This past December, Ohio became the 20th state to pass a law mandating that hospitals and clinics performing mammography screening to notify a patient in writing if results suggest something known as  "dense breast tissue".   Standard mammography creates a 2-D image of breast tissue.  In general, this is sufficient for screening purposes.  However, especially in younger patients, the presence of dense breast parenchyma can lead to higher false negative readings and more indeterminate results that may lead to higher rates of invasive biopsies.  

A newer imaging technology, called digital tomosynthesis, creates highly focused 3-D images of breast tissue.  Initial research seems to suggest that this can improve both early detection rates of smaller cancers and eliminate the need for unnecessary biopsy procedures on clinically insignificant findings.  The law passed in December is supposed to prompt patients to ask their respective health care providers about the need for follow up digital tomosynthesis.

Several questions are begging to be asked:

1) Why don't we just screen everyone with 3D digital mammography?  Well, it's an issue of cost, of course.  For most women, standard 2D mammography is sufficient.  The 3-D machines cost twice as much and some insurance companies will give patients a hard time about coverage.  Most tertiary care centers and dedicated breast cancer facilities have the technology but universal availability is a problem.  Rural and critical access hospitals simply cannot afford to invest in an expensive new technology that may only be intermittently indicated.  In the long haul, as costs inevitable plateau and decrease, it is certain that 3-D digital mammography represents the future.  But for now, we run the risk of creating tiered levels of care, depending on where one lives.

2) Why is this being handled by the state legislative bodies?  Wouldn't it make more sense for medical decision making protocols to come from , like, oh, I don't know, trained healthcare professionals rather than laymen elected officials in Columbus?  Wouldn't a consensus statement from, say, the American Society of Breast Surgeons or a similar entity, make more sense?  Do we not have enough laws on the books?  What would be the consequences of violations of such a law?   Criminal prosecution, in addition to any tort liability?  Doctors and hospital administrators cuffed and read their Miranda rights in the physician lounge?  Will this set the precedent for future legislation guiding physician/patient communication paradigms?  When I take out a patient's colon cancer, the expected standard of care surveillance recommendation would be for that patient to get another colonoscopy one year after surgery.  What if I don't document that recommendation exactly as per state guidelines?  What if the patient is either non compliant or never received the written notification because of a change in address?   Am I criminally liable?  It all just strikes me as unnecessary and absurd.  It ought to be enough to expect doctors and healthcare providers to be professionally responsible and to fulfill basic standard of care requirements.  Deviations from these standards put one at risk of malpractice litigation.  There's enough negative reinforcement in that threat alone.....

I saw a lady in the ER presenting with abdominal pain, nausea, progressive anorexia for about 6 weeks.   A CT scan suggestive high grade obstruction with intussusception of the small bowel. Now we don't see something like this everyday.  Intussusception occurs when the proximal bowel sort of telescopes itself into the more distal bowel lumen, leading to congestion, obstruction, and, in some cases, ischemia of the involved segments.  

Intussusception in an adult always raises concerns for underlying malignancy.  Intra-lumenal masses or tumors can act as a lead point wherein, via peristalsis, the more proximal bowel can "grab hold" and intussuscept.  

Fortunately, this patient had a benign submucosal fibroid tumor that led to her intussusception.  We resented the segment of bowel harboring the mass and she went home a happy camper in a couple of days.   Many times, intussusception is the initial presentation of a more sinister process, like lymphoma, or carcinoid tumors, or invasive adenocarcinomas.  

The concept of "patient satisfaction" has assumed a prominent perch in American healthcare delivery.  Somehow, this vague, nebulous metric has been indiscriminately tied into the way we reimburse hospitals and physicians.  In fact, patient satisfaction can represent up to 30 % of a hospital's score in the federal value-based purchasing system, which can greatly affect Medicare payments (by as much as 1%).  

Controversy has arisen, however, regarding the validity of "patient satisfaction" as a useful yardstick.  Two articles from the literature illustrating this recently caught my eye.  

