Category: Opinion

One Size Does Not Fit All

Post author By Lindsay Marszal
Post date December 11, 2014
No Comments on One Size Does Not Fit All

I recall being fresh out of my first year of medical school and ecstatic to be spending my break not in a class room, but at an actual pediatric oncology unit. The night prior to my first day in clinic, I spent time reviewing immunology and looking ahead at the oncology lectures from the Clinical Medicine class I would take the next year in school. I wanted to be prepared in front of my new mentor.

The next morning, I hardly had time to impress my preceptor let alone introduce myself before we were running around. We stopped at the pathology lab. I gazed through the microscope, trying to remember what I had read the night before about identifying abnormal cells.

“I have a new patient that arrived today. She is very sick. We have to tell the family the definitive diagnosis. Come with me.”

We urgently walked up to the inpatient floor into one of the rooms. A beautiful young girl was sleeping in the bed. Her parents and grandma were diligently by her side. They froze and looked at the doctor. This was the final confirmation they had been waiting for. They held onto the hope that they had been sent to the oncology floor by mistake.

“We have confirmed that your child has a rare cancer.”

I watched as any sliver of hope vanished from their eyes. They would not wake up from this nightmare. The moment my mentor delivered the diagnosis, I could feel the world take a 180 eighty degree turn for this family. It was as if their world froze at that moment. How could this be? The child looked so peaceful, fast asleep while hospital monitors blinked around her. Just a week ago, they were running around to sports practices and dentist appointments and going through the everyday motions that we consider to make up a normal life. I’m not even sure that this family was breathing at this moment. The room became deafening silent as all the color drained from their faces. The doctor proceeded to talk about what would happen in the days to come. What did this mean for their child?

Just when the family (and I) didn’t think it could get worse, they were told about the side effects of the medications – the only option to treat their child’s condition. The doctor began with the common side effects like nausea, vomiting, hair loss. Next, cardiomyopathies. Neuropathy. Loss of reproductive function. This is when this family broke. Loss of reproductive function. I always thought the diagnosis would be the hardest thing to hear. For them, the breaking point was learning of the adverse effects of the very medications intended to save the child’s life. These medications are meant to represent hope, protection, and reassurance for a life beyond disease. The doctor paused again, giving this family time to just cry. Tissues went around.

“This is hard. Take your time. I am here for you throughout this entire journey.”

I watched the mother of this little girl look at her own mother. It was a look of despair, yearning for answers that wouldn’t come. Even if her child survives, bits of the future have already been stolen. We left the room after two hours to let the family have time to process.

Outside of the room, I tried to process what I had experienced. The information I read in my textbooks and PowerPoints did not prepare me for that interaction. I looked at my preceptor for guidance.

“This is real. This is hard. We will fight with them, though. We do everything in our power not only to treat the cancer, but to make sure that cancer does not define their life. This is what we do.”

Throughout the rest of my summer, I went on a roller coaster from new diagnoses to the “completion of chemo party”, from being declared cured after a 5-year visit with no evidence of disease to the tragic death of a child. I watched children balancing school with chemo. I watched teenagers struggle with fear and bravery while grasping at any chance to maintain their independence. I watched parents struggle to care for a sick child while still being present for the other children they left at home. The things I learned that summer could not have been taught in a classroom. With every family I met from all over the world, I witnessed raw and vibrant emotions: fear, determination, sadness, and never ending hope, even in the wake of death. It is this hope that I take with me. It is contagious. These are the emotions that makes us human.

At one point during the summer, I asked my mentor what the secret was to enduring such difficult clinical conditions. I had watched him interact with all of his patients each day. Every single one loved him. The mother of that little girl later told me how he was able to comfort them, cry with them, joke with them, and laugh with them with such ease. He was able to guide them through this journey, with the help of hospital resources, to give them a life within this new normal. In response, he said:

“There is no such thing as being the best doctor in the world. You have to be the best doctor in the world for the patient sitting in front of you. That is my first priority, more than my research or my teaching. Get to know you patients and their families. Learn from their stories. Keep fighting to improve. That is how you become the best.”

