Paved With Good Intentions … Or, How Do I Do A Vaginal Delivery?

rectal

Here are some steps of vaginal delivery that have been used in various combinations over the last century:

  • In early labor, nurses should shave the patient’s pudenda; administer a soapy enema to empty the colon; wash the whole body with soap and water; scrub the vulva with bichloride of mercury or a iodine/mercurochrome solution.
  • During later labor, the vagina should be washed with lysol if a vaginal douche has not already been used.
  • When the doctor first examines the patient after bathing, he should wash his hands using sterile technique and then don sterile gloves; next, using his sterile gloves, he should perform a rectal examination to determine the position and station of the head and dilation of the cervix (in some cases, a vaginal exam may be necessary). If membranes are ruptured, the nurses should perform all subsequent exams rectally.
  • All “unruly patients” should be given anesthesia (DeLee, 1943). The woman should be prepped and draped in a complete aseptic manner.
  • When the head is crowning, an episiotomy should be performed. If the patient has previously been sedated with scopolamine and a narcotic, then forceps are applied to deliver the fetal head. If the woman is enough of a rube to not have anesthesia, then in some cases she may push the baby out. While she is pushing, stick your fingers in her rectum and perform a Ritgen maneuver to flex the head.
  • Once the head is delivered, STOP! Check for and reduce any nuchal cord; suction the mouth and nose out with a bulb syringe; if there has been meconium, then perform a deep suctioning of the meconium with a DeLee trap suction (also if there had been meconium noted during labor, this should have been flushed out and diluted with an amnioinfusion).
  • After the shoulders have restituted on their own, then the body can be delivered.
  • After delivery of the baby, hold the baby’s head down below its body and below the level of the placenta and clamp the cord as fast as humanly possible.
  • If the baby was born through meconium stained amniotic fluid and is not vigorous, it should be immediately intubated with meconium suctioned out from below the cords. Be careful not to stimulate the baby in case it cries!
  • Manually extract the placenta from the uterus or Credé the placenta from the uterus (unless the patient has no anesthesia – how uncivilized!).
  • After conducting a thorough exploratory inspection of the vagina and cervix, repair the episiotomy you cut.
  • Go find the husband in the waiting room and let him know his wife had a baby.

All of these practices have three things in common:

  1. All of them were dogmatically held as very important precepts by various authorities over the last 100 years.
  2. None of them have supporting scientific evidence.
  3. I don’t do any of them.

Most of these practices were introduced into Obstetrics with the best of intentions, often in response and in reaction to bad outcomes that were being observed. They were interventions that “just made sense,” given how the problems were perceived at the time. They were passed on to trainees with one part dogma and one part fear – fear that doing a delivery any other way would have disastrous consequences. Many of these practices persisted for decades after good evidence said they should be abandoned (and some are still used today).

Let’s look at a few examples.

A hundred years ago or so, before the discovery of antibiotics and after the development of aseptic and antiseptic techniques, obstetricians responded to puerperal fever (the once leading cause of death for pregnant women) by loading up as many aseptic and antiseptic principles as they could onto women having babies. Enemas were to prevent later defecation from spoiling the supposedly sterile field achieved with solutions of mercury and Lysol. Sterile drapes, gloves, and technique were prerequisite. Many of the practices, like shaving the women, actually increased the risk of infection. Women who give birth today rarely undergo any type of preparation at all. Infections still happen and many are unavoidable; when they do occur, they are usually easily treated with antibiotics. But in the belief that all peripartum infections were iatrogenic (and therefore preventable), we even went so far as routinely using only rectal examinations of the cervix (another procedure that likely increased cross-contamination rates). None of these interventions were evidence except hand-washing and glove wearing.

When fewer and fewer women were dying of infections (yay gloves!), neonatal and infant morbidities and mortality became the next cause célèbre. At the turn of the 20th century, cerebral palsy and other mental and physical disabilities of children were believed to be almost exclusively caused by birth trauma to the brain or other intrauterine events. This trauma supposedly occurred as the head was repeatedly assaulted by the perineum and vagina while the mother was pushing. So, once again, science came to the rescue in the form of the prophylactic episiotomy (to prevent the head from being bullied and to shorten the second stage of labor) and the prophylactic forceps delivery (with the blades of the forceps pushing out on the walls of the vagina, preserving the fetal head from trauma). Of course, these ideas seem silly today, but good intentions led to generations of children being born this way, all the while causing women and children to have countless severe traumas, perineal lacerations, incontinence, and dyspareunia. The widespread introduction of electronic fetal monitoring a generation later, without any evidence of its efficacy, was the next big push to end cerebral palsy. It did not; it did, however, hasten an incredible rise in both the cesarean delivery rate and obstetric lawsuits.

