Monday, February 22, 2016

Procedure Meat: How Procedural Lust Imperils Patients

I'll start with a macabre anecdote of crassness, to get everyone's attention.  It is apropos because procedural lust has crass and macabre consequences.

It was about 17 years ago, while I was in training, that an attending accepted a moribund woman from a faraway place in the hinterlands.  She had multiple hepatitides and uncontrolled bleeding from esophageal varices.  A collective groan among the housestaff met notification of the incoming transfer which would keep everybody up all night with the inevitable death forestalled only briefly, and in a streak of his usual candor, the attending admitted that he accepted her not because he thought there was anything that could be done to help or save her, but because she would serve as good "procedure meat for the interns."

There are a lot of problems with that entire episode as I reflect upon it, and I won't dissect them all here.  I've been thinking about procedure meat because I so often see physicians feasting on it, to the peril of the patients.  Ideally, each and every procedure that is done ought to be done because it is in the patient's best interest to have it done.  All too often, ulterior motives and unstated goals creep into decision frameworks and lead to unnecessary procedures and therapeutic misadventures.  To combat this problem, we need to start nudging physicians to consider and patients to ask directly, "Is this procedure the best thing for me?  Are there alternatives?  Do the expected benefits outweigh the costs and risks?  Where will I be in six days, six weeks, six months, and six years as a result of the proposed procedure?  Where will I be at those times without it?"

Several years ago a now deceased surgeon admitted to me that he wanted me to keep alive an octogenarian with dementia, bowel perforation, and sepsis on whom he had operated "at least until day 30.  I don't care what happens to him after that."  He was interested in his 30-day mortality statistics.  When I pressed him on why he operated in the first place, knowing that the outcome was likely to be poor, he confessed:  "Look, do you think if this was my own father I would have operated on him?  Hell no.  But I'm a surgeon.  I'm trained to operate.  It's what I do."  (That link is worth a click.)

As they say, the first step to recovery is overcoming denial.  With procedures, physicians often deny that they are doing them only or primarily because they lust to do them or they are compensated in some way for doing them.  As I have stated before, this often begins in training programs where trainees are taught to seek out procedures for the experience of doing them.  Rather, we should teach trainees judiciousness in their decision making.  Later when in practice, coupling of remuneration with procedural volumes reinforces the training effect.

I've insinuated that reimbursement reforms and more honesty and common sense in decision making can combat procedure lust, but I have no illusions that these are coming soon.  What, in meantime, is a patient to do?  The gold standard, in my mind, is to have a reasoned and careful discussion asking the questions in bold above, as well as others.  This is difficult, and I expect it may engender some resentment and frustration if patients (and other physicians) push physicians who may be in denial to answer these detailed questions about expected utility, goals, competing possibilities, and evidence.  But there are some heuristics, or rules of thumb that may suffice:
  • Consent to a surgery or procedure only if it is relatively clear that there is no alternative, especially if surgery can be delayed while attempting alternatives without obvious costs/tradeoffs/risks
  • Get a second opinion from a different physician
  • Ask directly about financial benefits to your physician from doing procedures
  • Ask your physician if he would do the procedure on his or her mother or his daughter under similar circumstances - or would s/he nudge them towards alternatives, saving surgery as a last resort?
Finally, consider approaching these decisions with an emphasis on cost.  The only thing that proceeding with procedures guarantees is cost, an incision, anesthesia and its risks, the risks of complications, etc.  Those things are guaranteed.  I would consent to a procedure or surgery only if it was abundantly clear that those factors were clearly outweighed by surgery, or if the alternatives (all of them) were not an option  or had already failed.

9 comments:

  1. I can't believe your attending had the audacity to say that out loud. (Yes, I have no doubt some of my attendings thought the same thing in similar cirumstances...I'm not that naive).

    Kind of on the same subject, what would you tell your patients if you were to be supervising housestaff to do a procedure on them (like a central line for instanct)? In my hospital, all procedures require an attending to be present (which is a good thing, given the low volume of procedures the housestaff get to do, with the resultant low skill level). I tell the patient/surrogate, "Dr. so and so will be assisting me with the procedure", when in fact, I will be letting them do the procedure (albeit with me scrubbed in at their shoulder and watching them like a hawk). Sometimes I wonder if it's dishonest to let the patient/surrogate think that I'll be doing the procedure, when in fact, a trainee will be doing most of it.

