Surgery Just for the Heck of It

Last week I was going over the list of inpatients on our service with two of my attendings when we came to a diabetic male who was admitted with fever and chills. The patient had an ulceration on the bottom of his foot resulting from something called Charcot Foot. Diabetics often develop what is called peripheral neuropathy...bascially, the peripheral nerves become damaged, and the patients develop numbness in their hands and feet. This not only affects the nerves that are responsible for our touch sensation, but the nerves that are part of something called the sympathetic nervous system as well. This results in the break down of bones in the foot with multiple fractures and dislocation of the joints. The patient often develops something called a roker bottom foot, or a bony protuberance on the bottom of their foot. Over time the skin overlying this area breaks down and becomes ulcerated...and so, this was the case for this patient. A very complicated (but high paying) foot surgery is a charcot reconstruction, or the surgical attempt at putting the foot back together again. Let me add here that this surgery does not have a great success rate. As soon as my attending saw that there was a patient on our list (without even seeing the patient in person), he wanted me to talk to the patient and book him for a charcot reconstruction with an external fixator. This is basically a big metal frame that goes on the outside of the foot and has pins going into the bones of the foot. This would be a 4-5 hour surgery with a long recovery time. The other option, which would be less costly (pay less), and have a much quicker recovery time for the patient would be to simply cut away the bony protuberance on the bottom of the foot and close up the ulcer. The attending who wanted to do the charcot reconstruction made an attempt at guilting me into booking the case by saying "I thought you guys wanted to do surgery! This is a surgical program, so if you want to do interesting surgical cases, book this patient!" He wanted to put a patient through a complicated (and unnecessary) procedure to make a quick buck and brag about the recontruction he did. Sure, in the right hands, and under the right circumstances, this procedure would have its place...but this was not it! The patient was lucky that there was more then one attending involved, and the other attending intervened preventing the surgery from going forward. It is sad when medicine becomes more about money and experience rather than the care of patients.

Pharmaceutical Reps Are Not So Bad

I know these days everyone loves to hate a pharmaceutical rep, especially with news reports of them doing just about anything to get doctors to prescribe their medications...even using non-FDA approved indications as a selling point. Most of them are salesmen types with fake smiles and company cars, but here is the scary truth...some doctors could not survive without them, especially the ones who sell the surgical equipment. I recently scrubbed into an ACL repair (knee surgery) that was being done arthroscopically (as most are done these days). The representative from the company that was supplying the equipment to perform the repair was present, and to be honest, he should have been the one doing the surgery! Beyond the basics, the surgeon did not know how to use the equipment, and needed the rep to guide him through each step. It was stressful, scary, and 2 hours longer than it should have been. Most surgeons who use more than a scapel and some sutures will have a company representative in the OR with them from time to time...and some of them will have a rep with them almost all of the time. I also scrubbed a shoulder case with an orthopedic surgeon recently who decided he needed to use a certain piece of equipment to repair a tear in area of the shoulder called the labrum. The surgeon was looking to the scrub tech and the nurse to put the equipment together properly, but they did not know how. The rep was called, and rushed to the hospital so the surgery could continue. Perhaps surgeons should be forced into taking training courses before they are allowed to use this equipment on real patients...but that would be in the perfect world of healthcare, not the real world of healthcare.

Surgery Booking Day

We have clinic 3 days a week at a certain city hospital where the majority of patients are Medicaid and Medicare. As a result, we are told as residents that these are our patients, and we can treat them in whatever way we deem necessary. All residents need a certain number of procedures in order to graduate from the program. We are told that this hospital is the place to get our numbers by seeking out patients that we can book for certain procedures, and then performing those procedures on them. There is always an attending in the OR with us, so we are not actually performing the procedures alone, but these are clinic patients, and as a result, we are able to choose which procedures we want to do on the patients, and we are allowed to actually perform the majority of the procedure in the OR. I know that the idea of a resident performing a procedure on you is frightening, but this really is not the worst of it. We do need the exeprience in order to practice in future, and to be honest, a well trained monkey can perform most of these procedures. The difficult part of medicine is deciding which patients actually necessitate a procedure, and which procedure to perform on them. Unfortunately, residents always want to perform procedures because they need their numbers. Physicians are not going to let them practice on their private patients, so we practice on the clinic patients instead. We are told that one clinic day in particular is supposed to be our "surgery booking day." On this day, we are encouraged..well forced..to try extra hard to find patients to book for surgery, and if we do not book enough for that day, we are ridiculed by our attending for not trying hard enough. Something is wrong with this picture.