The incorrectly named meconium aspiration syndrome (MAS) gave rise to decades of other ineffective and potentially harmful interventions. The belief that aspiration of meconium was mechanically leading to pulmonary hypertension in the newborn led to numerous efforts to prevent this aspiration, including amnioinfusion to dilute the concentration of meconium in the amniotic fluid, deep suctioning at the perineum, and intubation and suctioning of meconium below the cords (first in all babies, then in babies who were depressed, and now, finally in 2016, no babies). All of these practices were, as usual, introduced with no scientific evidence of safety or efficacy; and slowly, as studies were eventually performed that found them ineffective and potentially harmful, they have all been abandoned.

The practice of holding the baby below the level of the placenta and clamping the cord as quickly as possible was originally done because obstetricians realized that not doing so might allow the transfusion of another 100 ml or so of blood into the baby – and who would want that? Of course, over time, the extra 100 ml was understood to not be harmful and perhaps even beneficial (especially in preterm infants), and finally the 7th Edition of the Textbook of Neonatal Resuscitation recommends that all vigorous infants have at least 30-60 seconds of delayed cord clamping, with the baby right up on the mother’s chest! Joseph DeLee would roll over in his grave.

Vaginal birth is finally coming full-circle. Before doctors emerged on the scene, women gave birth in whatever position they wanted to and then they picked their babies up and held them to their chests while the cord slowly stopped pulsating and the placenta delivered. They received fewer, if any, vaginal exams (and when they did, the examiner wasn’t also sticking her hand in other infected women). If they had a small laceration, it wasn’t repaired (a practice currently endorsed by ACOG). When their babies didn’t cry, they warmed them and stimulated them until they (hopefully) started.

Now I am certainly not arguing for a return to the 18th century, where 1 in 8 women died in childbirth and half of all children died by the age of 5. I don’t think in the least that women should be denied the life-saving interventions of modern obstetrics or even just the benefit of a nice epidural. Yet, I can’t help but think that, overall, nature did a pretty good job in designing women to have babies. Birth is a natural process. Our job is to intervene when things go wrong (as they often do), but not try to redesign a natural process. Cesarean delivery is one of the greatest gifts to women and children; but its overuse today is a leading driver of maternal mortality. Too much of a good thing is not a good thing. This cautionary lesson is present in all of the above examples. Wash your hands when you do an exam; don’t use caustic acid to burn off the last remaining epithelial cells from the vagina.

What are the interventions and practices that really make a difference in a routine, normal vaginal delivery? I’m not sure that there are any. I’m just there in case something goes wrong: shoulder dystocia, prolapsed cord, labor dystocia, abruption, fetal distress, neonatal distress, postpartum hemorrhage, amniotic fluid embolism, fever and infections, etc. I have plenty to worry about. But I can worry about those things without reinventing the way women give birth.

Our predecessors were just as sure of the interventions listed above as we are today of the things we do. Which of the practices that we do today will those who come after us look at with equal scorn? I have a few ideas … but I don’t want to bias you.

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Filed under Cognitive Bias, Evidence Based Medicine, OB/Gyn

Ten Ways To Reduce The Cost of Healthcare

healthcare-costs

The cost of US healthcare is growing at an unsustainable rate. Despite measures that were supposed to lower the rate of growth of healthcare costs (like the Affordable Care Act), the rate of growth in 2015 was 5.8%, the highest in 8 years. The total cost of healthcare in 2015 was $3.2T, with the Federal Government spending 29% of those dollars, and state and local governments contributing another 17%. Overall, healthcare costs were 18% of GDP and healthcare costs are growing at a rate significantly faster than the GDP. In 1995, healthcare costs were only 13.1% of GDP.

More important, in 2015 the Federal Government spent $990B on healthcare alone, which was 31% of an all-time record tax revenue of $3.2T (the government spent $3.7T with a deficit of $439B). State governments spent an additional $200B on healthcare, which was about 11% of state revenues. Local governments provided a similar amount of funding. Despite this record spending, there are still about 30 million uninsured people in the US, along with many millions more who have insurance that cannot practically be used due to high deductibles.

If you remember none of the above numbers, remember this: we spent the same amount on healthcare last year as the US treasury collected in a year with record high tax revenue: $3.2T, even with 1 in 11 folks uninsured. While overall healthcare cost growth was 5.8%, the federal Medicaid growth rate was 12.6%. Total federal healthcare expense growth was 8.9% in 2015 and 11% in 2014.

If you favor a governmental single payer system, then historically high tax revenue will have to at least double to make that happen. If you took every penny from the top 5% of US earners (100% taxation), you would only have $3.1T, still not enough to cover the rising costs of US healthcare. If we assume that a stable cost of about $3.5T would be necessary for universal coverage, and add the other 2015 costs of government to that, the Treasury would need to collect about $6.3T in taxes. This is equivalent to the entire incomes of the top 30% of Americans and and 70% of all dollars earned in America by US citizens (total income was $9T). What about free education? Hah.