So much of early medical education involves pouring over books and PowerPoints, trying to memorize as many details as possible. It is important to have that foundation of knowledge, but what I have come to realize is that there are rarely pure “textbook cases” because so much more goes into caring for a patient. One size does not fit all in medicine. This experience brought back the humanity of medicine. I witnessed how knowing and understanding patients enables a physician to be an advocate for their patients, a role I consider to be the most important of the many roles a physician takes. I can never come close to knowing exactly what these families are going through. I also can’t thank them enough for allowing me to be present during their most vulnerable moments, for taking time to talk with me for a brief period to get a glimpse of their journey. Ultimately, this experience was a reminder that the art of medicine can’t be discovered in textbooks. It is learned from our patients and the uniqueness that their individual journeys bring to each patient encounter.

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Lou Bueno
Lorena
Alice Popkorn

Tags leukemia, lindsay marzal, medical school, pediatric oncology, pediatrics

General Narrative Opinion Reflection

Visit Your Ill Loved One Less, Please.

Post author By Mica Esquenazi
Post date November 20, 2014
1 Comment on Visit Your Ill Loved One Less, Please.

Mr. Gerald knew the exact day, three years ago that his wife moved into assisted living due to her early-onset dementia and primary progressive aphasia. After being admitted, she suffered a femur fracture, underwent surgery, and soon was no longer able to walk. Her dementia progressed rapidly. As I sat collecting interview data from Mr. Gerald in the hallway, his wife was being moved from her bed to her wheelchair; she was now unable to speak, only able to change her facial expressions and occasionally move her hands. I feared talking to Mrs. Gerald’s love, as I knew that he must be hurting tremendously. Making Mr. Gerald relay the struggles of the last few years simply for the sake of practicing my interview skills felt wrong. My sorrow began to mirror Mr. Gerald’s as the story of his wife’s incurable condition unraveled. He told me the intimate details of the Gerald family dynamic with great accuracy, stating that he was happy to be teaching medical students about their experiences.

“I am with my wife every morning and afternoon for six days of the week; our daughter comes on the seventh day. I am her companion and I keep her active constantly.” Honored to be speaking to such a dedicated husband, I asked, “…and what is that time like? Do you feel that your presence helps your wife with her condition?” Silence fell upon the room. Mr. Gerald tried to speak but was caught by tears. “Please,” I said, “you don’t have to talk about anything that you don’t want to – you are doing such incredible things for your wife. Thank you so much for sharing with us.” The other medical students added their humble thanks and Mr. Gerald continued,

“the aids here, the nurses, they tell me that my wife lights up when I am around – that it is simply not the same when I am not here.”

I asked Mr. Gerald about the strain that this illness has had on life and he relayed that tending to his wife was indeed difficult but it was his duty to do so for his loved one. Being by her side was crucial to him. He described his other daily activities, revealing the healthy social and family life that he maintains outside the assisted living facility.

The physical examination was next, so we moved into Mrs. Gerald’s room. Calling her by her nickname, Mr. Gerald walked in with great enthusiasm and began attending to his wife. Her eyes opened and she smiled, fixating all her attention on her love and ignoring the three white coats that brooded over her.

Once my time with Mr. and Mrs. Gerald was over, I consulted Mrs. Gerald’s medical file. As I read, I came across notes from the assisted living facility’s social worker:

“Mr. Gerald visits his wife frequently. With time, he should do so less.”

That is all that was written. Posing that family or friends aught to visit their ill loved ones less often is not such a cut and dry topic and surely does not merit such stringent of a statement. All families react to illness differently and this should not only be understood by healthcare providers but respected. This was a case of absolute dedication. The physician-patient relationship is secondary to the loving human relationships that enrich patients’ lives. Recognizing this essential fact is crucial to approaching patients and their loved ones humbly – without it, true healing is not attainable.

