What to do with abnormal PSA results in a young man

A 45-year-old man in excellent health with no family history of prostate cancer had a screening PSA done three years ago which was in the range of 4.0 ng/mL. He has been followed by a urologist, and the test was repeated several times without much change.

In June of this year, his PSA was 4.6 and the free PSA was 0.6 for a ratio of 0.13. He was given a course of antibiotics for presumed prostatitis, and repeat testing a month later showed a PSA of 3.8 with a free PSA of 0.5. Because the PSA was less than 4, a ratio was not calculated.

The patient obtained copies of the reports. The from June one states the following: "When total PSA is in the range of 4.0-10.0 ng/mL, a free PSA/total PSA ratio of less than or equal to 0.10 indicates a 49% to 65% risk of prostate cancer depending on age. A free PSA/total PSA ratio of greater than 0.25 indicates a 9% to 16% risk of prostate cancer depending on age." It does not comment on the significance of a ratio of 0.13, which I have looked up. The cancer risk is in the area of 20%-25%. However, no source gave estimates for men under the age of 50.

On examination, his urologist can feel no nodules. He has recommended that the patient undergo an MRI of the prostate.

Stating that an MRI is not indicated in a man of his age with his history, the patients insurance company will not pay for the test and suggested a trans-rectal ultrasound. The urologist advised the patient not to have an ultrasound due to his age and the potential for complications. A hospital quoted him an out-of-pocket price of $2500 for the MRI.

The urologist has told him that random biopsies may not be accurate and there is a risk of complications.

When he had his first PSA done three years ago, I had expressed surprise and wondered why it had been offered to him. The patient said his internist told him he should have the test.

He is concerned about these recent results and has asked me for advice which I am not qualified to give.

What would you advise?

Follow-up August 6, 2014

Numerous urologists responded on Twitter with more than 60 tweets about this post. Suggestions for the next step were as follows: trans-rectal ultrasound (TRUS) and biopsy as mentioned by Dr. Cooperberg below; going ahead with the MRI; repeating the PSA in 3 months; go for a second opinion by a recognized expert in prostate cancer.

One urologist emailed me to point out that even if the patient has cancer, it is probably not an aggressive type because his PSA has not risen in 3 years.

Another urologist gave me the name of an expert in the patients geographic area. 

The patient has already scheduled an appointment for a second opinion.

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How To Do Forum Post At Microworkers

I have posted an article about Microworkers few days ago. There I explained inside and out of that website. Here all jobs are very easy but some people find difficulty to do forum post. Many people post thread in forum and submit the link to get paid. But after that, there job is declined. Because admin of that forum has removed your thread before you get approved. In this article we will see step by step how to do forum post at Microworkers. This article also teaches you how to create backlink.

So you have entered into your account and saw available jobs. Now select one of the jobs by clicking it.

Now you can see the Job details. Read well. I am now writing job details for you as an example.

Job details:

What was expected?

Important:
This job is different from many other forum posting jobs. You cant just post a new thread with your existing account from forums you are familiar with. I only accept comment from existing relevant topic.
1. Go to http://www.itgot2be.com/aditional-instructions/ (Password: microworkers)

2. Learn about our services and check the additional instructions

3. Find a forum thread relating to the keyword shown at http://www.itgot2be.com/aditional-instructions/ "2. About the post"

Important:
- The forum must be in English and PR2+ 
- If there is already a comment about our service in the same thread, go and find another post.
- Make sure you know what anchor text is and how to make anchor text in a forum.

4. Reply with a 30 words+ positive comment in a current relevant thread

Notes:
- The comment should include one or more keywords shown at http://www.itgot2be.com/aditional-instructions/ "4. Keywords to be included.". Use one of the keywords as anchor text and make a clickable link to our website.
- Do not start a new thread.
- Do not comment on a thread that has already got a comment about our service.
- Do not link to http://www.itgot2be.com/aditional-instructions/. You need to visit the link to find the real website we are promoting.
- Do not try to cheat me by submitting non-related URL. I check manually. As a worker, you need to keep your successfully rate above 75%, so dont take the chance.
- Do not copy other comments.
- Do not spam the thread.
- Do not post comments on non-related thread.
- Do not post illegal, offensive, negative or harmful information.

Start Working:

So we have read the job details now it’s time to complete it. He has given a link and I visited the link and get description of his website. Now we have to find a forum which is related to his keyword. And the forum must be PR+2. You can check the page rank of a website by this link.Check PR.

It will take huge time to check every forum manually. So follow these steps.

Step 1: 

Go to Google and search Seo Quack addon for Firefox. Download and install it. Then you will see a SQ icon in the bottom of your Firefox browser. Click it once to activate it and click once again to deactivate.

Step 2: 

Now go to tools/Seo Quack/preferences. You can also go there by right click on the icon. A dialog box will appear. Now go to Parameter and put mark on the google. You may deselect others. See the picture.