The point? We need to lower the cost of healthcare. Here are 10 ways:

  1. Lower pharmacy costs. Prescription drugs in the US cost $324.6B in 2015, growing 9% over the previous year. This is 1/10th of the total cost of healthcare. We account for 42% of drug company revenue in the entire world while accounting for less than 5% of the world population. Drug prices are outrageous and the growth in cost is fueled by spending on new prescription drugs. Much of this total reflects a small percentage of branded drugs. Read my article about drug prescribing for practical examples of how prescription costs can and should be lowered. Lots of excellent raw data are located here. We need to:
    • End advertising and direct selling to physicians. The pharmaceutical industry spent $3B in 2012 marketing to consumers and another $24B advertising directly to doctors, or about 1/10th of total drug costs in the US. Marketing is not education, it is expensive salesmanship. Doctors don’t need to learn about new drugs over expensive steak dinners, they need to read journals.
    • Create price ceilings related to the international costs of drugs. The government could easily dictate that the US will not pay more than say 10% above the average international cost of a drug. There is no good reason why the same bottle of Humalog insulin costs $12.47 per ml in the US and only $2.78 per ml in Canada.
    • Lower the costs of drug development and sales by indemnifying approved drugs against lawsuits. These lawsuits don’t benefit consumers. In 2014, Merck, the maker of NuvaRing, agreed to pay $100M to settle a class action lawsuit related to the birth control product, and in 2012 Bayer paid over $400M related to lawsuits against Yasmin and Yaz. All three safe, quality drugs are still on the market and still very popular. What did this half a billion dollars get consumers? More expensive drugs and richer plaintiff attorneys. The drug companies just respond by setting aside billions of dollars into legal funds, assuming they will eventually get robbed in court by bandit attorneys who keep most of the proceeds for themselves.
    • Reform the FDA. The FDA has failed abysmally at approving the applications of generic drugs (thousands are currently awaiting processing) and creates so many regulatory hurdles that it costs just under $3B per drug to get approved and to market. This obscene number reflects an industry, not a mission-critical necessity to keep patients safe. The FDA has become a training ground for Big Pharma executives who have created a regulatory nightmare only an insider can navigate; they learn at the FDA and then parlay that experience into millions working for pharmaceutical companies.
    • Provide a government funded account for helping those catastrophically harmed by drugs that can be accessed through an application to an expert committee. Some folks are definitely harmed by drugs, but the plaintiff attorney industry that preys on every new drug that comes to market must end.
  2. Lower cost of other equipment and supplies. Retail medical equipment costs were another $107B in 2015. The pricing in this industry has many of the same influences as the pharmaceutical industry; companies will charge whatever the government will pay and their costs are high due to regulatory and legal considerations. But beyond the retail industry, hospitals pay way too much for durable equipment and supplies. Only in healthcare could a blanket warmer the size of a mini fridge cost $3200 or a hospital bed $25,000. This highway robbery is the result of regulation, a lack of transparency in cost, and a lack of competition in the industry (due to the high regulatory costs to compete).
  3. Lower regulatory burdens to hospitals that make operational costs too high. Over $1T was spent on hospital care in the US last year, and over $100B on building new structures and equipment. All this spending and most hospitals are operating in the red. Regulation hurts hospitals at every turn. Every detail of hospital form and function is regulated in enormous detail. Very little of this regulation is known to improve patient outcomes, but all of it makes a lot of money for a lot of people with their hands in the cookie jar. Construction costs are dramatically higher, competition is almost non-existent, and innovation is stagnant. Hospitals could operate at a dramatically lower cost  if they were allowed to innovate and compete, but they are suffocated by regulation.
  4. Enact real tort reform and some levels of indemnification for hospital and physicians. Tort reform works and the total dollar amount of malpractice settlements has dropped from about $4.8B per year in 2003 to $3.6B in 2014, mostly due to tort reforms at the state level. But the real cost comes in practicing defensive medicine (over-ordering tests and interventions for fear of being sued), which BlueCross BlueShield estimates to cost about $46B per year. Other countries in the world are far ahead of the US in terms of tort reform and the number of lawsuits and settlements reflects this difference. Physician charges should go down with increased tort reform. For some specialities like mine (Ob/Gyn), malpractice premiums are 1/4-1/3 of our salaries.
  5. Promote transparency about physician (and hospital) quality and promote competition that includes pricing rewards/penalties. The current system doesn’t really allow consumers to reward good doctors and good hospitals with their business, nor does it allow them to reward those doctors and hospitals who work hard to lower costs. There is no reason why patients should not have access to data about individual physician costs and quality metrics, as well as information about hospitals and other facilities. Physicians who provide too expensive care or poor quality care should feel a financial motive to improve, driven by a savvy segment of their patients who shop based on quality and low cost. What is quality? Quality ratings should include things like overall cost of care, adherence to evidence based guidelines, and appropriate utilization of resources. In Atul Gawande’s article ‘Overkill’, he discusses a 2010 Institute of Medicine report that found that some $750B per year was spent on waste – mostly unnecessary health care services – each year. This number (more than is spent on all K-12 education in the US) is more than 23% of all healthcare dollars. These unnecessary services are mostly eliminated if physicians adhere to evidence-based guidelines. Quality care and lower cost are intimately related. Please read The Financial Impact of Not Utilizing Evidence-Based Medicine.
