Better outcomes and lower costs: The perioperative surgical homeWhether it’s a knee replacement avoided for years or an urgent life-saving tumor removal, when the decision for surgery occurs, too often the patient begins a journey into a complex system of fragmented medical care. Perioperative care, which generally refers to the three phases of surgery -- preoperative, intraoperative and postoperative -- can be variable and fragmented. ...

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When I graduated from my residency, far from my current professional home, I wanted to write a book called How Not to Get Yelled At in the Operating Room. Or How to Clear the Fear from Your OR. I had these titles in mind because I struggled so much during my intern year. It was a tough year, full of intense patient care and sleep deprivation, but the challenge that I most wanted help ...

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The Institute of Medicine in 2010 famously recommended that nurses should be encouraged to practice “to the full extent of their education and training.” Often, you’ll hear people advocate that every health care worker should “practice at the top of their license.” What this concept is supposed to mean, I think, is that anyone with clinical skills should use them effectively and not spend time on tasks that can be ...

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The idea behind surgery is a really simple one: You come to me with a specific problem, I fix it, you go away happy. And when you come back, you're still happy. What's so wrong with that? If I wanted to be miserable, I'd have gone into primary care. When a surgeon screws up, his/her role is clear: Admit it, make it better, or as good as possible, and stick with ...

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Recently, there was an issue in my O.R. No, the surgery went well. The patient was healthy and tolerated the procedure just fine. And, yes, we had the proper equipment and it all functioned perfectly. This was another kind of issue, something that I had not encountered before. It turned out to be a life lesson. My team and I were getting started in the O.R., for a fairly routine day. ...

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The man who saved more lives than any other physician (in the history of humanity combined) died in a mental institution -- unrecognized and shunned by the medical community. He was beaten by guards and died a miserable death. Dr. Ignaz Semmelweis was a Hungarian obstetrician practicing in the mid-1800s, years before Louis Pasteur came up with his germ theory and Joseph Lister popularized hand washing. While working as an assistant ...

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Writing in the Wall Street Journal, Daniel F. Craviotto Jr. an orthopedist, made a plea to physicians to declare independence from third parties and emancipate themselves from servitude to payers, mandates and electronic health records (EHR). As rants go, this was a first class rant. But its effect was that of a Charles de Gaulle’s whisper to Vichy France rather than a Churchillian oratory at the finest hour. The article went viral ...

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Two recent papers have added more fuel to the debate about whether appendicitis can be managed without surgery. The first paper is a prospective observational study from Italy involving 159 patients over the age of 14 who were thought to have uncomplicated appendicitis. Nonoperative management with oral antibiotics was planned for all of the patients. Nonoperative management failed within 7 days in 19 (11.9%) patients, all of whom underwent immediate surgery. Appendicitis ...

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Speaking only for myself (but guessing I'm not alone), I can say when a patient develops post-op problems, there's a strong tendency to deny it: not to deny there's something wrong; not to dismiss the patient's concerns or symptoms. Just to grasp first at the less dire set of possible explanations. Maybe it's just the flu, constipation, drug reaction. That sort of thing. It's not about blowing it off -- ...

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Nobody stands up to argue against quality and value in health care. You might as well argue against motherhood, or puppies. Yet many physicians are inherently skeptical of definitions of “quality” that are imposed from above, whether by outside evaluators like The Joint Commission, or (worse) by the government. There’s good reason for skepticism. Some of the “evidence” behind “evidence-based medicine” has turned out to be flawed, tainted by financial conflict ...

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