Step 3:

Now go to Google and type Keyword+ forum in the search bar. Make sure your Seo Quack is on. Now you will see a list of website and below them you will be able to see there page rank. See the Picture

Step 4: 

Now select a forum that has high page rank. Create an account at that forum. Sign up is simple so I am not showing this. I suggest you to create a different gmail to do this type of work. I don’t do this work by my personal email. Also ensure another thing that the forum allows you to put link. There are few forum which doesn’t allow to give link. See some post before sign up.

Step 5: 

Now we have to find a thread that tells about poker game. I have found this thread and created a comment. Try to ensure that your comment is natural. You can read the comment that I made from the picture.

Step 6: 

Now our job is done we will give username and the link of my comment in the box. Now click the button I confirmed that. Your task will be approved within 2-3 days.

I think you enjoyed this article. If you face any problem to work in Microworkers then please make a comment and I will create an article for you. You may also share your opinions and your experience of work in Microworkers. I am waiting for your response.  

  

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Make Money By Clixies

At Clixies you earn money by completing free
offers. These offers will be to sign up with various companies online. You are
only to sign up with those that you are really interested in. Also some offers
are surveys where your opinion is asked for and all you have to do is
participate. You will start at the rate of $0.10 for every offer you take, but
you will be able increase this rate up to $0.25 by referring other members.

You can request payment as soon as you have at least $2.00 on your account.

You can also increase your earnings dramatically by referring other people to
join Clixies. We offer very high referral commissions 5 levels deep:

1st level – 20%

2nd level – 10%

3rd level – 10%

4th level – 10%

5th level – 10%

The referral compensation plan is shown in the chart below:



If you refer just 3 people and each of your direct and indirect referrals also
refers an average of 3 people, you will end up with 363 referrals in your
downline. And if they all complete at least 10 offers a day each, your daily
earnings will be US $36.60.

for sign up click this banner

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How much money do journal publishers make A lot

Many, including me, have written about who is making money in healthcare. Sure doctors do very well, but not as well as hospitals, hospital administrators, insurance companies and their corporate officers, drug companies, device manufacturers, and others.

Another lucrative area is medical journal publication, especially if you are the publisher. A researcher gets an idea, plans and carries out a study, writes a manuscript, and submits it to a journal. The research may have been funded by the government, i.e., you and me.

An associate editor or a member of the journals editorial board looks at the manuscript, and if it is deemed worthy, it is sent out to two or more people in the same field for peer review. This process may be repeated for papers that require revision.

All of the players in the above scenario—the researchers, most of the editorial board members except maybe the editor, and the peer reviewers—are paid nothing for their work. Factor in that the cost of producing a journal has plummeted in the computer era.

How much money do journal publishers make? Here are some impressive numbers from an article that appeared on a French website called "Rue89." The figures are for the year 2011 and are in euros. They include revenue from all science publishing, not just medicine.



As you can see profit margins range from 32% to nearly 42%. Elseviers profit of over €878 million converts to just over $1 billion.

To put that into perspective, the most recent figures for Apple Inc., arguably the most successful company in the world currently, show a profit margin of 20%.

The Rue89 piece was written as an exposé about the French governments having to pay Elsevier $172 million in subscription fees to access information generated by scientists who were funded by that same government.

But the French have nothing on us.

In his presidential address to the American Surgical Association, Dr. Layton F. Rikkers, editor emeritus of the Annals of Surgery said:

Nearly $10 billion is spent annually by [US] universities and governmental agencies for access to research findings that their scientists and clinicians give to publishers for free, that their faculty peer review for the alleged honor of doing so, and that are funded by taxpayer dollars and charitable trusts. It is unclear why library budgets continue to increase above the rate of inflation when nearly all the journals they now receive are delivered electronically in large packages from the few remaining consolidated publishing houses. Examples are Wolters Kluwers Ovid and Elsevier’s Science Direct each of which contain hundreds of journal titles. Some individual journals not available within these large collections, such as Brain Research, can cost libraries more than $20,000 annually.

There are more than 9000 open access journals, and 3.5 new ones per day are setting up shop. Instead of charging for subscriptions, open access journals are free to the reader, but the authors must pay "processing costs." Many of these publications have exorbitant fees with little or no true peer review.

Before submitting any paper to an open access journal, authors should be sure they understand the fee structure and check Bealls list of predatory publishers, which has recently been updated and expanded.

Dr. Rikkers feels as I do that print journals will gradually disappear. Post-publication peer review is already gaining momentum through blogs and sites such as PubMed Commons and PubPeer. Even major journals like the BMJ have established rapid response systems for immediate feedback to authors.

The heady days of 40% profit margins may soon be over, but for now big bucks are being made.

More about journals:

How are journal articles peer-reviewed?
How journal articles are peer-reviewed: Part 2
Journals, Open Access Journals and More Journals
What you need to know about some open access journals

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Work From Home

Many people work from home. It is also a dream of millions of others who would like to do so, but dont know how to start. Those who work from home usually work for themselves. In other words, they run their own business.