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    1. Attendings have to be scrubbed for central lines? At my place we do lines and chest tubes with the attending asleep at his house. I cant imagine having to wake up an attending and have him come in so I could place a central line.

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    2. I work at a private community hospital, whose parent corporation has recently experienced two disastrous complications by resident-placed central lines (one tension pneumothorax where the patient almost died, one triple lumen placed in a carotid artery) in a couple of their other hospitals. Therefore, the corporate masters decreed the new rule.

      At night, well-trained and experienced PA's place all invasive lines, and anesthesia is in-house 24/7 for airways. As far as chest tubes, I have had to come in once to do one of those (and internal medicine residents would never do that procedure anyway).

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    3. We are fast approaching a time when IM residents don't get to do ANY of these basic ICU procedures because we recognize that we need to consolidate the experience of the fellows. It makes little sense to "waste procedure meat" on an IM resident going into any specialty other than PCC or cardiology. We should allocate this valuable resource for those and their future patients who will most benefit from the patients' sacrifice.

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    4. Im pretty sure I have placed more lines this year than all of my attendings combined (apart from ports placed in the OR).

      I would be interested to see research on if attendings actually have lower complications. The majority of complications I have see are from ED and medical attendings placing emergent lines.

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    5. "Im pretty sure I have placed more lines this year than all of my attendings combined (apart from ports placed in the OR)."
      The caveat here is the old saying, "your experience may vary"

      Without seeing any research, I feel fairly certain number of complications have zero correlation to attending vs resident/fellow status, and a high correlation with the volume of procedures that the operator regularly does. It's the old adage, the more you do it, the better you become at it. For instance, one of the PAs I work with has been working in critical care for 20+ years. I have no problem admitting that he's probably better at central lines than I am (I only started doing central lines 13 years ago during my intern year).

      It seems that the housestaff in your hospital does a lot of procedures, which will naturally lead to a higher skill level, which is great. In my hospital, on the other hand, various factors (political, corporate, and otherwise) operating over several years have led the the residents having fewer and fewer opportunities to do procedures, which leads to slippery slope of declining skill levels over the years.

      This kind of goes to Scott's point, is that we need to ration the declining resource (procedural experience) to those that will benefit from it the most. I will let the prelim intern who is going into anesthesia, or the categorical who wants do to pulmonary/critical care, do the central lines when I'm on service. The prelim going into PMNR or the categorical going into outpatient primary care, on the other hand, will get a polite but firm "no". Again, this does not apply to every training program (it appears to not apply to yours).

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  2. I've thought a lot about this. In the strictest sense, yes it is a lie and it does not respect patients' autonomy, and it jeopardizes the legitimacy of the consent process. On the other hand, we do it all the time, so we must classify it as more of a "white lie." If we were unwilling to tell a white lie, we could obfuscate and create the "appearance" of the resident assisting in a variety of ways, thus making our involvement a ruse. Because our intents are internal thoughts, it would be hard to get caught. So in this analysis, I would say that strictly speaking, yes we need to inform patients that so and so is a trainee and s/he will be learning on you with my supervision, and there may be a further obligation to tell the level of experience of the trainee also. Or we intentionally or by convention without thinking about it, undermine patients' autonomy by withholding information that a reasonable person may want prior to granting consent for a procedure. It's tricky business on the slippery slopes.

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    1. Yea, how many patients/surrogates would consent to a trainee performing an invasive procedure on them? Not many. I think the "white lie" may be a subconscious sacrifice of some of the patient's autonomy in order to serve the greater good (of future patients). The greater good in this case is ensuring that the trainee physicians will be skilled enough to perform these procedures safely in the future (and then pass on those skills to their own trainees), when the the current generation of physicians will be long retired and playing golf in Florida.

      Or this could all be mental gymnastics on my part to make myself feel better about it.

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    2. I have acted in the past, generally as you have - the white lie approach. But if I'm going to be critical of myself, I have to admit that Immanuel Kant would not be impressed - because I'm using the patient not as an end in himself, but as a means to another end. Granted, not all philosophers and ethicists agree with the Kantian perspective.

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