  6. Legislate transparent pricing for all services with fixed and rational costs. The truth is, doctors and patients really have no idea how much services actually cost. Patients are often not financially incentivized to care about the cost of labs or imaging, and doctors check boxes without really understanding the value of the service to the patient, rapidly spending thousands of dollars in a few seconds. Patients and physicians need a cost sheet so that they fully understand what they are spending, and then better appreciate its worth to them. Transparent pricing includes making the cost of health insurance itself transparent. Private health insurance companies spent over $1T dollars on healthcare in 2015, and patients spent another $338B out of pocket. They should know exactly what they are getting for those dollars. Most employees who receive health insurance through work don’t really appreciate how much their employers are spending. A worker making about $20,000 per year may have another $20,000 per year spent on healthcare for her and her family, but because she only pays a small premium each month for that insurance (say 10% of the monthly cost while the employer contributes 90%), it doesn’t feel like she is spending half of her income on health insurance – but she is. Let’s pay her $40,000 per year and make her write the check for the full amount of the premiums. This will greatly increase her interest in the largest single expense in her budget and she will demand low cost and high quality.
  7. Make all patients have some degree of financial responsibility. Patients usually have no concern about healthcare costs, particularly if they are a government-insured patient. Since they are responsible for none of the cost, they don’t care what that cost is. On the other hand, those patients with high-deductible insurance plans may avoid accessing healthcare services at all because they will be paying for 100% of the outrageous cost until their deductibles are met. Of course, once that $5,000-or-so deductible is met, then they want as many services as they can get, regardless of the cost. Both extremes are broken and do not really engage the patient to be a savvy consumer. Instead, patients should always pay 10-20% for every service (up until a predefined cap that varies with expense of policy). This will empower patients to make better financial decisions and promote competition among providers. But it must be every service – every prescription, every test, every surgery. The out-of-pocket expense can still be capped, and this cap will effect premium prices. But if a patient has to pay 10% for her hysterectomy, she will choose a hospital that charges $5,000 for that service rather than $55,000; or if she needs an antihypertensive drug, she will pick the one that costs $3 per month rather than the one that costs $350. Patients are our best check against run away costs, but under the current system, they are not engaged.
  8. Mandate a low-cost catastrophic plan for those who don’t have (or don’t want) normal insurance. I opposed the individual mandate that was part of the ACA (Obamacare). But I am not opposed to mandating that patients have catastrophic plans. Such coverage is in the public interest in the same way that liability car insurance is in the public interest (but not comprehensive coverage). If I drive a car and hit you, I am required by law to have liability insurance to pay your expenses, but I am not required to carry insurance to pay for my own losses and my own car. In this same way, it is reasonable that patients be required to carry a catastrophic plan that picks up costs over, say, $250k, but nothing under this amount. If a patient otherwise chooses to go uncovered, they will be responsible for every dollar up until that threshold is reached. Such insurance would be relatively inexpensive and could be based on the patient’s age and perhaps living will intentions. This type of catastrophic policy would also dramatically lower the cost of all other insurance products, because those companies would have a cap for the risk they are assuming by providing coverage to each patient. Most of us would never use the plan, but if it became necessary, it would save our families from bankruptcy and hospitals form unpaid bills.
  9. Encourage more humane and rational end of life care and more clear end of life planning. We spend probably about 30% of healthcare dollars on end of life care provided in the last year of life. Frankly, many hospitals, cancer clinics, and doctors are predators – seeking every last dollar from elderly patients for care that does very little to extend life or provide meaningful quality of life. We need a society that promotes death with dignity, not death with exploitation by the healthcare industry. Too many families see their inheritance depleted by vultures picking the last bit of flesh off the bone. The fact that nearly 1 in 3 dollars are spent on the elderly in the last year of life demonstrates a serious gap in personal and societal ethics. A serious public debate about euthanasia should be part of this conversation.
  10. Demand transparency about the risk/benefit ratio (and cost/benefit ratio) of our interventions and services. Just as we exploit the dying to make a buck, we do tons of unnecessary interventions just to make money with very little or no benefit to the patient. Many surgeries are performed unnecessarily: 70% of hysterectomies, 12% of angioplasties, 22% of pacemakers, at least 17% of spinal fusions, 26% of hip replacements, 38% of knee surgeries, and probably half of cesarean deliveries are unnecessary (sources). Overall, 10-20% of surgeries are performed for no benefit. Even when benefit is present, it may not be worth undergoing surgery to the patient. The same issue exists for prescription drugs; it is estimated that at least 1 in 3 drugs are unnecessary and many more provide such a marginal benefit that the cost/benefit ratio is probably not justified. Doctors should be required to express risks and benefits to patients in numbers that can be understood, like numbers need to benefit or harm, and costs of interventions should, of course, be transparent. Please read Lesson #5 here if you haven’t already.