Featured image:

MTSO Fan

Tags alzheimer's, alzheimer's family, dementia, dementia family, hospital visitation, hospital visitor

Law Opinion

Medicolegal Issues: Physician Involvement in Litigation

Post author By Ankur Narain
Post date November 6, 2014
No Comments on Medicolegal Issues: Physician Involvement in Litigation

The medical and legal landscapes are intertwined much more so than ever before. With the advent of this close relationship between the medical and legal fields, physicians have become involved in a multitude of legal proceedings. Physician involvement ranges from consultation on legal matters to testifying in open court to contesting malpractice lawsuits. In part 2 of our review of medicolegal issues, we are going to look at a few different types of legal cases that physicians are involved in, and what their roles are in those proceedings.

Social Security or Supplemental Security Disability Hearings

One of the major case types in which physicians are involved is for determination of an individual’s eligibility for Social Security or Supplemental Security Income Disability. Both of these programs provide financial assistance for those with disabilities. Social Security Income Disability pays benefits to people who are “insured”, meaning those who have worked for a certain number of years and have paid Social Security taxes. Supplemental Security Income does not have those restrictions, and pays benefits based on the financial requirements of the applicant.

Cases involving income disability center around a hearing, where citizens can appeal decisions made by the Social Security Administration (SSA) involving eligibility or specific monetary payouts. In these types of cases, physicians often testify for both the claimant and SSA. When physicians testify for the claimant, their purpose is usually to summarize key information about the claimant’s medical history and to provide the judge with evidence justifying the awarding of income disability. When physicians testify for the SSA, the purpose of their testimony remains to summarize key information about the claimant’s medical history. However, physicians are often called by the SSA to help support SSA decisions and prevent the case from being remanded or appealed again. Irrespective of which party the physician testifies for, they are also exposed to questioning by the other side involved in the hearing.

Criminal Trials

Another key case type that physicians testify in, and probably the one most notable to the public, is criminal trials. In criminal trials there are two notable roles that physicians may play. Physicians in the field of forensic pathology fill the first notable role. Forensic pathology is a sub-specialty of pathology and requires an additional year of fellowship training after completion of a pathology residency program. The role of forensic pathologists is multiple, with their primary objective being to analyze biological evidence. This analysis can include such things as performing autopsies on postmortem specimens to determine cause of death, examining wounds for possible etiology, inspecting histological slides to identify a disease process, or interpreting toxicology screens to determine drug exposure or impairment. Forensic pathologists are often called upon as expert witnesses to provide their testimony in open court, and they are subject to questioning by both parties involved in a case.

Forensic psychiatrists fill the second notable role for physicians in criminal trials. Forensic psychiatry is a sub-specialty of psychiatry, with an additional year of fellowship training after completing a psychiatry residency program. The responsibilities of a forensic psychiatrist include determining a person’s ability to stand trial in the context of mental competence. Further responsibilities include giving an opinion to the court about the mental state of a person during the commission of a crime. If a forensic psychiatrist determines that the party in question has some mental defect or illness, the party may be found “not guilty by reason of insanity.” The validity of these judgments are controversial, as many are suspicious of attorneys using “insanity defenses” when they are not typically warranted. Like forensic pathologists, forensic psychiatrists are subject to questioning by both parties involved in any legal case in which they testify.

Malpractice Cases

Medical malpractice is defined as professional negligence by a health care provider where the treatment provided falls below, or deviates from, accepted standards of care. The specific course of action taken by the health care provider results in injury or death of the patient. In these types of cases physicians are the defendants, and they often employ legal advisors to aid in their defense. In order to further protect themselves from malpractice suits, physicians and hospital systems spend significant sums of money on malpractice insurance.

The statistics behind medical malpractice are both interesting and striking. In 2012, malpractice payouts totaled $3.6 billion from 12,142 claims. Cases involving death (31%) and significant permanent injuries (19%) encompassed 50% of all payouts. 5 states (New York, Pennsylvania, California, New Jersey, and Florida) had total payouts exceeding $200 million. The significant monetary burden of malpractice claims has created a controversy surrounding tort reform. Malpractice tort reform will be the topic of the next installment of the series, so stay tuned!