This may not be for everyone. It means that you and you alone, are responsible for your income. If you dont work, guess what - you dont earn anything. On the other hand, if you find a way to make money by working at home, and you work hard, you will probably a lot more than you did in your old job. It really is up to you. 

Getting started is the difficult bit. You need a plan, one that works. You need ideas, ones that are not glorified scams, but good, solid ideas that others are using to successfully work at home. Here are a few ideas that work, ideas that you can use too to work at home. 

1. One of the easiest ways to work at home is to sell a service. What are you good at? Can you write well? You could write articles. Millions of webmasters need good articles. The pay isnt high, at least to start with, but you can earn as much as $30 for a 500 word article. 

Dont expect to start out at this rate. You will almost certainly have to work up to it, and that may take a few months. But it can be done and it has been done. Try learning about search engine optimization, or SEO. Essential SEO can help you in that respect.

Once you feel you know what SEO writing entails, try contacting SEO companies find them through http://www.Google.com/ and offering your services as an SEO content writer. Its just a fancy name for an article writer who knows how to inject the necessary SEO elements into an article. You will find to your delight that SEO companies are happy to pay, and pay well, for results.

2. You could set up affiliate websites and promote other peoples products. Go to an affiliate network like Commission Junction or ClickBank , sign up and choose a product to promote. Set up a small website using the free Squidoo platform or the Bloggerplatform.

Write an article pre-selling the product. Dont try to hard sell it here. Just write what you think the product is like. Include a few bad points, but not too many. That can make your review sound much more real and honest. Conclude your article by suggesting that the reader may like to check out the product for themselves, and include your affiliate link. You can learn more about being an affiliate from Affilorama: http://www.affilorama.com/.

Flipping websites is big business. Learn more at Website Flipping Advice and download their free report. You can build small websites and sell them for money. It can be a very lucrative business model, and easier than you may think. Websites like Flippa are dedicated to buying and selling websites. Take your time and browse through it and learn what sells and what doesnt. When you are ready, start flipping!

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How To Do Web Research Job At Odesk

I have written an article about creating account at Odesk. I hope you have opened account and made your profile 100%. If not then please see my article. Now it’s time to work. The aim of today’s article is to show you a way to complete web research job at Odesk. Here we will show some tips. This article will teach you how to do web research job at Odesk. We will see an example today.

Apply for the Job: 

Go to your odesk account and select administrative support. You will see web research sub category. Only select this to see only web research job. Now click the apply button.

Now set your hourly rate. And write a cover letter. Don’t copy others cover letter. Your cover letter should be unique. Give some time to write. See the picture what I have written. You should give your previous job history and portfolio. Don’t forget to tell him to call you interview. According to my opinion cover letter should not be big. Client has not much time to read all cover letter. Try to summarize the whole thing within 2-3 sentences. Now click apply.

Start working:

Suppose you have got the job. You may have to give interview before getting job. If it is a hourly job then you should download Odesk Team Room Software. No need to open this software in case of fixed job. We will see details in another article.  

Example of Job at Odesk:

Job Title:  Collect 500 Business details at Sydney.

Details:  I need details of at least 500 Electronic companies at Sydney. I will need the following details presented in an Excel file Business Name, Business Owners Name (if able to find), Phone number(s), Website, E-mail, Operating hours,

I need this done within 2 days. Only apply if you can start now.

How to complete:

Now we have read the details, we have only 2 days 2 complete. We can’t get huge information by google search. Here I am giving tips to complete.

First we have to go to yellopages It is a business directory.  Here many businesses are listed. After going there you just put search terms in the fields. It will show you thousands of website. See the picture below.

From here you will get business name, website link, phone number, email, address. You may not get owner name or some information. To get this information I will suggest you to go their website. 

Other business directory:

There are many websites like Yellowpages. I am giving few of them.

• Yelp 
• Whitepages 
• Manta 

I will make a tutorial of how you can work here and talk about its features.

Tips for finding email address and owner name:

1.  1.     Open the website and try to find “contact us” page. You can find it in the footer, or in the side margins or in the header area of the page. If you can’t find the page then try to find page that says “Feedback”, “About Us”, “Our team”, “Where to find us”. You can find email address and owner name of that business.
2. 
   
3. 2.     If you can’t find these page then check “Privacy”, “Disclaimer” or “Terms and Conditions”.  You can find these page in the footer area.  Finding owner name is difficult  in my opinion.
4. 
   
5. 3.     Sometimes client give sheet where name of person is present you just have to find email.  For example the name of person is “Hasim Amla” In that case you can search for Hasim Amla @domain.com
6. 
   
7. 4.     You can use the public WHOIS database when the above procedures are not useful. Here ‘s how to do it. Go to http://www.whois.com/whois/  type the domain of the website by removing   "http://" part.

