A paper of mine was published Did anyone read it

An orthopedist asked me if I could explain why a couple of papers of his did not generate any feedback. He wasnt even sure that anyone had read them. He enclosed PDFs for me.

Not being an orthopedist, I cannot comment on their validity.

But I think I can explain why the papers have not created much interest.

Are you familiar with the term "impact factor"? If not, here is a link explaining what it is:

A journals impact factor is an indication of how widely cited its articles are. One can also assume that it is a good indication of how popular the journal is and by inference, how many people read its papers. The impact factor has been criticized, but it is one of the few measures of a journals influence.

The two papers in question were published in Orthopaedics & Traumatology: Surgery & Research. A list of the top 40 orthopedic journals ranked by impact factor in 2013 showed that it ranked 37th with an impact factor of 1.061. That means the average number of citations for any paper published in OTSR was about 1, and 36 orthopedic journals were more widely cited than OTSR.

A paper in Physics World claims that that 90% of published papers are never cited and 50% are never read by anyone but the authors and the journals peer reviewers. I believe this is true of papers in medical journals too.

I was unable to obtain any figures regarding the number of subscribers to OTSR, but I suspect it is not large. This may also account for the lack of responses to the papers. My own experience is similar. It was very rare to receive any feedback about any of the over 90 peer-reviewed papers, editorials, or reviews that I had written.

Consider this. A blog post of mine "Appendicitis: Diagnosis, CT Scans and Reality" which I wrote 4 years ago has received over 19,600 page views and more than 100 comments. I am certain that post has been read far more than all of my published research papers combined. In fact, my 550 blog posts have recorded over 1 million page views.

What does it all mean?

Journals may have to adapt and become more like blogs. In the future, medical information may be disseminated by blogs and comments rather than journal articles and letters to the editor.

Will scientists CVs be valued more for the number of page views their papers receive than the number of peer-reviewed papers they publish?

Read More..

OR delays Whos responsible and what can be done

Every two or three years, someone, usually a hospital administrator, decides that delays in operating room turnover time need to be looked into. A committee of 20 or 30 stakeholders (love that term) is appointed and assigns someone the job of measuring the time between cases and identifying reasons for delays. In years when turnover time is not being studied, first case starting delays are on the agenda.

In my nearly 24 years as a surgical department chair, one or the other of these issues was investigated at least 10 times. We were never able to conclusively determine the exact causes of delays or solutions to the problem, and we returned to business as usual.

An article in Anesthesiology News about a paper that looked at causes of operating room delays in over 15,500 cases at a single hospital got my attention.

The number one reason for delays was that the nurses did not have the operating room ready for the patient. Nursing also was responsible for the third most common cause "preop prep (IVs, meds, etc.)."

Surgeons were the reason for the second most common problem, "notes, consent, patient marking not complete." A few more of the top 10 included surgeons running two rooms, surgeon unavailable, and my favorite, "last case ended early." I’m not sure how a case ending early causes a delay in starting the next case. Usually we are blamed for underestimating the length of time we need to do an operation.

Anesthesiologists were cited for only one of the 10 most common reasons for delays—placement of an IV line or regional block.

Not surprisingly, the study was done by anesthesiologists using data they collected.

When I expressed skepticism about this on Twitter, I was accused of implying the research was fraudulent. Not so. Some of my best friends are anesthesiologists. In fact two of my medical school roommates became anesthesiologists. Fraud is not the issue. Its a matter of perspective.

For example when the nurses investigate OR delays, the problem never seems to be nursing.

Im not saying that surgeons dont cause delays. A task force once found that one of my surgeons was late for his first case every time he operated because he had to take his kids to school.

Another surgeon would disappear between cases and was always late for his next one. No one knew where he went. Some thought he may have been calling his broker or perhaps having an affair.

Here’s what the anesthesiologist researchers may have overlooked.

