Thursday, March 23, 2017

Evidence? We don’t need no stinkin’ evidence

One of my posts requires clarification. The post "A paper of mine was published. Did anyone read it?" went live in August 2014 and has been viewed 5133 times to date.

A reader had emailed me to ask if I might know why two papers he had written did not cause much of a stir in the orthopedic world. One reason might have been that the papers appeared in an obscure orthopedic journal.

I then wrote: "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." This is simply not true.

The link in the above paragraph originally went to a nebulous Indiana University web page and eventually became a "file not found." The source of the 2007 Physics World paper remained elusive. The subject came up again about a week ago on Twitter and a follower, @TirathPatelMD, sent me a link to the full text.

Friday, March 17, 2017

Brief summary of 2017 residency match data

Here are some snippets from the NRMP Advance Data Tables for the 2017 Main Residency Match.

The number of PGY-1 positions offered was the highest total ever. US allopathic medical school seniors in the match numbered 18,539, which is also a new high. Only 5.7% of US seniors failed to match. That was a slightly lower percentage compared to 2016 and 2015.

The numbers were not as good for previous graduates of US allopathic medical schools with only 46% of 1472 applicants matching. Osteopathic graduates fared better with 81.7% of 3590 applicants matching.

I have blogged about the prospects for international medical school graduates. Of the 5069 US citizen graduates of international medical schools, 54.8% matched—a rate consistent with the totals for the last four years.

Wednesday, March 15, 2017

Nonoperative treatment of appendicitis in children: Is it safe?

After writing my 21st post about appendicitis back in November, I swore I would not write about it again for the foreseeable future.

Well, the future is now because investigators from the United Kingdom and Canada just published a meta-analysis including 10 papers and 413 children about the efficacy and safety of nonoperative treatment for appendicitis in children.

They concluded that nonoperative management is effective in 96% of children with acute uncomplicated appendicitis during their initial hospitalizations with just 17 (4%) children requiring appendectomy before discharge. An additional 68 (16.4%) developed recurrent appendicitis later, and 19 of these patients were treated with the second course of antibiotics. The other 49 underwent appendectomy with histologic evidence of recurrent appendicitis.

Another 11 patients underwent appendectomy in the follow-up period for various reasons. In all, 77 (18.6%) patients initially treated with antibiotics eventually underwent appendectomy.

Although the initial hospital length of stay for appendectomy was shorter than that of patients treated with antibiotics, complication rates were similar.

These findings were met with headlines like "Antibiotics, not surgery, could treat appendicitis in children, study suggests" from The Guardian and "Is Surgery Always Needed for Kids' Appendicitis?" from US News.

What are the problems with this paper?

Wednesday, February 22, 2017

Vacation notice

As of the evening of February 22, I will be out of the country with limited Internet access. I'll be back on March 12.

Comments left on posts may not be approved for a few days. Please be patient.

Thanks for reading.

Friday, February 17, 2017

Will robots eliminate the need for surgeons?

A medical student from Germany emailed me saying he had always wanted to be a surgeon, but someone told him that by 2030 surgeons would no longer be needed because robots would be doing all the operations. He worried that after years of studying and hard work, he might lose his job to “R2-D2.”

He mentioned IBM’s Watson and a recent paper that appeared in the journal Science Translational Medicine about a robot that can handle and suture bowel.

He asks, “What do you think about the future of surgery?”

Thank you for your email and the link to the paper.

I read the paper and was amused by its title "Supervised autonomous robotic soft-tissue surgery" which is an oxymoron. The definition of autonomous is "acting independently or having the freedom to do so." This “supervised” robot is not really autonomous.

The robot is capable of performing a nearly technically perfect intestinal anastomosis but still needs a human surgeon to open the abdomen, prepare the bowel for the procedure, tidy up, and close. I'm not sure that this is any different than when surgical staplers were introduced. This robot is simply making the operation easier and possibly more precise.

Surgeons will still be needed in case the robot makes a mistake like causing bleeding while placing a suture near the mesentery. If bleeding in that area is not promptly controlled, a large hematoma can develop and possibly compromise the blood supply to the anastomosis. And will the robot be able to decide who needs an operation and when to do it?

One worrisome byproduct of surgical stapling is that many graduates of residency programs within the last 15 or 20 years have little experience in performing a hand sewn bowel anastomosis. What will they do if the hospital runs out of staplers? Soon, I guess they could consult the (somewhat) autonomous robot.

I have written about automation and the erosion of surgical skills. This problem also affects pilots. I have also addressed the concept of  robots operating alone. I don't see it happening any time soon.