      

      Well you will not be an expert in one day. Try hard and practice more. I am also learning, I will share more tips in near future. If you know some techniques then please share with us.  

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Blame the patient

The other day some cardiologists on Twitter were discussing whether a patient should be blamed if a permanent pacemaker lead became displaced. The consensus seemed to be that it was probably poor placement (i.e., operator error), rather than patient behavior that caused leads to dislodge.

The discussion reminded me of an attending plastic surgeon of mine during my resident days. He was one of the most obsessive-compulsive people I ever met. When he applied a dressing, he always cut the tape with scissors instead of tearing it. He felt that torn tape looked sloppy, and that if a patient saw a ragged edged of torn tape, she might think that the surgical procedure itself had been done without meticulous care too.

When he wrapped a hand, he used a very bulky dressing with yards and yards of carefully cut, not torn, tape over the ace bandage to prevent from slipping or unraveling.

But my favorite eccentricity was what he told patients who had any sort of facial surgery. He had a thing about the role of movement of skin possibly causing scars to separate and permanently widen.

So he gave this written instruction to every patient who had so little as a facial mole removed, "Do not talk or chew for 10 days."

Think about it. Could any patient possibly comply with that? Some of us more cynical types figured that should a scar not have turned out perfectly, the conversation might have gone like this.

Surgeon: "About your scar, you must have talked or chewed during the first 10 days after surgery."
Patient (sheepishly): "Well doc, I must admit I did say a few words, and I had to eat something."

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Do surgeons still do postop care

Heres an email I received the other day (edited and posted with the authors permission):

I am a recently retired internist. I have noticed some evolving trends over time and had an interesting experience that illustrates this issue.

A 77-year-old friend went for check up due to urinary incontinence. He was found to have a large prostate and a PSA of only 2 so was given Flomax . This helped somewhat.

At the time, an asymptomatic hernia was found. He was immediately scheduled for surgery which went well. His Foley was removed, and he was sent home.

At home he could not void, called the surgeon, and was told to go to the ER, There the Foley was replaced, and he was to see his urologist in 2 days. The urologist removed the Foley. Later he was in agony and walked the floor all night. He called the urologist and the service said that the office was closed. He was told to drive to the other office in the next town only 15 miles away. They replaced his Foley again.

Two days later he went to the surgeon who did the hernia repair and explained his postop adventures. The surgeon said, "Those things have nothing to do with the surgery. Your wound looks fine."

Things have changed. IN THE OLD DAYS:

• After surgery, patients were not sent home until they could eat, void, and walk. Those days are history. 
• Surgeons took care of their patients post op. Those days are gone.
• Urinary retention was a recognized complication of hernia repair, especially in someone with known BPH. Are those days gone too?
• If you sent someone home after pulling the Foley, you waited till the patent had voided being aware that massive urinary retention has the potential to induce damage to the bladder muscle itself (He had retained over a liter of urine) as well as cause great pain and distress.

I am aware that surgeons are not paid for postop care, but the global fee includes the surgery and the postop care (Follow the money). Hospitals need beds for new patients (Follow the money). [Dont forget that third-party payers wont fund any extra time in hospital.]

Are surgeons no longer trained in post op care? Are surgeons not exposed to the concept of surgical complications? Isnt it interesting how things change for the worse and nobody notices?

I wondered if the friend had really needed the herniorrhaphy. The writer replied:

I looked up that question and found that only 1% of hernias need surgery by becoming symptomatic. I mentioned this to my friend, but he had been "seduced" by the authority of the surgeon who acted as though not operating was inconceivable.

I once had an echocardiogram for occasional PVCs (probably not indicated). The tech discovered gallstones. Within an hour, a surgeon stopped me in the hall and wanted to remove my GB. (So much for privacy!) As luck would have it, I had had the experience of caring for patients who had had GB surgery and had terrible results involving damage to the hepatic duct resulting in liver failure and jaundice. I looked it up and found that asymptomatic gallstones may not need surgery. I have done fine for 30 years. (Knock on wood.)

I think no postop care by the surgeon is "THE NEW NORM."

As a hospitalist, I was assigned to care for surgeons postop patients—one reason I finally retired. This was challenging at times. For example, one day a lady had a tummy tuck by a plastic surgeon. I was "consulted" to follow her and noticed her Hct had dropped. After investigating, I concluded that she must be bleeding into her wound. The surgeon never saw the patient post op. A nurse practitioner saw her but was clueless. I called the surgeon but no response came. When her Hct got down to 25, I gave her some blood and she stabilized and went home. A month later the surgeon stopped me in the hall and said when he had taken out her stitches, a huge amount of black gook plopped out. "She had a wound hematoma," he said. "Thanks for taking care of it." He was not embarrassed at all. I guess my caring for this was the new norm.

Stuff like this happened too often. If I called another surgeon for help they always refused. There was nowhere to turn.