Sources

Featured image:
Cast Aluminium Nurse with Stethoscope (Ne Kensington, PA) by takomabibelot

Tags criminal trials, disability, malpractice, medical malpractice payouts, medical school, medicolegal, physician involvement in legislation, physician legislation, supplemental security diability hearings

General Opinion

Doctor Google

“I’ve got a headache.”
“Google it.”
“OMG, it might be a brain tumor!”

Have you overheard or participated in a similar conversation?

Doctors cannot avoid Doctor Google: it makes patients happy to have a virtually unlimited amount of information just one click away, easier and faster to access than ever before. In turn, self-diagnosis annoys medical professionals.

As a medical student, I can see both points of view. Patients are often left hungry for a few more words, as the information they receive from doctors can be minimal at times. Where else should they turn for answers to their questions? Patients enjoy reading about a new diagnosis, a diagnostic test they are about to go through, or exchanging experiences with other patients online.

The information that patients access, however, often raises more questions than it answers. It takes a certain amount of background knowledge to be able to sift through all the facts and tell what is true and relevant and what is not.

Doctors do not have all the answers, but they do know how to ask the right questions. Non-medical professionals have difficulty determining what is and is not important. This makes doctor Google dangerous: lay people are lost in a sea of misinformation and frequently prioritize facts inappropriately, leading to an incorrect diagnosis. When people fancy themselves doctors, most medical professionals lose patience. Yes, Google always has answers; however, the answers are always multiple, and most patients cannot critically evaluate the information they find. This is why patients need doctors.

Does this mean that the internet is bad? Doctors and medical students use the Internet. Resisting the shift towards electronic data would be antiquated as well as pointless. Electronic resources help physicians in numerous ways. They are used, for example, to check for drug interactions, find new treatment protocols, and read about cutting-edge research.

Still, some doctors seem to fear knowledgeable patients. It is entirely possible that a patient will know more about his or her condition than a doctor. This is particularly common for patients diagnosed with rare conditions. This embarrasses some doctors. But why should it? In training, students and residents are taught that it is acceptable to tell a patient that you need to review the literature before making a treatment decision. Again, it is the ability to ask the correct questions and then find the answers that separates physicians from non-physicians.

While we should strive to provide our patients with as much information as we can, we shouldn’t limit their curiosity. In fact, directing patients to reputable web sites might be an appropriate answer to this multi-faceted dilemma.

Featured image:
Snide Google by Lucas

Tags google, self-diagnosing

Clinical General Lifestyle MSPress Announcements Narrative Opinion Reflection

“Preserving the Nobility of Medicine” Dr. Robert Alpern, 2014 Commencement Address of the Northwestern University Feinberg School of Medicine

In continuation of the Medical Commencement Archive, this Friday we are releasing a new commencement speech. Today’s commencement speech is titled Preserving the Nobility of Medicine. This commencement speech was given by Dr. Robert J. Alpern, a Northwestern University alumnus, to the students of the Northwestern University Feinberg School of Medicine. The esteemed Dr. Alpern is Ensign Professor of Medicine and Dean at Yale University School of Medicine. He also is President of the American Society of Nephrology, as well as a sitting Advisory Council Member of the National Institute of Diabetes and Digestive and Kidney Diseases.

Dr. Alpern took a moment for students to take a closer look at the value and weight of the two-lettered title: MD. He reflected upon the unique status given to physicians, and the reverence given to doctors from the community and from patients. Yet, at the same time the medical paradigm continues to evolve. Dr. Alpern astutely foresees a future where physicians must adapt to the growing roles in the medical team, changes in bureaucracy, and the changing expectations of patient’s for their treatment. Dr. Alpern also notes that these changes will influence the training and education of physicians. On top of our own desire to stifle the monsoon current of medical information during our education, there are legitimate concerns that the future medical student will receive but an abbreviated biochemistry course, or won’t need to take an MCAT, maybe even spend less time in medical school. Yet, Dr. Alpern urges one thing: to value the pursuit of scholarship. He reminds us that only with a strong foundation may a strong physician be built.

