One of the obligations of a medical or surgical specialist is to communicate with the referring primary care provider.  This can take many forms--- a phone call, texting via smart phone, email, messages sent via EMR, and dictated letters.  The format is pretty standard no matter what medium is chosen.  You thank the referring doc for the consult request, you give some brief background info about the patient in question, and then you articulate an assessment and plan.  Then you thank the doc again.  Multiple times if necessary.  Because your livelihood depends on whether or not that doctor decides to continue to send patients your way.  

My practice is to freely text physicians I know well about their patients.  It's instantaneous, it's informal, it breeds a certain collegial connectivity that is good for business.  I also like free-form written emails via our internal encrypted system.  In addition, our outpatient EMR auto-creates "referral letters" to primary doctors.  These get sent to the doctor's inbox as soon as I click "sign" on my office notes.  These notes are really something.  Not exactly an unearthed archive of F Scott Fitzgerald corresponding with Hemingway, these babies.  Some computer algorithm takes your office note, chops it up into relevant blocks of transferable data and information, splices in seemingly human-sounding phrases and sentences, and then synthesizes it all back together to make it look like an actual letter.  I sometimes try to type in a block of text toward the end in an attempt to personalize things but that usually just gets buried under an avalanche of x ray reports, review of system minutiae, exam findings, and various instances of tortured computer-generated syntax.

Prior to EMR and texting and instantaneous communication, most specialists had no other option but to dictate referral letters to their feeders.  And for some reason it evolved that the referral letter had to be composed in this faux-formalized, knock-off Henry Jamesian diction and syntax, as if American doctors were a bunch of 18th century courtiers.  

Ezekiel Emanuel's group has a paper in JAMA Oncology this month that seeks to assess the role "demanding patients"  have on overall health care costs in oncology.  They conclude as follows:

Well that's all good and well.  I don't necessarily agree with the conflation of "demand" with "request"--- to wit, a cancer patient asking for an adjustment in dosage of pain medications ought not to be equated with a patient who insists upon an MRI for low back pain.   But whatever.  I don't disagree with the results.  In my own clinical practice I cannot remember an incident where I was forced to order some expensive test because an overly Google-ized patient demanded it.  

My problem with this paper is the underlying premise.  The opening sentence of the abstract is:

Who, I wonder, are these "surveyed physicians"?  Is there a citation in the bibliography to support such a claim? Of course not.  Who exactly are all these physicians who are blaming patients for the healthcare cost spiral?  Why is it taken as indisputable, unassailable knowledge that doctors attribute health care costs to patient demands?  And yet, this "fact" serves as the premise of the entire project.  And the Emanuel group dutifully goes about proving that, no, patient demands do not significantly impact either physician decision making or the number of tests ordered.  They have demonstrated the invalidity of a claim that no one is making anyway.  At least not by doctors.  I guess that counts as research these days.  

The reality is that this is propaganda.  Physicians are greedy.  They will do anything to preserve fee-for-service models.  They blame others for healthcare costs.  They blame patients for the tests they order.  See?  This study has proven it.....

JACS this month has a solid study from Japan on the use of diverting stomas in the setting of rectal cancer.  This was a prospective, multicenter cohort study of 936 patients who underwent low anterior resection (LAR) for rectal tumors within 10 cm of the anal verge.  The results were as follows:

This suggests that diverting ostomy (either a loop ileostomy or transverse colostomy) constructed during a LAR for lower rectal tumors can attenuate the deleterious effects of anastomotic leaks.  Which makes complete sense.  Leaks happen in gastrointestinal surgery.  This is a vexing, unspoken problem for surgeons who perform a lot of bowel surgery.  Did you know that, depending on the literature cited, leaks can complicate anywhere from 3%-28% of anastomoses?  That's a lot of leaks!  And the consequences of a leak, especially pelvic colorectal connections, can be devastating.  The idea behind a diverting stoma is to protect an immature, potentially compromised anastomosis.  Patients with rectal cancer are often treated with neoadjuvant chemo-radiation (not specified in the paper above) and that distal rectal stump used in the anastomosis is not always the best hunk of flesh to work with.   Small leaks, which, unprotected, can lead to rapid pelvic sepsis and eventual complete anastomotic dehiscence, can be mitigated by proximal diversion.  Instead of stool pumping out through a micro-perforation, a small leak can, with time and re-direction of fecal flow, be allowed to scar down and heal spontaneously.