In my fairly extensive experience, postop care by the surgeon is now seen as optional. Hospital employed surgeons are expected to operate, and NPs and/or hospitalists [Dont forget the PAs.] are assigned to do the postop care. This permits more surgeries (revenue).

On a more philosophical note, I am fascinated how "standards" change right before our eyes, but the process goes on unnoticed, slowly, almost invisibly. Then a few people speak up. They notice things. But it doesnt pay to agree with those people. Eventually, the process becomes obvious, and everyone says, "You know what? Health care in America really sucks. When did this happen?"

Are surgical residents being trained in postop care? Do surgeons no longer take care of their patients? I think this is true in orthopedics and plastics. Has it spread to general surgery too?

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More evidence that the manuscript peer review process is broken

To the surprise of almost no one, asking authors of research papers to submit names of potential peer reviewers for their manuscripts turns out to be a bad idea.

According to a recent New England Journal of Medicine article by Dr. Charlotte J. Haug, a number of research papers have been retracted because reviews were fabricated. Email addresses of suggested peer reviewers were not legitimate. The bogus email addresses were almost all created by authors of papers who then reviewed their own work favorably using fake identities. 

More about the problem can be found on the blog Retraction Watch.

This type of fraud is simple to do because anyone can set up an email address on Gmail or Yahoo mail using any name. Unless a reviewer has an academic email address, proving legitimacy is impossible.

However even if a reviewer has an “edu” address, how would an editor know that a suggested reviewer is not the author’s sister-in-law or a former mentor?

Every medical student who applies for residency knows that you don’t ask someone for a letter of recommendation unless you are sure that it will be favorable. Why would an author take a chance on recommending someone to review a paper without knowing that the review would be a good one?

I agree with the Dr. Haug that soliciting the names of possible reviewers from authors can save editors time and bother. Having spent three years as an associate journal editor, I have experienced the frustration of trying to find high quality reviewers or even a warm body of any quality to do the job.

I also agree with her that a root cause of this problem is the pressure on faculty to publish.

Another problem is that there are too many journals. In 2014, well over 5000 journals and 760,000 papers were included in Medline. The combination of “publish or perish” and superfluous journals leads to the proliferation of marginal papers.

The problem is not simply fake reviews. Since journal reviewers are not paid and have many other responsibilities, they may not thoroughly read papers or provide useful comments about manuscripts.

Some have suggested paying peer reviewers, but who would pay them? Certainly not publishers, even though they make tons of money. And paying might attract unqualified people looking to make a little extra cash.

What about post-publication peer review? It is already happening on blogs, on sites like PubPeer, and even on PubMed. However, the volume of papers published in medicine alone certainly precludes post-publication review of all of them.

Maybe it doesn’t matter. New journals are appearing every day. Most are “open access” and the charge authors “processing fees.” For many of these publications, processing fees do not include even a cursory manuscripts peer review.

With so many journals publishing just about anything for the right price, readers will have to do their own peer reviewing. Be skeptical my friends. 

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Do doctors charge too much

We all know that some doctors’ fees are excessive. I have blogged about this myself citing a neurosurgeon’s $117,000 charge for assisting on a case.

We also know that doctor bashing is a popular sport right now.

In an otherwise reasonable article about high-deductible health insurance on Vox.com, reporter Sarah Kliff’s second paragraph read as follows:

The bolded text was hyperlinked to a Washington Post piece about a study that showed wide variations in hospital charges for appendectomies in California. The study was not about physician fees. No matter how difficult the case was, no surgeon would ever have been paid $186,955 for performing an appendectomy.

Yesterday, I twice asked Ms. Kliff to please correct this grossly misleading paragraph. She acknowledged my request that evening, but as of 9 AM today, nothing had been changed.

Even if Ms. Kliff had correctly identified the hospitals as the culprits, using appendectomy as an example of why patients should shop for the lowest prices was a poor choice.

Nearly every patient with appendicitis does not know he has it until he has gone to an emergency room, seen an ED physician, and had some tests. I doubt most people in this situation would A) ask how much it’s going to cost to have an appendectomy and B) decide to go to another hospital for care. The fact is, hospitals are so secretive about their charges that a patient would be unable to comparison shop especially if the emergency department visit occurred outside of normal working hours.

Even trying to find out the charges for elective surgery remains difficult in 2015.

Physicians—particularly surgeons—have taken a lot of heat recently. We don’t need articles like this to inflame patients (and journalists) even more than they already are.

ADDENDUM 9:45 AM 10/15/15

The article was just changed. The bolded mistaken passage was corrected, but the next sentence (underlined in red) remains the same. Still blaming those "really expensive doctors."