“We observe the patient and draw on our scientific understanding of how the body works and sometimes does not work, to develop a truth that we can implement as an action plan. We must know clinical guidelines and the most up-to-date treatment algorithms, but we must also be ready to identify clinical circumstances in which they do not apply.”

Dr. Alpern eloquently explains that, above all else, the pursuit of knowledge and scholarship is indeed the nobility of medicine. He reminds us to respect this pursuit in lieu of the changes we will see in our futures as physicians, such that “we do not return to the era of trade schools of medicine”. Dr. Alpern further mentions that, in addition to being a scholar, the physician must be compassionate, and that neither trait is mutually exclusive:

“I also want to make the point that an emphasis on science is not the antithesis of compassion, but it is rather the complement of compassion”.

At the end of his speech, Dr. Alpern concludes with this piece of wisdom:

“Do not be intimidated by the evolving healthcare system. Rather, as the next generation of physicians, you will define healthcare, and you must define it well.”

Tags Alpern Yale, Dr. Robert Alpern, Feinberg 2014 Commencement, Feinberg Alpern Commencement, Medical School Commencement, Northwestern School of Medicine Commencement, Robert Alpern

Law Opinion

Medicolegal Issues – Medical Personnel as Expert Witnesses

Post author By Ankur Narain
Post date October 16, 2014
No Comments on Medicolegal Issues – Medical Personnel as Expert Witnesses

The role of physicians and scientists within the legal system is ever expanding. Medical and scientific personnel are frequently called upon to analyze evidence in a wide variety of legal cases, ranging from worker’s compensation claims to felony trials. The expertise of physicians and scientists is often so valuable that the result of cases hinge on their professional opinions. While the importance of medical involvement in the legal field is implicit, certain ethical issues do arise. This is especially true when physicians are on retainer or are compensated by certain parties in a legal dispute. The importance and intricacies of medical involvement in the legal process has inspired curiosity in me. What is the history of the use of expert witnesses in common law? Where do scientific and medical expert witnesses fit into our legal code? Most importantly, how are these witnesses used in current court proceedings, and what are the prospects for the future?

The Origin of Expert Witnesses

The origin of expert witnesses is in England. According to English law, the first expert witness was used in a 1782 case involving the silting up of Wells Harbor in Norfolk. In that case, renowned civil engineer John Smeaton testified, signifying the first use of an expert witness’ opinion in common law. In the United States, expert witnesses were codified into US law in 1975, under the Federal Rule of Evidence (FRE) 702. The FREs represented general rules passed by congress governing how evidence is presented in both civil and criminal cases.

Scientific and medical witnesses have greatly helped to shape the rules governing expert witnesses. Prior to FRE 702, rules for admissibility of scientific evidence were established in Frye v. United States (1923). In Frye, the question at hand concerned whether scientific evidence in the form of a systolic blood pressure deception test was admissible in court. The Frye ruling indicated that such evidence was admissible as long as the test or theory was “generally accepted” among a meaningful portion of the scientific community. To prove that something was “generally accepted,” parties often put a number of scientific experts on the stand to verify certain tests or theories. This rule for establishing the admissibility of scientific evidence is colloquially known as the Frye Test.

After the adoption of the FREs in 1975, they, along with the Frye Test, remained the seminal rules governing scientific expert witnesses. However, in 1993 a new case would open those rules up to interpretation and eventual amendment. In Daubert v. Merrell Dow Pharmaceuticals (1993), two citizens born with birth defects sued Merrell Dow Pharmaceuticals claiming that Dow’s drug Bendectin caused their conditions. Both opposing parties relied upon scientific expert witnesses to prove their claims. A district court ruled that the testimony from the citizens’ expert was inadmissible because the evidence came from methodologies, such as in vitro and in vivo studies, that were not “generally accepted” at the time.

