Clawback provisions in medicine?

There was a great review of the non-surgical management of appendicitis by one of the senior residents yesterday during surgery grand rounds, our weekly educational conference.  She showed data from two randomized controlled trials one done in sweden and one in the US showing that non-surgical management of an infected appendix was indeed possible and efficacious 90% of the time. Despite this data, she did not suggest that we try nonsurgical management for appendicitis (she probably would have promptly been excused from the room). Instead she simply suggested that medical management be recommended in cases where patients are not good surgical candidates such as when they are elderly with heart problems and taking drugs that thin the blood and increase the bleeding risk. Despite this seemingly modest suggestion and some pretty strong evidence, several older surgeons in the room were pretty adamantly against this sort of “uncomfortable medicine”. One reason given was, well if I didn’t operate on this patient I would be really worried and have some sleepless nights wondering whether I should have operated and I still might take them to the operating room.

This made me feel that we still have a long way to go before we “change” medicine. After all, what manager (hospital administrator) would fire their productive employees (surgery is still very profitable much more so than medicine)?

One idea I thought of was the idea of having a clawback provision in medicine. Like with airplane parts manufacturers whose supplier contracts may include what is effectively a “guarantee” that if anything went wrong with the manufacturing that was attributed to a manufacturer error, the supplier could “claw back” their purchase of the engine. Perhaps if suppliers in medicine such as device suppliers, pharma companies, physicians themselves were subject to such a provision. For example, pharma companies have to guarantee that their treatment was for the proper diagnosis as enforced by audit. Would that herald more high quality diagnosis in medicine?

Sleep is good

Amazing what happens when you get 7 hours of sleep! Yesterday felt very blah just as described in my last entry but today even though I was on call and slept in a call room last night, getting 7 hours feels awesome. I feel energized physically and emotionally and headed home ready to plan some productive and some fun things like planning a Xmas party, sending out some emails, working on some things, going to the beach, working out. I keep thinking of what Dr. Oz says were the four keys to changing one’s behavior to reduce stress eating 

1) Don’t drink in calories – get rid of sugary drinks, juices, milk, it strikes me that the reason I drink juices are that they are easy and cold, one thing worth looking into is an easy cold drink I can make at home. I think having ice readily available (auto ice maker) and something with milk, honey and lime would be excellent if I can make it

2) Sleep! – Ozgur sleeps 7-7.5 hrs a night and if he can do it and still be the Vice  Chair of an academic surgery department, researcher, teacher, surgeon and have his own prime time show and have time to read to his family, what excuse do I have?

3) Keep moving – US Preventative task force recommends 150min of activity per week (half hour a day) – I think for compliance purposes I am going to try for daily activity just in the same way once daily dosing is more effective than any other regimen for drugs

4) Stress buddy – I find that even thinking about Jane before I make bad behavior choices is great, I can hear her voice “don’t do it bear! Its bad for you!” and it replaces the empty calories with a smile

A wedge of lemon, warm compresses and a touch of TLC

First night on surgery call and had an 86yo lady with “frozen bowels” aka postoperative ileus. She had just had her bladder removed five days before and was having a prolonged recovery from surgery. Because her bowels were not moving which is a common condition after surgery, she developed nausea and vomiting and had to have a tube placed in her stomach to drain the vomitus out and we were keeping her “NPO” which means nothing by mouth. I noticed this morning that she had some swelling of her left cheek just above the angle of her jaw. This progressively worsened and became very painful over the course of the day to the point she was grimacing in pain and not moving her head at all due to the pain. After a quick consult with Jane, I thought she might have an infection of one of her salivary glands from lack of salivation due to not having anything by mouth. It turns out I was right and with a little massaging of her cheek, I was able to get a whole bunch of pus (and hopefully a stone) out of her mouth. The treatment is actually something my mom could have come up with: twice daily massages to get the pus and any stones out, warm compresses and wedges of lemon to stimulate the gland to secrete saliva!

Afterwards she felt better and I felt super satisfied! Where else in medicine can a little TLC, some lemon and warm compresses do THIS?? :)