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Variation is not causation

I made a rookie mistake in statistics of the “correlation is causation” genre by confusing variation for causation in the recent JAMA Surgery paper referred to in my last post. I contacted Dr. Timothy M. Pawlik, the lead author of the Johns Hopkins study, who said the following:

"The model is explaining and attributing variation in readmission and not attributing readmission itself to the different domains. The model suggested that only 2.8% of the variation in readmissions was attributable to surgeons. This is different than saying that only 2.8% were the fault of surgeons. A more accurate interpretation would be that only 2.8% of the variation seen in readmissions was attributable to provider level factors. The majority of the variation in readmission was due to patient factors."

He added that some of the 82.8% variation in readmissions attributable (note: attributable doesn’t mean it’s the patient’s fault) to the patient could be modified by better medically managing patients comorbidities or not operating on some of these patients.

That readmissions can be explained by a single domain or a single person is simplistic. Dr. Pawliks clarification confirms my original concern that attributing differences in patient outcomes solely to differences in technical quality of surgeons is probably inaccurate, statistically speaking.

Variation is not causation but variation is still a call to action. Regardless of who is to blame for unfavorable outcomes, surgery is a team sport. The incision is just as important as the community care. In this regard, I am certain that ProPublica and I are on the same side. Let’s work together so that we see the whole story behind the numbers.

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Medicare is changing the way it pays surgeons

Starting in 2017, Medicare will end global payments for operations. The current payment scheme combines preoperative, operative, and postoperative care into one fee. When the change occurs, each of those events will have to be billed separately—otherwise known as “unbundling.”

I missed this news when it first appeared late last year and thank one of my blog followers who calls himself Artiger for bringing it to my attention. An Advisory Board piece summarized the situation.

After analyzing a number of claims, Medicare came to the conclusion that it was paying for duplicate services. What a revelation! I could have told them that without a claims analysis.

For many years, certain surgical specialists have been delegating preoperative evaluations for “medical clearance” and postoperative management of everything but the incision to internists and hospitalists. Since the global fee was meant to include pre-and postop care, Medicare was indeed paying twice for the same service.

Representatives of the American College of Surgeons expressed concern that sicker patients would need more in-hospital postoperative visits thereby incurring more bills. [If they receive more care, maybe they should pay more.] They also worried that since postoperative care was covered under the global fee, patients might forgo office visits after surgery because of increased costs.

The unbundling of the global fee may have other unintended consequences. Since preoperative and postoperative care reimbursement will be separated from the fee for the operation itself, surgeons will be paid less for performing surgery.

Most surgeons would rather operate than make rounds and may look to perform more surgery to make up for the loss of income. This could end up costing Medicare more money.

With global payments, there is no incentive for a surgeon to keep a patient in the hospital longer than absolutely necessary. When the payment method changes, the exact opposite will exist. And surgeons who aren’t very busy might schedule more postoperative office visits to make up the difference caused by the reduction in the surgical fee.

This might all become moot anyway because Health and Human Services Secretary Sylvia Matthews Burwell has proposed that 30% of Medicare payments be converted to a non-fee-for-service model by the end of next year rising to 50% by the end of 2018.

According to a news@JAMA article, doctors may be given incentives to join Accountable Care Organizations. Quality indicators such as readmissions and infections currently applied to hospital fees might be imposed on doctors too. More bundled payments for acute care illnesses may be created. [This of course is the exact opposite of the plan to unbundle global surgery fees. Im getting confused].

One thing Im sure of is that none of this is making me regret that I retired.

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Live tweeting from ACSCC15

As many of you know, I have not been a fan of live tweeting conferences. I blogged about the issue last year (here and here) and received a lot of feedback about the posts, most of it strongly opposing my views.

Vigorous live tweeting from the American College of Surgeons Clinical Congress (#ACSCC15) in Chicago is underway. Here are a couple of examples of tweets from that meeting. Twitter handles are blocked to protect the innocent (or guilty).

First, the good. Here is a nice montage showing what surgical program directors are looking for in residency applicants.

The photos are in focus and well-positioned. Anyone not in the audience for the talk can get something useful from this tweet. My one complaint -- we do not know who the speaker is. That information may have been provided in an earlier tweet, but this retweet is the only one I saw.

Now, the bad. The slide below probably contained some valuable information. Only the live audience knows for sure.

Since I havent seen all of the live tweets from #ACSCC15, I cant say which type is prevalent.

I can only hope its the former.

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Earn Money By Answering Questions

Answering questions may not seem to be an obvious way to make money online, but it can be. You may be familiar with Yahoo Answers where you can pose a question and invite others to answer you. Its a bit like that, but if you are the person who supplies the answers, you will get paid. 

Unlike Yahoo Answers, the sites that answer questions and pays those who supply the answers screen their experts a lot more closely. Anyone can supply an answer to any question on Yahoo Answers, but only those approved to do so will find themselves answering questions for pay. 

Some of the sites that pay you to answer questions are general and cover most subjects. Some of them are more specific and target a particular niche only. There are a growing number of these kinds of sites and some pay quite well too. 