In effort to avoid delays, I would often ask for an anesthesia consult on complicated inpatients booked for surgery a day or two later. On nearly every occasion, the anesthesiologist who saw the patient was not the one assigned to do the case. The consulting anesthesiologist never said a certain lab test was necessary, but in the holding room, the one who was going to put the patient to sleep said it was. A spirited discussion, phone calls, and a delay ensued.

Sometimes a day surgery patient who arrived 2 hours ahead of schedule wasnt interviewed by anesthesia until the scheduled time of the case.

Then there was my patient whose operation was postponed for 6 hours because she had a piece of hard candy in her mouth when she got to OR. The anesthesiologist said it was the equivalent of having a full stomach. Read the full story here.

Can delays be shortened by working together? A 2014 paper in the Journal of Surgical Research by a surgeon and four anesthesiologists found that “various events and organizational factors created an environment that was receptive to change.” The authors were able to decrease their general surgery OR turnaround times from 48.6 minutes to 44.8 minutes, a statistically significant (p < 0.0001) but hardly clinically important difference.

Let me hear your experiences with OR delays.

Read More..

Are guidelines a safe harbor against malpractice suits

Several months ago, Physicians Weekly featured an article describing a bill that was introduced into the House of Representatives called HR 1406 The Saving Lives, Saving Costs Act. It would create a "safe harbor" for physicians who could show that they followed best practice guidelines when faced with a malpractice suit. At the end of the piece, a question was asked, "Do you think this bill will help safeguard physicians against the influx of federal rules and regulations?"

Knowing little about the bill at the time, I tweeted that such a bill would never pass.

I couldnt list the reasons in a tweet, but here are a few.

Although guidelines are useful, they can be controversial too. Take the guidelines on screening mammography and PSA testing. When they came out, there was so much criticism that it would be difficult for any lawyer to use them as safe harbors. Plaintiffs experts would simply say they disagreed with any guideline. A seed of doubt would be planted in the minds of jurors, and the safe harbor defense would fail.

The Dr. Whitecoat blog published a conversation between an emergency physician and a plaintiffs lawyer. It should be read in its entirety, including the comments, to be appreciated.

The conversation was mostly about the Choosing Wisely campaign, in which specialty societies publish guidelines listing certain tests and treatments that they feel can be avoided.

The lawyer said, "There will be a lot of bad discharges, refused admits, procedure delays, diagnoses delays, all in the name of ‘costs.’ Your societies and hospitals are masking this as evidence based practice, etc. But I can get a jury to see that very differently. A lot of physicians will be paying out before long, as will hospitals…Testing is what makes diagnoses, saves people.

"I have a pretty set script here. To the effect of ‘so Doctor, you just didn’t care enough about my client to order this test?’ Or ‘so my client was just a statistic, just a percentage to you?’… [Juries] love that stuff!”

A post I wrote last year about a supposed set of common goals shared by lawyers and surgeons had these comments from another plaintiffs lawyer.

Regarding the use of guidelines as a malpractice defense which some have labeled a "safe harbor," the lawyer said, "The safe harbor concept becomes unacceptable if it allows guidelines to be used as a get out of jail free card. Guidelines must be useful in exonerating and implicating clinician wrongdoing." My interpretation of what he said was that its OK to use a guideline to prove a clinician did wrong, but following guidelines should not be a fail-safe defense strategy.

Just for fun, I looked up HR 1406s history. It was introduced on February 27, 2014 and immediately referred to three committees—the Energy and Commerce Committee, The Judiciary Committee, And the Subcommittee on Health. On March 20, 2014 it was referred to the Subcommittee on the Constitution and Civil Justice, and it hasnt been heard from again.

A website that tracks bills lists its status as "Died in a previous Congress."

I dont think you will be sailing to a safe harbor any time soon.

Read More..

My blog cited in JAMA Surgery paper Progress for bloggers

About a year and a half ago, I blogged that a medical student on Twitter used a blog post of mine as evidence. In January, the Canadian Journal of Anesthesia published an article I wrote under my pseudonym called “Why I blog and tweet.”