Bonus tip: Healthcare is not a right, it is a privilege; that doesn’t excuse us from decency and charity. Nothing that can be paid for can be construed as a right. The freedoms of speech and assembly don’t come with a cost to the right-bearer nor to the entity that grants the right. If you haven’t recently, take a look at our Bill of Rights; nothing in there costs a penny. I have the right to own a gun, but the government isn’t obligated to buy me one, nor are any of my fellow-citizens; if I want it, I’ll buy it, and me being unable to afford a gun doesn’t compel you to buy one for me.

There are a lot of things that are hard to live without, but that doesn’t give us a Constitutional right to posses them. Imagine if car ownership were a right: would everyone have a Pinto or a Ferrari? If everyone drove a Pinto, then innovation would by stymied and quality low. By everyone having a Pinto, the true right to car ownership would actually be dampened because choice and aspiration are removed; even if everyone had a Ferrari, some would want minivans and Toyotas instead (or maybe a Rolls).

In any event, the dream of universal Ferrari ownership would bankrupt us all. If this sounds like a false comparison, it is not: most poor Americans would prefer to have a functioning car with prepaid maintenance and gas expenses than health insurance. Mobility in most parts of the US is key to pursuing the American dream (to getting a job, visiting friends and family, even going to the doctor). The point is, healthcare is a luxury, not a right. We cannot lose track of this fact in our public discourse.

If we choose to define healthcare as a right (a relatively modern idea), then we must constrain it. What are the minimum aspects of the medical industry that must be granted to all? Breast implants? Lasik eye surgery? And what are the maximums? Liver transplants for 90 year olds? Perpetual life support for someone who is brain dead? By robbing people of their choice in healthcare, we rob them of their freedoms. It would be akin to granting you the right to free speech as long as what you say is contained on a certain list (don’t laugh – we live in an age where more and more people believe that speech should be limited). If it seems crazy to you that healthcare shouldn’t be considered a right, then you probably work in healthcare and have a rather biased and myopic view. Just because it is a priority for those of us in the field doesn’t mean it is a priority for others.

The belief that we should work to give healthcare to everyone in need has nothing do with the belief that healthcare is a fundamental right. Indeed, imagine a world where medical charity was common (right now the tax code doesn’t incentivize it and regulatory hurdles all but prevent it). Such changes are needed so that we can truly fulfill our ethic to serve those in need. But in the meantime, we must face the reality that serious (and painful) reforms must happen, or none of us will be able to benefit from healthcare in the future.

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People Still Matter

Laparoscopic Burch

Laparoscopic Burch Colpopexy

Uncontrolled variables are a huge problem with every scientific study. When we compare two blood pressure medications to one another, the results will have more validity if the two groups of patients are very similar in every characteristic. Differences in age, severity of preexisting disease, ethnicity, gender, etc. could make whatever conclusions are found next to worthless. Randomization and blinding are our best available tools to control for variables – both those we recognize and those we don’t – as well as for controlling for biases that we are aware of and those we haven’t even imagined.

Yet studies comparing one drug to another – fraught as they are with complexity and unknowns – are still incredibly simple when compared to studies that compare surgical techniques to one another. Not only are randomization and blinding major issues, but the individual skill of the operator (which can’t be controlled for) may turn out to be the biggest variable, and there are serious concerns about the general applicability of the findings of any surgical technique study.

Imagine we were comparing the quality of kitchen cabinets built with two different machines, say two different types of wood shapers. We select a variety of outcomes to follow. Some are subjective, like beauty, sales price, and machine operator satisfaction (compare to pain scores, cosmesis ratings, or surgeon satisfaction), while other are objective, like time to manufacture, material wastage, and cost (compare to operating room time, complication rate/blood less, and cost of procedure). The tricky bit comes next. In order to produce a higher quality study, we would like to track several thousand cabinets of different sizes and styles, and we would like to do so in a short amount of time.

We could find two different factories that already use the two different methods and look at their outcomes, but that’s not very satisfying. There are many hundreds of other important differences in the two factories that might actually be responsible for the different outcomes, and adjusting for even the known variables is an almost impossible task, let alone the unknown variables. So we can either have the same factory use the same methods and then switch to another method, have different factories using a third method switch to new methods, or some other mishmash. What’s worse, individual machine operators within each factory may have vastly different levels of skill and expertise.

