Surgery

Surgeons writing on KevinMD about the craft and the culture of surgery: training and who holds the knife, the operating room and its checklists, outcomes and whether the public should see them, the robot and now AI, women surgeons, and what it is like to be sued over an outcome rather than a decision. Three maintained records draw on this archive: Surgeons and surgery: what surgeons say, in their own words, Residency: what residents and attendings say, in their own words, and Medical malpractice: what physicians say, in their own words.

Preventing doctors from practicing at the top of their license

Karen S. Sibert, MD

Physician

May 29, 2014

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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 …

Managing unhappy patients after surgery

Sid Schwab, MD

Physician

May 29, 2014

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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Managing unhappy patients after surgery

A life lesson in the operating room

Starla Fitch, MD

Physician

May 26, 2014

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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A life lesson in the operating room

Ignaz Semmelweis and the lessons of fear and medical innovation

Alberto Hazan, MD

Physician

May 25, 2014

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 …

Rebutting a physician’s plea to declare independence

Dr. Saurabh Jha

Health Policy

May 22, 2014

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 (it has …

Can appendicitis be managed without surgery?

Skeptical Scalpel, MD

Conditions and Diseases

May 20, 2014

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 …

For better or worse, doctors are human

Sid Schwab, MD

Physician

May 15, 2014

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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For better or worse, doctors are human

Why the quality measures used in health care are deeply flawed

Karen S. Sibert, MD

Physician

May 12, 2014

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 …

Are today’s newly graduated residents ready to practice medicine?

Christopher Johnson, MD

Medical Education

May 8, 2014

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 …

Sitting with a patient: The least practiced communication skill

Howard Luks, MD

Physician

May 3, 2014

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 …

The problems with making oral board recertification universal

Skeptical Scalpel, MD

Medical Education

May 1, 2014

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 …

Technology and confidence: Working with surgeons in Kenya

Bruce Campbell, MD

Physician

April 18, 2014

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 …

Why should practicing medicine be compared to any other occupation?

Skeptical Scalpel, MD

Physician

April 15, 2014

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 …

A patient nearly died to save him $1110

Robert Gray, MD

Physician

April 15, 2014

Where I’m from, you can have someone killed for $5000. I will do it for $1110. I’m a hand surgeon.

I practice (or practiced, by the time you read this) in an area that is what we often refer to as “underserved.” Rather, the area isn’t, but the people I treat are. I work in a large urban referral center that has a very high proportion of Medicaid as well as …

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A patient nearly died to save him $1110

Post-operative check

Shara Yurkiewicz

Medical Education

April 14, 2014

It’s okay that you don’t remember me. My name is Shara, and I’m part of the surgical team. I’m checking to see how you’re doing after your surgery.

Do you know where you are right now?

Actually, you’re in the hospital. You had surgery a few hours ago, for a broken hip. You used to be able to walk before you broke it, so it was important to fix it as soon …

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Post-operative check

Why the future of health care can be found in the Cayman Islands

Robert Pearl, MD

Health Policy

April 9, 2014

The Cayman Islands are nestled in the Caribbean Sea some 430 miles south of Miami. The three-island cluster is known for its inviting coral-sand beaches, laid-back island culture and tax-free status.

While it lures many tourists and big banks, it’s not the first place you’d expect to find the future of American health care. That may change soon.

Last month, I flew to the Caymans to moderate an afternoon-long panel on delivering …

What goes through a surgeon’s mind after a complication

Sid Schwab, MD

Physician

April 8, 2014

One of the hardest things about being a surgeon is the inevitability of complications. It’s true for any doctor; but with surgery, it’s as if they are lit in neon and given a soundtrack. At least to me. Aiming for perfection (as do we all) and beating myself up (more than healthier people) when I miss the mark, I found bad outcomes of nearly any magnitude deeply disturbing. The big …

Physician report cards make no difference in referral patterns

David B. Nash, MD, MBA

Health Policy

April 6, 2014

Back in 1986, the Health Care Financing Administration launched the brave new era of quality reporting in this country by releasing “report cards” that detailed hospital-specific, risk-adjusted mortality rates for coronary artery bypass graft (CABG) surgery.

Since that time, the number and type of publicly reported quality outcomes has grown exponentially with the goal of helping patients make informed decisions when selecting doctors, thereby driving quality improvement by doctors and hospitals.

Has …

Is nerve block anesthesia better for surgery?

Susan G. Curling, MD

Conditions and Diseases

April 6, 2014

A guest column by the American Society of Anesthesiologists, exclusive to KevinMD.com.

More needles … who wants that? You probably do! Nerve block anesthesia, also called regional anesthesia, requires localized numbing and additional needle sticks, but it has many advantages. Primarily, it can have a profound effect on your pain after surgery, and improve your rehabilitation and decrease …

Surgery

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