Last month, medical blogging took another step toward legitimacy. A JAMA Surgery Viewpoint formally cited my post critiquing the Finnish randomized trial of antibiotics versus surgery for the treatment of acute appendicitis.

Here is the first page with the portion of the piece discussing what I had written in the blog post.

Click on figure to enlarge.

Here is how citation appears in the JAMA Surgery article.

If you havent read my entire post about the randomized trial, click here.

Last year I said this: “Journals may have to adapt and become more like blogs. In the future, medical information may be disseminated by blogs and comments rather than journal articles and letters to the editor.”

We have already seen prominent publications such as the New England Journal of Medicine starting online forums and the BMJ hosting blogs (at least 36 so far) and rapid responses to published papers.

The sea change in the way medical research is disseminated may be happening sooner than I thought.

Read More..

Which is better—an electronic or a paper progress note

It depends on whom you ask.

A new study says internal medicine house staff generally feel that the quality of progress notes is unchanged or better since the implementation of an electronic medical record, but the attendings feel that progress note quality is unchanged or worse.

Over 400 interns, residents, and attending internists at four university hospitals were surveyed. The paper appears online in the Journal of Hospital Medicine.

Specifically, 50% of residents felt that the quality of notes was unchanged and 39% thought the quality was better or much better. Conversely, 39% of the attendings felt the note quality was unchanged, and another 39% felt that it was worse or much worse.

From the paper: Half of interns and residents rated their own progress notes as “very good” or “excellent.” A total of 44% percent of interns and 24% of residents rated their peers’ notes as “very good” or “excellent,” whereas only 15% of attending physicians rated housestaff notes as “very good” or “excellent.”

When the 9-item Physician Documentation Quality Instrument was used to evaluate notes, attending perceptions of housestaff notes were significantly lower than housestaff perceptions of their own notes, p < 0.001. One of the PDQI items asked for a rating of how succinct resident notes were. That feature was rated lowest by attendings and residents alike. I can think of a lot of words to describe electronic progress notes, but "succinct" isnt one of them.

In all, 16% of interns, 22% of residents, and 55% of attendings reported that copy forward [copy and paste] had a “somewhat negative” or “very negative” impact on critical thinking, p < 0.001. Auto population of fields in notes was judged similarly.

The authors felt that these differences could be explained because Attendings may expect notes to reflect synthesis and analysis, whereas trainees may be satisfied with the data gathering that an EHR facilitates. I agree.

Can all this be remedied?

Dr. Daniel Sexton, a Duke University internist, authored a three page guide [link is safe] on how to write effective progress notes. Here are just a few excerpts:

DO NOT TRANSCRIBE LAB DATA INTO THE PROGRESS NOTES UNLESS YOU INTEND TO COMMENT UPON IT. [All caps by Dr. Sexton]

It is often good and useful to explain your thinking in the chart.

Do not mindlessly repeat yourself in daily notes. [That goes for "copy and paste" too (my extension of this recommendation)]

LENGTH OF NOTES DOES NOT RELATE TO RELEVANCE OF NOTES. [All caps by Dr. Sexton]

I have written about the pitfalls of electronic medical records several times. In my blogs search field to your upper right, insert "electronic medical record" or "EMR" and click "Search This Blog" to see my other posts.

Its early in the academic year. Start writing better notes now. And please dont copy and paste.

Read More..

Dont jump to conclusions about that JAMA surgical readmissions paper

On February 3, JAMA published a paper online about readmission rates after surgery. The focus of most tweets was on the most common cause for readmission—surgical site infections (SSIs)—in 19.5% of readmitted patients.

At first glance, this suggests that infection rates after surgery were 19.5%, but that is not so. The paper said that 19.5% of the readmissions were caused by infections.