A very competent and seasoned machine operator may get excellent results out of both machines, while I (having never used either) may get bollocks from both. Or, someone very competent with one machine may struggle adapting to the other machine and vice versa. A new method or machine may have a steep learning curve, and learning curves vary widely. Someone naive to both machines may still have inferred skill from another similar process with which he has competency. A group of naive operators may produce better results overall with the machine with a shorter learning curve, even though in the long term (after the study has ended), the other machine is vastly superior. What’s more, the folks who design and implement the study may favor one machine over another (perhaps their company makes that machine) and when they teach operators how to use the two machines, they are just simply better at teaching their own machine (because they have more experience with it, more familiarity, truly believe in it, etc.).

Such are the problems with surgical technique/tool studies. It should suffice to say that an excellent surgeon is likely to produce better results with the worst technique on most days than a bad surgeon will produce with the very best techniques on the best days; and, in most cases, a surgeon will do much better with a technique with which she is familiar and accomplished than she will with a new technique with a steep learning curve. It turns out, people truly are the most important variable in such studies.

Randomization is difficult. Usually in such a study, different operators who use different techniques are being compared, so it is difficult to truly randomize the technique to the patient. Blinding is nearly impossible; obviously the surgeon knows what method she is using. These pitfalls automatically tend to land studies about surgical technique near the bottom of the quality evidence pile.

Even if these limitations can be overcome, the general applicability of a technique may be wanting. Just because I’m really, really good at something – and demonstrate it with super-awesome reports of my amazingness – doesn’t mean that everyone else can read a paper or watch a video or attend a weekend workshop and all of a sudden share in those amazing outcomes. A technique may be amazing, but if it is not generalizable to a large population of average-skilled surgeons (and assistants), it doesn’t mean a whole lot.

Take this study for example, which found that laparoscopic hysterectomy (LH) was associated with less pain, less need for pain medicine, and a shorter length of stay than vaginal hysterectomy (VH). This study was heavily promoted by the surgical equipment industry, since it purported to show a definitive advantage of LH over VH. The patients were randomized to receive one of the two surgical approaches and the surgeries were performed by the same team, who presented themselves as adept at both approaches. But were they? Are these finding generally applicable?

For starters, they did not use two techniques of VH that are known to decrease postoperative pain (an energy sealing device for sealing pedicles and intraoperative paracervical blockade). But aside from this, the most telling statistics presented in the paper are the average lengths of stay: 1 day for LH and just over 2 days for VH. This is simply an amazing statistic for VH length of stay in an era where same day discharge for VH is common (I personally have sent hundreds of VHs home within 5 hours of surgery). This bizarre finding tells me that the surgeons were simply more skilled with LH than VH.

What was purported as a strength of the study (the same surgeons performing both approaches) is actually a weakness when we realize that they are not equally adept at both techniques. The article reports no conflicts of interest, but a simple Google search reveals that the lead author (Ghezzi) has a financial relationship with Karl Storz GmbH & Co, KG, whose products he endorses in this and other articles. Hmm.

Not all great surgeries are generalizable. Here is Part 1 and Part 2 of an awesome straight-stick, laparoscopic extraperitoneal aortic lymph node dissection. This guy is fantastic and if I were a woman with cancer I would let him operate on me. But his skill level and seeming ease in doing a complex surgery are not necessarily teachable to average surgeons. Fun to watch, but I don’t expect the average surgeon to be doing this anytime soon. Sometimes the techniques that get published for certain surgeries or a certain series of patients reflect outcomes and complication rates not attainable by we mere mortals. That’s okay, but it reinforces the idea that sometimes the best surgery is the one we can all do well.

The point of all of this is that when it comes to surgery, the surgeon (in most cases) is by far the most important factor in outcome differences.  This excellent piece discusses some research that drives home this point (and shows some cool videos). If you are interested in finding out who the “good” surgeons are, by the way, don’t waste too much time looking. With a few noted exceptions, such transparent data simply isn’t available. Because surgeons fight against such transparency, there is sometimes an idea that we are all interchangeable cogs of a machine; scientific studies need to assume this for standardization and employers and payers don’t always recognize the importance of high quality physicians.

But the skill of the surgeon is likely the single most important variable of any surgery. Are all board-certified OB/Gyns equal? Of course not. There is a wide variation in competencies and outcomes. Cesarean delivery rates range from around 10% to over 60% among obstetricians in similar communities who are supposedly all following the same evidence-based labor management guidelines. Vaginal hysterectomy rates vary from 0% to 95+% among board-certified gynecologists. Are we all equally competent? Hardly.