Defensive Medicine At Its Worst

On Friday I scrubbed a complicated orthopedic case that took about 4-5 hours involving the cutting of bone, and insertion of screws. Typically I order a post-operative x-ray while the patient is in recovery to make sure everything is in allignment and all of the hardware is in place. This is what I was instructed to do as a student and during my early residency training. I ordered the x-ray, and was beginning to preop the next patient when the attending physician approached me looking angry. "Never order a post-operative x-ray on my patients!! Do you understand?" Seeing that I responded calmly with an "ok, no problem," his tone softened.."you are just setting yourself up for a lawsuit" he said. "If you want a postoperative x-ray, take it in your office. There you will be the only person looking at it, and no one else will be able find anything wrong with your work." I am sure he thought he was giving me a good piece of practice managment advice..a tip on how to avoid a lawsuit, but in my mind, this was verging on the brink of malpractice. We are told that malpractice is anything that goes against the "standard of care," and the standard of care is to take a post operative x-ray in the hospital. We often hear about how doctors are scared into ordering too many tests on patients for fear of missing something and being sued, but here is an example of a doctor not doing something for a patient out of the same fear.

Nurses and Internist Are Your Best Friends

I know surgeons usually get all the respect and admiration, but if you find yourself in the hospital for whatever reason, do remember that the nurses (especially the experienced ones) and the internists are your best friends. The hospital is structured with salaried employees that make the same amount of money no matter how many patients they treat (nurses and internist), and doctors who have privledges at the hospital who make money based on how many consults they see (surgeons). The surgeons want to do surgery, because that is what they get paid to do, and the more surgery they do, the more money they make. I was recently following a 98 year old patient who had a rare type of skin cancer, and had already received the maximum amout of radiation. She now had a new outbreak on her skin that may have been the same type of cancer again. The patient was also found to have a small hip fracture. She was bedbound, and never expected to walk much anymore. The orthopedic surgeon who came to consult on her simply saw a money making opportunity. He booked her for a hip replacement, and put in a certain type of joint replacement (because he could get paid more for using this particular type) that is meant for people who are young and need to get back to full activity. A hip replacement in no small surgical procedure, and this surgeon put this old frail woman though the trauma of this surgery unnecessarily in order to make some money. So, getting back to the internist and the nurses..an internist truly wants to diagnose you, treat you, and send you out. They do not get paid per patient, or for the amount of times they see you. The experienced nurses have seen it all, and if you really want a 2nd opinion, you should ask them. If you go to another surgeon, you will probably get the same answer, because they want to make money too. Although I plan on being a surgeon, and I realize that a healthcare system where surgeons do not get paid per patient would mean less money for me after all this schooling and hard work, I think this would be a better system for the patients. On the other hand, this would also mean long waits for surgery for patients..there would be no incentive for surgeons to work long hours if they were not getting paid per patient. So, what is the answer? I am not sure that anyone has come up with a good one yet.

Healthcare for Illegal Immigrants

So, I was in one of the NYC hospitals that we rotate through the other day, and I saw a poster hanging on the wall with the exact words "We don't care about your immigration status, we care about your health...to get health services at little or no cost, call this number.." So, we have millions of uninsured legal citizens in this coutry, but we are providing healthcare at "little or no cost" to illegal immigrants!? Where is this money coming from to pay for this!? Obviously it is not coming from the immigrants themselves..even if they have jobs, they are not paying taxes. I can understand if they have something that is contagious, and is a threat to the larger population, but routine care should not be covered! I see it all the time...families flying in grandma from their home country, and bringing her to the hospital to get free care. They might want to consider this problem when putting together a healthcare reform bill. If it was possible, I would be all for legalizing the hardworking illegal immigrants and having them pay taxes while kicking out all the lazies living off of welfare and Medicaid while finding new excuses not to work..but since this will never be a reality, we need to figure something out. Unfortunately real healthcare reform can not happen overnight. Pushing for something to pass quickly is not the solution. The president and legislators need to do their research to find the real problems and ways to fix them.

It's a Scary Healthcare World

Hello Readers,

At first I created this blog as a place for other residents to come and seek support of their co-residents who are going through a similar experience, but I have recently decided to scrap that idea. I have just completed a year of residency, and I think it's important to share what I have seen and experienced, especially as healthcare has taken front page in recent days with the Obama administration proposing a universal insurance plan.

First, let me start by saying that although I like Obama, I am not sure he knows enough about the ins and out of healthcare to remodel the system. If I could, I would sit down with him and share my personal experiences, but since I can not do that, I will share them here instead in the hope of educating other readers.

This is just my introduction, and what will follow in the days ahead are actual stories of what I am describing above. It's a scary healthcare world out there, and unfortunately there is yet to be a good plan to fix it.