After the Ninth Circuit Court upheld this decision, the citizens’ took their claim to the Supreme Court. The citizens’ reasoned that the Frye Test was no longer the governing standard for admissibility of scientific evidence as soon as FRE 702 was passed. The court agreed, reasoning that, since FRE 702 made no mention of “general acceptance,” the Frye Test was not to be applied in discerning the validity of scientific evidence.

The implications of the Daubert ruling were significant in amending the rules for the admissibility of scientific evidence given by experts. No longer was evidence only judged on its “general acceptance” among the scientific community. Under Daubert, scientific evidence can be admissible if it is “relevant to the task at hand” and “rest(s) on a reliable foundation.” In determining what makes up a “reliable foundation,” conclusions made from evidence must be based on sound scientific methodology. Sound scientific methodology rests in using proper scientific method, including empirical testing of evidence, peer review, proper controls, and determination of potential error rates. In order to prevent the presentation of “pseudoscience,” judges are given the power to be the final arbiter of any submitted scientific evidence. These guidelines outlined in the Daubert ruling were eventually added as amendments to FRE 702.

Understanding the history of expert witnesses allows us to determine how science and medicine shaped one aspect of the US legal code. In the next part of this series, I will provide an overview of current medical and scientific involvement in court proceedings. I will examine not only common case-types in which physicians testify, but also case types in which physicians are directly involved in. Check back soon!

References
1. http://www.law.cornell.edu/rules/fre/rule_702
2. http://www.casebriefs.com/blog/law/torts/torts-keyed-to-prosser/causation-in-fact/daubert-v-merrell-dow-pharmaceuticals-inc-4/

Featured image:
Cast Aluminium Doctor with Stethoscope (Ne Kensington, PA) by takomabibelot

Tags expert witness, law, medicine

General Opinion Public Health

Are You Prepared For the Walmart Storm?

Post author By Czestochowa Francois
Post date October 2, 2014
No Comments on Are You Prepared For the Walmart Storm?

Clouds, storms and sunsets

Ten years ago, the idea of going to Walmart for a primary care check up would have seemed completely foreign. Walmart, as the largest American employer, previously seemed to limit itself when it came to health care. Currently, it is branching out into the discount drug industry, owning roughly 100 retail clinics and working in conjunction with a few large hospitals. Now it appears that they’re ready to branch out with more clinics. Since they already have a number of clinics, it begs the question: why are many major television networks and newspapers only now showing alarm over the idea of Walmart becoming a serious contender in the healthcare market? There are several reasons: first, the clinics that Walmart are now endorsing are completely owned by them. Furthermore, they are being branded as “one stop shops” for primary care. Second, the new clinics are run solely by nurse practitioners and are open longer and later than their competitors (such as, private practice physicians), thus launching a full front assault on the family medicine practitioner. Thirdly, due to the reach of the company, its potential as a disruptive innovator and giant in the industry is unparalleled. Experts are now saying that Walmart can single handedly change healthcare as we know it.

What does this mean for us as medical students, soon to be working in the medical field? It seems to me that the greatest thing that Walmart is offering customers is choice. Rather than simply offering healthcare at a lower cost, they are offering customers a simpler way of dealing with their health concerns. They also seem to be veering away from the procedural based medicine that physicians seem to practice currently. Instead, patients are allowed to buy doctor visits in bulk— thus the “retail” if you will. Though this inevitably means more competition for contenders, it may also prove useful. With cheaper, more readily accessible primary care, emergency rooms will be less full with repeat offenders. People who would greatly benefit from primary intervention (those suffering from diabetes, obesity and high cholesterol) –those who typically slip under the radar due to lack of insurance – could get covered for a cheap cost. Finally, extraneous hospital costs would be cut down, allowing patients a certain amount of control over insurance and their insurance provider. With Walmart entering the industry, other companies will be forced to offer more competitive and reasonable rates.

Who knows, Walmart might be the thing to make healthcare equitable in this country.

Featured image:
Clouds, storms and sunsets by MattysFlicks

Tags primary care, retail clinic, Walmart

Innovation Opinion Technology

Medical Technology: Implementation Without Cause?