I don't do a lot of low rectal cancer resections but I find the diverting ileostomy to be an extremely useful tool in my armamentarium in the setting of severe perforated diverticulitis.  A lot of these patients need urgent or semi-urgent operative intervention after failure of conservative management.   A bowel prep is usually contra-indicated.  The pelvis is contaminated.  The surrounding tissues are often edematous and friable.  In the old days, everyone got a Hartmann's procedure (end colostomy and Hartmann's rectal pouch left in the pelvis.  But we found over the years that reversing a Hartmann's colostomy was frought with morbidity.  Leaks could occur.  Surrounding structures could be injured.  And sometimes the post peritonitis scarring resulted in a frozen, socked in pelvis with marginally identifiable anatomy.  As a matter of fact, for a variety of reasons, only about 70-75% of Hartmann's colostomies ever get reversed.

My practice is to make liberal use of the loop ileostomy if I have any concern about my pelvic colorectal anastomosis.  This allows the new conduit to heal without the stress of fecal matter flowing through it.  A barium enema is ordered after 6 weeks or so to confirm healing and the patient is brought back to the OR  for a pretty straight forward, far less stress-inducing loop ileostomy reversal.  

There is an interesting paper from JAMA Surgery this month (on-line version only as of yet) that studies the use of NSAID's  (non steroidal anti-inflammatory drugs) in the post operative period and their impact on anastomotic leak rates.  NSAID's are medicines like Alleve and Motrin.  As a surgeon, I prescribe Motrin to most of my post op hernia and laparoscopy patients for non-narcotic pain control.  I am also a big fan of the intravenously administered NSAID, Toradol.  Toradol is an extremely useful adjunct in the management of post operative pain in the inpatient setting.  I order it often.  (Also, NFL football players seem to like it, not always to their benefit.)

The risk with Toradol and other NSAID's in the post op period was usually related to kidney injury and potential bleeding complications.  But NSAID's work by attenuating the body's natural inflammatory response to stress.  And sometimes that inflammatory response is beneficial.  As a surgeon I need that inflammatory response to occur, especially if I am sewing one end of bowel to another.  Those inflammatory mediators bring the kinds of cells and proteins necessary for a strong anastomosis.  

The JAMA paper is a large retrospective cohort study over over 13,000 patients who had undergone colorectal or bariatric surgery at over 40 hospitals in Washington state.  The question the investigators asked was: how was the leak rate affected when NSAID's were started within 24 hours of surgery?  The findings:

That's a significant finding!  The good news is that the statistical differences were only seen in patients undergoing non-elective colon surgery.  These are typically semi-urgent cases in a patient population already compromised by factors of infection or malignancy.  NSAID's, given their mechanism of action, could very well function as a tipping point that compromises anastomotic healing in such cases.  Further study is certainly warranted, but I'm inclined to change my practice.  The next perforated diverticulitis case I get that can be treated with a single stage sigmoid colectomy will probably just get a PCA post op.  

The construction of her sentences leads one to believe that "quotidian" mistakes, like BEDSORES, are the biggest killers.  This should strike an average healthcare professional as ridiculously absurd.  Bedsores demonstrably are not striking down thousands of patients every year, like an army of ghastly demons leeching onto unsuspecting patients' sacrums and heels and ischial tuberosities.  And Ms Kliff seems to know this as well, as betrayed by this line:

So yeah.  Bedsores are found in frail, elderly, non-ambulatory, demented patients who present to hospitals with a host of medical problems.  Many of them die.  Many of them have incidental bedsores.  Correlation is not causation, of course.  Ms Kliff acknowledges this.  And her unnamed "experts" sure are getting a lot of mileage out of the phrase "almost certainly" when asked to provide evidence of an association.   This is obscurantism is its finest form.


After the bed sore non-sequitor, Kliff makes some valid points about physician transparency and the difficulty of identifying errors when they occur.  She also assails the "fee for service" model as a source for disincentivization to correct mistakes and prevent them from happening again.   Finally she assures her readers that this post is the first in a year long series investigating fatal medical errors.  She then affixes a form for readers to fill out if they or their loved ones have been the victim of a medical error.  This form asks "Type of Harm" (and the participant is to check all that apply).  Choices include: "Infection", "Surgical Injury", "Bedsores", "Fall", "Medication error", "Blood Clot", "Device (ortho or cardiac).  

Ms Kliff has committed a very common error here, creating a false equivalence between the concept of known complications related to procedures or disease processes and true negligence/malpractice.  Surgical injury, of course, is my personal favorite listing.  I love the use of the pejorative  word "injury" rather than "complication" or "unexpected outcome".  So now surgical site infections, post op pneumonia, hernia recurrences, duct of Luschka leaks, anastomotic dehiscences, and other surgical complications are re-defined as "injuries" suffered as a result of "medical errors".  Certainly many bad surgical outcomes are the result of incompetence or negligence.  Most are not.  Most are simply known complications of a well described procedure.  Mixing up the two is tantamount to journalistic malpractice.   

It will be interesting to read Ms Kliff's follow up articles on this important topic.....