JAMA Surgery in April 2013 published a much cited article that evaluated the relationship between patient satisfaction scores and hospital compliance with Surgical Care Improvement Project (SCIP) metrics.  Interestingly, in a study of 31 hospitals, patient satisfaction was found to be independent of the extent to which hospitals followed standard guidelines to help reduce post operative infectious complications.  

A couple of months ago, Annals of Surgery studied 171 hospitals over 11 years, looking for a correlation between patient satisfaction and surgical outcomes.  The findings of the study certainly raised some eyebrows.  The only surgical outcome indicator associated with high patient satisfaction scores was a low mortality rate.  (Let us hope that no one is surprised by this particularity.)  More confounding was that complications and higher readmission rates after surgery had no statistical effect on a patient's reported satisfaction experience.  The only variables associated with high satisfaction scores, other than low mortality, were larger hospitals (in square footage, I guess) and hospitals with a high surgical volume.  

These papers highlight the concern many of us in the trenches have with using subjective, highly capricious metrics like HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores as a reliable measure of quality.  You end up in an upside down world where patients with horrible surgical complications effusively praise their doctors and nurses for being so "compassionate and caring during a difficult time" and, on the other hand, where patients who sail through difficult major colon resections give a hospital a bad score because their TV only had three working channels and the newspaper delivery volunteer was rude every morning.  

Quality is a metric that cannot be measured via proxies.  We need to start being more honest about it.  Using HCAHPS and patient satisfaction scores is just a fancy way of equivocating on transparency.  We have a perfectly fine, already available method of measuring quality: simply open up the drapes and let some light into the world of surgical outcomes.  If you want to let the public know how well a hospital or surgeon is performing, don't think you are providing a valid answer by instead publishing bullshit like "patient satisfaction is very high!".  Publish the actual outcomes.  If a hospital performs 1,000 hernia repairs every year, then maybe the public has a right to know recurrence rates, infectious complications, mortality rates, etc.  Same thing with abdominal procedures and orthopedic interventions.  We have been doing the exact same thing in the realm of cardiothoracic surgery for years.  Open up the books.  May the best man win.  

Inguinal hernia represents one of the more common indications for referral to a general surgeon.  Patients who come see me describe a variety of symptoms ranging from "slight groin bulge when I cough" to "a dull ache" to "weird burning sensation" to "severe pain with activity". Hernias that are causing symptoms significant enough to incite a patient to seek an opinion from a physician (especially an older male who hates going to the doc, in general) probably ought to be repaired sooner rather than later.  Not many surgeons would debate such a management protocol.

The more controversial clinical scenario is the mildly symptomatic or asymptomatic inguinal hernia.  Previous surgical literature has suggested that a conservative apporach of "watchful waiting" is appropriate.  If symptoms worsen, then surgical intervention would be the next step.  

A new article from Annals of Surgery, however, suggests that, in select circumstances, even patients with minimally symptomatic or aymptomatic inguinal hernias ought to at least consider elective repair.  This accords with an earlier study from the UK that found a benefit to earlier repair in patients without incapacitating symptoms.  The driving rationale for this new recommendation is that 70-75% of men with initially asymptomatic hernias in the long term studies eventually developed symptoms (pain, most prominently) and elected to undergo surgical repair within 7-8 years.  

MY TAKE:

I have several guiding principles when it comes to minimally symptomatic groin hernias.  

• Can I see it across the room?  Hernias that are obvious upon visual inspection (big balloning inguinal canal bulge or scrotal mass) generally are a problem waiting to happen, as opposed to subtle defects that require interrogation of the internal ring in order to appreciate.  
• Patient characteristics.  A wheel chair bound 88 year old male doesn't need surgery on a hernia that doesn't bother him.  On the other hand, a fit and healthy 75 year old who golfs three days a week ought to consider getting pre-emptive repair.  
• I think it's hard to justify just ignoring a younger patient (i.e. < 45) with an obvious hernia, even with zero symptoms.  That thing is not going to go away, it will probably get larger, and at some point it will start to cause pain/discomfort.  And it's always easier to fix a small hernia; quicker surgery, better anatomy, fewer post op issues.....