However, it is quite intensive work as you will have to be present at your computer and online waiting in real time for people to pose a question that you are qualified to answer. You may also have to do some initial research to come up with the answer. While you are likely to know most things in your chosen field of expertise, you cannot reasonably be expected to have everything right at your fingertips every time. 

One popular question and answer site is Just Answer . They have over 100 categories with experts to answer questions in every one and more. For example, while researching their site they claimed they had 159 experts on hand, ready and waiting for questions to be posed to them. This number will likely vary at different times, but this is an indication of their popularity. 

The experts on these sites are often subject to a feedback system. This means that customers rate them according to how well their questions were answered. A feedback rating of 100%, for example, would mean that the expert concerned would have fully satisfied every customer with the answers they provided. In this way customers can choose the expert they feel is most likely to provide the best answer.

To earn money answering questions you will have to undergo an expert screening process. You will be expected to be an expert in your chosen field, and you will be tested on this. You may also be scrutinized by customers as well as by other experts as this is the real test of your skill. 

If your knowledge is in a subject that is taught at college or even in school, then you may be interested in Student Questions . This site is geared towards students who need the answers to questions concerning their homework. There are certain ethical questions in this regard, but you will have to answer those for yourself. 

If your expertise is in small business, then Small Biz Advice could be ideal for you. This is a site where people pay to receive business advice and answers to their perplexing business questions. 

One site that is slightly different from most of the others is ChaCha . They accept questions from people using cell phones. This means that people may ask questions that are area specific, such as, "Where is the nearest gas station?" They would of course have to also provide their geographical location and you would then have to provide them with an accurate answer.

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A medical riddle Where do incident reports go

Incident reports are frequently submitted by hospital personnel. Did you ever wonder what happens to them? I have.

Over the years, I estimate that I’ve heard of hundreds of such reports being filed, but rarely have I heard of a problem being solved or for that matter, any action being taken at all.

In fact, I don’t even know where they went or who dealt with them. When I was a department chairman, I sat on quality assurance and risk management committees. Yet we never discussed individual incident reports.

The original intent of incident reports was to identify patient harms and increase patient safety.

According to a 2009 post by patient safety expert Dr. Bob Wachter, hospital incident reports are a spinoff from the Aviation Safety Reporting System which had successfully used them for identifying potential safety issues such as near misses.

At Dr. Wachters hospital, San Francisco General, about 20,000 incident reports were filed every year. That is about half of what the Aviation Safety Reporting System receives per year, and San Francisco General Is only one of about 6000 hospitals in the United States.

Dr. Wachter feels that analyzing incident reports is not worth it. He estimates that each incident report creates about 80 minutes of work times 20,000 reports, which equals about 26,600 hours of wasted time. He also estimated that about one fourth of US hospitals do nothing with incident reports. That saves time but renders the reports useless.

He says an even bigger problem is that incident reports in his hospital fail to capture most events that harm patients.

That has also been my experience. I think most incident reports were filed by people wanting to "cover their asses" and most of the reported incidents were minor. A reference in Wachters article states that most incident reports are submitted by nurses with only about 2% by doctors.

Incident reports can backfire too. From a 2002 Medscape article: "In some states, under certain conditions, the incident report is considered confidential and cannot be used against the nurse practitioner in a lawsuit. However, if copies are made or the chart reflects that an incident report was completed, the incident report can then be subpoenaed by the patient and used against the defendants in court."

And from the Louisiana State University School of Law: "The nonjudgmental nature of an incident report is very important because in most cases the incident report will be discoverable in litigation. An accusatory remark in an incident report may gain unintended weight in a legal proceeding."

Since incident reports generate a massive amount of wasted time, fail to identify most events that harm patients, are frequently ignored, and can possibly have a negative effect on lawsuits, why are they still being filled out by the thousands?

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Improving the M M conference

"Surgical pathology works more than 80 hours per week, has no regard for your gender or your life situation, and can be devious and sneaky in its presentation."

The following is a guest post by Dr. Leo Gordon, a surgeon from Los Angeles.

A recent paper in Annals of Surgery found that 24% of graduating surgical residents "were unable to recognize early signs of complications." One possible solution is a redesign of the morbidity and mortality (M&M) conference .

I have spent a significant part of my professional life in an effort—at this point it is a crusade—to change the nature of the M&M conference. For 11 years, I moderated 495 conferences, 1485 presentations, and 30 written examinations based on the error and complication-reducing points raised during the discussions.

If properly implemented, a redesigned M&M conference can satisfy the ACGME core competencies, the suggestions of the Institute of Medicine, and the publics demand for a reduction in medical errors.

What I have dubbed the "M&M Matrix" converts the weekly conference into a vibrant educational effort and creates a constantly updated patient safety curriculum for the resident and attending staff.

If the M&M Matrix is such a valuable idea, why hasn’t it been widely adopted?

