such calls; three strikes and you’re out. Pharmacists have taken it upon themselves to discontinue antibiotics in septic patients because they are “SCIP patients.” I know of two such incidents which occurred in a span of 2 weeks, both patients suffering.
And I am called before the inquisition board to explain my heresy. Welcome to modern medicine.
Only ten years until I can retire.