Of 498,875 total operations reviewed, only 30,270 (6.1%) were readmitted for any reason, and only 5576 (1%) of all patients were readmitted for SSIs.

According to the full text of the paper, the authors had two main points:

One, "because most readmissions were attributable to well-described postoperative complications, readmissions after surgery are mostly a proxy measure for postdischarge complications and in effect penalize hospitals twice [my emphasis] for postoperative complications (ie, other pay-for-performance programs include postoperative complications such as SSI)."

Two, "the majority of hospital readmissions were related to SSI and ileus [non-mechanical failure of bowel peristalsis]. Identifying clinical interventions to reduce the occurrence of these complications to below current levels has been challenging."

An article about the paper in US News quoted an editorial by Lucian Leape who said "system-wide changes need to be made." One such system change, the Surgical Care Improvement Project (SCIP), has been ongoing for more than 10 years.

The paper confirms what I wrote in 2010 about SCIP and other process measures and points out that "Most hospitals in the United States have high adherence rates for the SCIP SSI-prevention process measures; however, compliance with these process measures has not been shown to be strongly associated with reduced SSI rates."

And I am unaware of a conclusive study showing that the incidence of postoperative ileus can be lowered by any intervention.

I agree with the comments of the papers authors who say, "It is important to note that many readmissions may be unavoidable and are actually the correct course of action for surgical patients. [My emphasis] Many complications should be treated in the inpatient setting, and surgeons should not be deterred from readmitting patients because of concerns about quality measure performance and resulting penalties."

Every effort should be made to lower the infection rates of all procedures. But this papers results should be viewed not with alarm, but rather as reassurance that the problem is not out of control.

Read More..

German airliner crash A system error with a system solution

From the Associated Press: Airlines around the world on Thursday began requiring two crew members to always be present in the cockpit, after details emerged that the co-pilot of Germanwings Flight 9525 had apparently locked himself in the cockpit and deliberately crashed the plane into the mountains below.

This represents an organizations typical response to a problem. The crash, which by all accounts was caused by a single deranged individual, has been perceived as the result of a “system error” and will be dealt with as such.

The idea that a flight attendant going into the cockpit whenever one of the pilots has to pee will prevent anything seems a bit absurd to me. How is a 5’2” 120 pound female flight attendant supposed to stop a 6’3” 210 pound pilot who is hell-bent on committing suicide by airplane?

When I tweeted a similar thought yesterday, someone suggested that she could simply sound an alarm and unlock the cockpit door. I suppose that’s true as long as the crazed pilot does not punch her in the face and knock her out or shoot her first.

After 9/11, a federal law was passed allowing pilots who were properly screened and trained to carry guns. If an armed pilot decides to commit suicide, an unarmed flight attendant will not be able to stop him or her.

According to a CNN story, Andreas Lubitz, the pilot who drove the plane into the mountain, had passed all medical tests before being hired. He recently had been given a medical leave note by a doctor. However, Lubitz ripped it up and threw it in a wastebasket in his apartment. He did not disclose the fact that he had been undergoing medical treatment to the airline. So much for self-reporting which is standard for pilots.

Why didnt the doctor tell the airline? I dont know. Do they have HIPAA in Germany?

The two people in the cockpit rule is smoke and mirrors. The airlines can now say that they have taken steps to prevent something like the Germanwings crash from happening again so dont worry, its still safe to fly. But as I have pointed out, a determined maniac will be able to easily overcome this system solution.

I am reminded of the proposals like arm the janitors, arm the teachers, or give them shields or scissors that always come forward after school shootings.

Footnotes:

1. "Two people in the cockpit” is not an FAA regulation but is said to be a standard policy for US airlines. Its purpose is not to prevent a suicide but to have someone available to let the other pilot back into the cockpit in case the pilot who did not leave passes out or is otherwise disabled.

2. The Germanwings incident represents an unintended consequence of reinforcing and locking cockpit doors after 9/11.

Read More..