The surgical skill of surgeons, like most things in life, tends to fall along a bell-shaped curve. If we want to improve the quality of care provided to a wide variety of our patients, there is only so much that we can do in terms of increasing the surgical skill of surgeons. Residency programs are providing fewer opportunities than ever to develop the surgical skills of our future physicians (too much too learn, too little time to do it, and fewer patients who need complex surgeries). Some skills are being lost to history as the techniques and practice of them are going extinct with a retiring generation of physicians (e.g., breech delivery, Scanzoni maneuver) while other skills are threatened species that exist only in some zoos and preserves (e.g., vaginal hysterectomy, external cephalic version, forceps delivery).

To increase the quality and safety of surgery, we need to address improving the surgical skills and education of our residents and young physicians in practice. But we also need to focus on enabling technologies.

An enabling technology is an innovation or invention that can be used to enhance the ability of a user. The personal computer is an example of an enabling technology. I can do a lot more things today (make movies, edit photos, write this blog, do calculus, make music, search the world’s libraries, etc.) than those who lived a generation before me; and I can do them better, quicker, and cheaper.

Ted Anderson (Vanderbilt University) has described this concept extensively in the field of gynecology. He points out that global endometrial ablation devices (like the NovaSure) are an example of an enabling technology. Ted is an expert in rollerball endometrial ablation. Yet it is unrealistic that he will be able to train the vast majority of gynecologists to be as good as he is; apart from innate skill, there just aren’t enough cases available for learners to gain sufficient experience. The outcomes of rollerball ablations performed by his trainees are considerably subpar compared to outcomes of his own series of hundreds of rollerball ablations. But with endometrial ablation devices, his learners can achieve similar outcomes. What’s more, the safety of endometrial ablation devices, cost, length of surgery, etc., are all superior. So without having to make surgeons dramatically better, we can extend the safe, quality outcomes of endometrial ablation to millions of women, not just the few thousand who have access to high quality surgeons like Dr. Anderson.

The mid-urethral sling is another example of an enabling technology. Prior to transvaginal (TVT) and transobturator tapes (TOT), incontinence procedures required a considerably greater amount of surgical skills and were more morbid for patients. Only a small percentage of gynecologists were good at things like retropubic urethropexies (i.e., Burches and MMKs) or pubovaginal slings with harvested autologous materials. I enjoyed doing laparoscopic Burch procedures and always thought it was a fun surgery; but I would much rather teach a resident how to do a TOT. I can teach almost any resident to do a TOT, but a laparoscopic Burch to only a handful. A TOT is therefore an enabling procedure: it greatly expands the reach and safety of incontinence procedures.

Use of an energy-sealing device (like the Ligasure) for vaginal hysterectomy is my favorite enabling technology. The device greatly expands the number of gynecologists who can competently perform vaginal hysterectomy and it also greatly expands the number of women who are candidates for vaginal hysterectomy. Patient outcomes are uniformly better, and even though we have to spend money on the device, total cost goes down due to shorter surgeries, fewer complications, and shorter lengths of stay.

An enabling technology might also be a particular technique for a surgery. An enabling technology doesn’t necessarily provide the best outcome in the best hands, but it provides the best outcome in average hands. There are dozens of similar examples. Yet, many surgeons are opposed to using enabling technologies. Imagine if you went to work for a typesetter who refused to let you use your computer and laser printer because “real” typesetters should know how to make lead-type by hand or use a Linotype machine. It may make him feel superior to all the ‘hacks out there using Macs’ but he is providing more expensive work to fewer clients for higher cost. He will soon find himself without any clients (or students).

We should all embrace enabling technologies. The hallmarks of a great surgeon are not stubbornness and anachronism but rather flexibility and innovation.

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I Read It On The Internet…

echo

Most people, it turns out, aren’t really all that skeptical. The 2016 election has taught us that what passes as ‘news’ isn’t always very true. Fewer and fewer things seem implausible to people who have stopped being surprised by what once was seemingly impossible; and folks don’t distinguish between what’s possible and what’s probable. There are three different issues that independently and sometimes simultaneously lead people to believe untruths. Let me explain.