Post author By Ankur Narain
Post date September 25, 2014
No Comments on Medical Technology: Implementation Without Cause?

A trip through my apartment is a serious lesson in buyer’s remorse. My iPad? What I thought would be a useful note taking and studying tool is more of a $500 YouTube and Netflix consumption machine. My spiffy dual monitor setup that I thought would amp up my productivity? Most of the time I forget to plug in my other monitor and spend my computing sessions staring at my 13” MacBook screen. In fact, that exact situation is occurring right now as I write this. My fancy Bluetooth speaker that I thought would be useful for jamming out when I had friends over? I’ve used it a handful of times, lost the charging cable so the thing won’t even turn on, and have absolutely no desire or intention to either find or buy a new cable.

You may be asking yourself what the point of that rant was, and I don’t blame you. What unifies all those examples is that they are situations when I either purchased or was given a new tech toy that I thought would be life changing, but instead turned out to be unnecessary or obsolete. What I’ve learned from years of accumulating new technology is that while everything comes with copious advertising and monstrous hype, few devices actually deliver as promised.

The medical field is no stranger to this. Hospital administrators and clinical program directors are people too, and they enjoy new toys just as much as the rest of us. Hospitals and universities try to justify their actions by citing journal articles and claiming that having “X” item allows them to remain “on the leading edge of Y specialty.” Let’s be honest, no one is being fooled here. Those new collections of surgical mallets aren’t any better at impacting components than the ones made 20 years ago.

One of the most sought-after technologies is robot-assisted surgical systems, such as the da Vinci^©. Are these systems, while definitely innovative and interesting, akin to my iPad? Are they just shiny new toys that don’t justify their cost? Well, let’s find out.

What exactly is this technology?

Robot-assisted surgical systems are surgical workstations, containing robotic arms with cameras and tools, which can be controlled and manipulated by physicians. The most prominent and successful robotic system is the da Vinci^©, manufactured by Intuitive Surgical of Sunnyvale, California. The features of this system include four robotic arms that can control surgical tools, a magnified 3D high-definition visual system, and wristed instruments that can produce a range of motion beyond that of the human wrist.¹ The claimed benefit of this system is that surgery can be performed with smaller incisions, thus decreasing the pain and recovery time that is usually associated with open surgery.¹ These and other systems are currently in use in many different fields such as cardiac, colorectal, gynecological, thoracic, and urological surgery.¹ These systems are not cheap however, running upwards of $1 million plus large maintenance and service contracts that can reach into hundreds of thousands of dollars per year.²

What does the literature say about these systems?

There has been much study about these surgical systems, with the number of peer-reviewed articles reaching into the thousands. However, there have been a few recently published studies that have shed some concern about the use of robotic surgical systems. In a letter to the New England Journal of Medicine, physicians from Sloan-Kettering Memorial Cancer Center found little to no advantage when using the da Vinci^© system for radical cystectomy.³ They found robotic and open surgery to have similar rates of perioperative complications. They also found that while the patients who underwent robotic surgery had lower blood loss, they also had longer mean length of stay after surgery.³ The longer mean length of stay invariably led to greater costs when using the robotic system.

The American Congress of Obstetricians and Gynecologists, in a March 2013 statement issued by President James T. Breeden, denounced the use of robotic surgical systems.⁴ Dr. Breeden claims, “There is not good data proving that robotic hysterectomy is even as good as – let alone better – than existing, and far less costly, minimally invasive procedures.”⁴ This speech came after studies published by researchers at Columbia University cast doubts about the perceived advantages of robotic surgical systems.²

These two examples only represent a few of the many opinions divulged about the topic of robotic surgical systems. The literature is rife with both positive and negative opinions, and it is up to hospital administrators and faculty to gauge the worth of these systems.

Why do so many hospital centers have this technology?

