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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As everyone knows, residents are now restricted to working 80 hours per week. One of the lesser known side effects of this work hours limitation is the drastic loss of educational conference time. Since at least one third of the residents must now go home after morning rounds, afternoon conferences are no longer possible. Most residency programs now devote part of at least one morning per week to dedicated educational time. JAMA ...

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A newly minted physician, one who has just graduated from medical school, is not yet ready (or licensed) to practice medicine. The next phase in medical training is called residency, a 3 to 5 year span of time during which the new doctor is given teaching, supervision, and increasingly allowed to function independently in his or her chosen specialty. Since 2003 residents have been limited to working 80 hours per week, averaged over ...

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In a voice confident and ringing with anticipation, Mr. A explained with meticulous detail how he determined which approach shot to hit to the second green on the Black Course at Bethpage State Park. Only ten minutes earlier, when we first met, Mr. A had been weary, his face drawn, and his speech so quiet that the sound of the aortic balloon pump keeping him alive made it nearly impossible to ...

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A loyal reader, who agrees with me that we may be teaching and testing medical students and residents the wrong way, asks why aren't all board recertification examinations given orally. She correctly asserts that oral examinations are better because they assess how people think rather than how much they have memorized. Here's why it would be difficult to do. The initial surgery board exam is given in two parts. First a written ...

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Confidence is contagious. So is lack of confidence. -Vince Lombardi “So, can you leave this here with us?" I was part of a group of U.S. surgeons traveling to Eldoret, Kenya, seeing patients and helping the Kenyan ENT surgeons learn surgical techniques. Our two week mission allowed us to work across-the-table from Kenyan colleagues, discussing surgical approaches, demonstrating techniques, and reviewing all aspects of surgical care. “I have never seen such a thing!” my ...

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A while ago, Atul Gawande, the noted surgeon-author, wrote a long piece in the New Yorker on why health care should look to a restaurant called the Cheesecake Factory for some guidance on how to standardize things. This was met with some derision by a number of physicians who pointed out, among other things, that the food at the Cheesecake Factory is not great and is loaded with calories. But I ...

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