  1. The Echo Chamber. People tend to give credence to those who echo their current beliefs (whether true or false). It is easy to understand how the Confirmation Bias leads  people to accept evidence or arguments for their current beliefs without any skepticism or fact-checking. If you already believe in aliens, then you will take every report of a possible alien sighting as further evidence that you are right, without questioning the veracity of those reports. But once you enter into an echo chamber filled with fellow alien believers, you are more likely to give blind credence to any other unrelated stories they might have to tell. You didn’t enter the echo chamber believing in unicorns, but once you heard about unicorns from fellow UFO gazers, you were convinced. Otherwise highly discredited sources are in this way given too much credence because they dovetail nicely with some current belief (where true or untrue). If you are right about the truth being reverberated in the echo chamber, that still doesn’t validate accepting other information without scrutiny. Being right about one thing doesn’t mean you are likely to be right about another thing.
  2. An awe of science. A recent poll indicated that 45% of Americans believe that aliens have visited Earth (and, yes, those space cadets are allowed to vote). What’s really sad is that this number is at an all time high. Widespread belief in extraterrestrials began in the 1950s with incredibly cheesy reports of UFO sightings and abductions. But a large portion of the non-skeptical and willing public accepted these amateurish claims because they truly were in awe of science. Yes, that’s right: they accepted them because of science. Imagine being an adult in the 1950s: in your life time, you had seen the emergence of the car, the plane, the computer, and the atomic bomb. The world that was had been overturned by a never-ending onslaught of science. Penicillin, insulin, and the polio vaccine were modern miracles. Nothing seems out of reach. So the idea of flying saucers and alien visitation actually seemed to comport with science, not contradict it.An awe of science is vastly different than an understanding of science. An actual understanding of interplanetary distances and physical limitations in travel speed (something less than the speed of light) should all but convince anyone of the virtual impossibility of alien visitation to earth. Yet, public tax dollars are today being spent on searching for life in outer space. Modern society is no longer awe-struck by the next big scientific breakthrough; but with little general scientific understanding, most people cannot tell the difference between the conclusions of this work on the transformative hermeneutics of quantum gravity and the conclusions of this work on Bohmian mechanics. Scientism is dangerous when we accept anything just because it is veiled in science.
  3. Respect of the establishment. Einstein said, “Blind belief in authority is the greatest enemy of truth.” Just as science has become an establishment of sorts that is accepted too nonchalantly, so also we tend to accept news or truths from those people, businesses, and institutions that have gained come credibility in our eyes. If the government says it, or CNN, or NASA, or Oprah … it must be true (or maybe it must not be true, depending on your predisposition). In fact, when CNN runs pieces like this one, ‘How to outsmart fake news in your Facebook feed‘, they are seeking to gain that sense of establishment from you (“Trust us, not those other guys”). But CNN, like every other outlet, makes serious mistakes, reports false news, accepts bogus tips, and draws false conclusions based on bias. Just last week, CNN falsely reported on itself. It is true that some organizations deserve more scrutiny than others (I’ll take CNN over these guys any day, but I will remain skeptical of everything I read). The Internet adds a new source of establishment – crowd sourcing. We see positive elements in crowd sourcing, and Wikipedia and Reddit are, for the most part, examples where crowd sourcing works well. But just because something has a lot of hits on YouTube doesn’t make it accurate.

Our patients (and our colleagues) source information in this way. Don’t be surprised when they present with far-fetched ideas (“my IUD is causing me to have headaches”) because they definitely “researched it” and have it on good authority (here and 124,000 other places). This trending video on Facebook, published by the respectable sounding healthforallwomen.com, currently has over 12 million views (and counting). Why so many views? Because it is a video about the “health benefits” of not wearing bras (hopefully you can figure out why it so popular). Among the video’s several claims is that wearing a bra increases the risk of breast cancer, up to 100x! This type of social media-promulgated drivel is what our patients see and accept at face value. Before you hate on Facebook, realize that a video like this is no less factual than a typical episode of Dr. Oz. This same website also recommends using milk thistle and dandelion root to counteract the oncogenic effects of estrogen. Wow. Does wearing a bra increase the risk of breast cancer? No it doesn’t, but as of this writing about 12 million more people have watched that video than have read this article.

Often, our patients are most convinced by the experiences and opinions of other patients, found on message boards and chat rooms. These sources of information seem to be the best to them, since other patients appear to answer their common questions honestly and without ulterior motivation. But, this source of information is often the least informed and least evidence-based. We call it anecdotal evidence. This type of evidence is betrayed by the patients’ biases, false conclusions, and misassumptions.

So are doctors any better? Not in the least. The lack of robust skepticism is not related to educational attainment. Physicians live in echo chambers. They associate with colleagues who echo back to them their own practice patterns and beliefs. Physicians accept things as true because of science that they don’t really understand, believing that a p-value below 0.05 is as good as gold (especially if the conclusion of the study already agrees with what they thought anyway). Physicians have their own establishment and authority figures: if a study is printed in the New England Journal of Medicine, it is often given a pass as factual, high-quality, and impactful. And physicians crowd source information (e.g., regional standard of care) and ask their colleagues what to do (e.g., curbside consult) rather than analyze a problem using high-quality evidence (when available). The majority of physicians narcissistically prefer anecdotal experiences over systematic evidence.

We all need to step out of the echo chamber. The more firmly you believe something, the more vigilantly you should seek to challenge it. Be skeptical of all sources of information  and seek to disprove what you read, like a true scientist. Don’t accept anything just because it makes sense, nor reject anything just because it seems implausible or unconscionable. Seek quality evidence for all your beliefs and theories. Consider the real possibility that you might be wrong about almost everything you believe.

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Filed under Cognitive Bias, Evidence Based Medicine, OB/Gyn