Here are the reasons:

1. Implementing the M&M Matrix is a ton of work.

Setting up this program and changing the culture of a traditional conference requires acceptance at all levels of the department. It is a week-long effort, not a one-shot Tuesday morning flirtation with surgical education. To pull this off, someone is going to have to be paid, which is a stumbling block. The residents have to buy into this program. It is more work for them, but think of the benefits of the cautious analysis of a complication. Most departments look at the concept, realize how much work it will take, and revert to the traditional conference.

2. The M&M Matrix requires a moderator with specific talents.

Effective moderation of this conference requires a certain set of skills that not every attending surgeon possesses. The moderator has to select educationally valuable complications to discuss. The moderator has to…well…moderate the conference, focus on worthwhile comments, recognize the difference between a legitimate statement and the sweet reverie of surgical anecdote, and do it in a respectful manner. The moderator has to summarize the conference in a HIPAA compliant manner, distribute the teaching points, and construct an examination based on the conference.

3. The M&M Matrix relies on a structure of classic surgical education, a structure suffering advanced erosion.

I am entering my 36th year of practice. My view of surgical education is inconsistent with work-hour restrictions, life-style considerations, hand-offs, and current methods of patient care. I view the discipline of surgery as an effort to eradicate surgical pathology. Surgical pathology works more than 80 hours per week, has no regard for your gender or your life situation and can be devious and sneaky in its presentation. The method of assessing the effects of surgical pathology should be just as rigorous. I hate to fall back on a military analogy, but the M&M conference should be a boot-camp or basic training for the real war.

4. There is no statistical proof that the M&M Matrix decreases the incidence of complications.

The academics and statisticians have got me here!

How do you get inside the head of a senior resident as he is digging out the left colon in a tough diverticulitis case and show that in that fecund mind, because of this educational format, the resident is thinking:

"Gee, we discussed a lacerated ureter a few months ago. Remember the techniques of assessing the ureter that we discussed at the Matrix Conference? Didnt the outline we got and the test questions suggest that we should identify the ureter above and below and make sure we stay close to the colon?"

How does one quantify that a complication was avoided because of an educational effort?

These four reasons for lack of wider adoption can be overcome by a thoughtful analysis of the benefits of a redesigned conference. Given the current problems confronting surgical education, I believe that the idea will be re-evaluated and will eventually be adopted.

Time will be increasingly valuable in upcoming 60-hour work week. The hour allotted for the analysis of surgical complications has to be leveraged into a durable learning experience.

The incoming president of the American College of Surgeons, Dr. Andrew Warshaw, has chosen Dr. Ernest Codman as the subject of his presidential address. Dr. Codman invented the M&M conference. He conceived and implemented it, and in so doing improved surgical care. I hope that Dr. Warshaw’s remarks will spark a renewed interest in a re-design of the M&M conference.

I have a viable plan. Now I need the support to implement this plan. Perhaps I can complete Dr. Codman’s work!

If you have an opinion about the M&M Matrix, please comment below or contact the author—LeoGordonMD at gmail.com

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OR tech How do I deal with an abusive surgeon

Have you ever come across problems with rage and temperament issues in the OR. I have been an operating room tech for many years and have been in a variety of surgical settings.

A certain surgeon brings in a lot of money to the hospital, but he is terrible. I have been called things no one has ever called me. He throws instruments on my table and mayo stand, screams, and implies that I and my colleagues have no idea what we are doing. I have reported him to my manager and the OR director, but nothing ever comes of it.

Other surgeons have witnessed his behavior and have said something, but nothing was ever done. I understand the OR is a beast of its own, but the culture has to change with these newer guys coming out of residency. The mindset of the surgeon being our customer, which is being rolled out to us now, is not reason for us to put up with abuse. What have you encountered on a peer-to-peer level on how to handle such demeaning behavior? I trained and worked at a level 1 trauma center with emotions that constantly ran high, and still it was less stressful than this particular surgeon. Thank you for your advice. 

A recent paper in the American Journal of Surgery addressed this topic. The authors interviewed 19 OR personnel including nurses, medical students, surgical residents, anesthesiologists, and 2 scrub technicians. Dr. Amalia Cochran, the papers lead author, told me the reason there werent more scrub techs was that they were reluctant to participate.

This figure, modified slightly from the paper, describes the harm that disruptive surgeons can do and suggests some coping strategies.

Italicized items are discussed in the paper

I suggest you read the entire paper. Your hospitals medical librarian should be able to obtain a copy for you without difficulty.

Its a tough situation. When I was a surgical chairman, I had some experience with surgeons behaving badly. I always had trouble getting the nurses and techs to go on the record with their complaints.

If your immediate boss cant help, maybe you could try your hospitals risk management department. A surgeon who bullies the staff is a patient safety risk. Some hospitals have anonymous hotlines where complaints can be lodged.

The only other thing I can suggest is to get several other staff to join in the complaints. Administration can ignore one or two people but not eight or ten.

Can anyone else comment?

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