I think there will always be a need for surgeons. Even the smartest robot is going to have some trouble dealing with a trauma patient who is hypotensive.

The future will take care of itself. In the 1980s, people were concerned about the demise of general surgery. Opinion pieces with titles like “Will the general surgeon become extinct?” and “Is general surgery a dying specialty?” appeared in major journals like JAMA and the World Journal of Surgery.

Then in 1990, laparoscopic cholecystectomy opened the door to a whole new area of general surgery that no one had ever dreamed of.

Good luck with your studies and your surgical career.

Tuesday, February 14, 2017

Can a cop’s baton accidentally slip into a man’s anus?

I doubt it.

A French police officer has been charged with rape after a black man who was being arrested suffered severe anal injuries.

After witnessing an officer slap someone, the 22-year-old had allegedly approached a group of policemen. The victim claims he was handcuffed, called names, and beaten. He says his pants were lowered and he felt pain in his buttocks.

At the police station another officer noted that he was covered with blood. He was taken to a hospital and diagnosed with the anal trauma which required “major surgery” including a colostomy. The family was told incontinence may result.

Doctors said the injury had been caused by a police baton which had been forced into his anus.

The Washington Post quoted the findings of a police investigation: “The violent sodomy was accidental and occurred when the officer’s expandable baton happened to slip into the victim’s anus.”

According to another story, “a French police union spokesman said there was no evidence so far that ‘the truncheon was actually introduced’ into the victim's rectum. And if that actually happened, it was likely done ‘accidentally.’”

A third story said, “a lawyer for the officer charged with rape said ‘the blow had been carried out in a totally involuntary manner, without his being aware of any injury.’” The word “his” must be referring to the officer because I have no doubt the victim was quite aware.

Based on my 40+ years of experience as a surgeon, I can assure you the police version of the incident is highly implausible. A patient who does not wish to undergo a rectal examination by a physician with a gloved and lubricated index finger can easily prevent it from occurring by voluntarily contracting his anal sphincter and gluteus muscles.

I would imagine a healthy 22-year-old man would react in exactly the same way if a policeman’s baton “happened to slip” with the end anywhere near his anus.

The incident has sparked many protests in France and has been widely reported by news media. Of the several accounts I have read, not one has asked a surgeon to comment on the nature or possible cause of the injuries.

Bottom line: A police baton slipping into a man’s anus is about as likely as a man accidentally falling on a woman and penetrating her.

From International Business Times
Thanks to @Tosk59 for the tip on the International Business Times story.

Thursday, February 2, 2017

Yet another new medical TV drama

“'The Resident’ follows an idealistic young doctor who begins his first day under the supervision of a tough, brilliant senior resident who pulls the curtain back on all of the good and evil in modern day medicine.” So says the article announcing Fox’s pilot for a new medical TV show.

As opposed to all the other medical dramas, this one features an idealistic young doctor and a tough, brilliant supervisor. How original.

I tweeted the show's premise and got several humorous replies prompting me to write this post.

There is no such thing as an original medical show. Original would be a resident sitting in front of a computer 75 percent of the time and then leaving the hospital in the middle of a great case because of work hour restrictions. While at home he plays video games for five straight hours.

Someone wondered if “The Resident” would find romance—possibly in a convenient storage closet. I wouldn’t know about that because I trained at a Catholic hospital.

Another asked if there would be a tough staff with soft hearts, a hospital administrator who put profit before patients, a second-generation physician who cracks under pressure, and a renegade doctor who breaks all the rules but saves the day.

What about a show with overworked, stressed, but oh-so-average attending physicians and idealistic, but basically inept residents?

I’d like to pitch an idea. It’s called “The Administrator” and follows an idealistic young deputy assistant junior vice president who begins his first day under the supervision of a tough, brilliant hospital CEO who pulls the curtain back on all of the evil and none of the good in modern day medicine.

Think of all the dramatic meetings involving committees, ad hoc committees, lean, six sigma, budgets, root cause analyses, public relations, whether to buy a third robot, and so much more. True to life, the administrators never leave the C-suite*.

*C-suite (def): A widely-used slang term collectively referring to a corporation's most important senior executives. C-Suite gets its name because top senior executives' titles tend to start with the letter C, for chief, as in chief executive officer, chief operating officer and chief information officer. [From Investopedia]

Thanks to the Twitter folks who contributed: @smootholdfart, @DrDes1970, @geekpharm, @JessicaDeMost, @DrMikeSimpson, @jsekharan, @mjaeckel