Implementation of these robotic surgical systems has occurred in major surgical centers in the US, France, Italy, Germany, Spain and many other places. If the literature is conflicting on the efficacy of these systems, why is implementation so widespread? I believe the answer is marketing. Top medical centers have a need to “keep up with the Jones’.” If one renowned medical center acquires certain technology, all of the other medical centers instinctively implement that technology as well to avoid a perception of inferiority. There is also a marketing aspect in terms of patient recruitment, as new technology and the promises of a “superior” surgical experience may lure prospective patients away from competing hospital systems. Whether or not the added income from patient recruitment offsets the initial and recurring costs of these systems is, to my knowledge, yet unknown.

My conclusion on this topic is that these surgical systems are akin to my iPad. They are good in theory, but their cost and relative utility make them a bad investment at the moment. However, this is not to say that these systems will never find justifiable use. With new innovation these systems may find a niche that makes them both efficacious and profitable. Just as a new app may breathe more life into my iPad, new research and better training with the robotic surgical systems may lead to advancements that will justify their implementation.

References
1.http://www.intuitivesurgical.com/
2.http://online.wsj.com/news/articles/SB10001424127887323764804578314182573530720
3.Bochner, B. H., Sjoberg, D. D., & Laudone, V. P. (2014). A randomized trial of robot-assisted laparoscopic radical cystectomy. N Engl J Med, 371(4),389-390.
4.http://www.acog.org/About-ACOG/News-Room/News-Releases/2013/Statement-on-Robotic-Surgery

Featured image:
Da Vinci Surgical Robot by Ars Electronica

Tags Da Vinci, Medical technology

Clinical Opinion

Physicians in Pre-Hospital Emergency Medical Systems

Post author By Marija Kusulja
Post date September 11, 2014
No Comments on Physicians in Pre-Hospital Emergency Medical Systems

Franco-German and Anglo-American models of emergency medical care differ. The first brings the physician to the patient on scene, while the latter brings patients to physicians in hospital. In a recent German study, physicians remarked, “Do we really have to study whether a high density of less qualified EMS personnel leads to similar or even better outcome than a system in which highly qualified physicians, providing better transportation stability, take care of the critically ill patient?” Are physicians needed in pre-hospital emergency care settings? If so, in what medical setting is such a system tenable?

On-scene time
Time is of such importance in medical emergencies and trauma that the term, “golden hour” has been designated to the period during which treatment is most likely to have a positive effect on a patient’s outcome. The two EMS models make an effort to treat the patients as soon as possible using different approaches. The Anglo-American model revolves around the “scoop and run” idea, bringing the patient to the physician in a hospital as quickly as possible. The Franco-German utilizes the “stay and play” concept, reflected in longer on-scene time. This time is not wasted though, and may even be considered better utilized as the physician is brought to the patient and can begin advanced and/or aggressive treatment on scene, improving the outcome and chances of survival. In the Anglo-American model, time is lost on many minor cases, because paramedics and EMTs must transport most patients to hospitals in order to be cleared by physicians, whereas in the Franco-German model, physicians can treat patients at the scene and decide which patients do not require hospitalization. Another factor that may prolong on-scene time in a negative way in the Anglo-American model is the skill level of paramedics and EMT. Lastly, there are situations with unavoidably prolonged pre-hospital time, for example when ambulating the patient may be difficult and transport to hospital delayed. In this case, the presence of a physician significantly improves survival rates. A large group of studies has demonstrated that the benefit of helicopter emergency medical service (HEMS) is not to be attributed to faster transportation, but rather to the presence of a physician.

Expertise and skill
The length of EMT and paramedic training programs ranges from a few months to two years depending on the policy of the country and the specific degree. EMTs are required to follow standard operating procedures, whereas physicians may, in certain circumstances, act autonomously. There is an ongoing debate on skills which paramedics should or should not be allowed to utilize. It has been found that there is a relatively high rate of misplaced endotracheal tubes in patients intubated by paramedics. Even with adequate training, skills deteriorate over time, as is the case with paramedics who mostly attend minor cases and do not regularly utilize practical skills such as endotracheal intubation, and intravenous drug administration. Physicians usually practice these skills in their hospital settings as well as in pre-hospital environment, allowing them more of a chance to practice their skills. In addition, specialists are more qualified to perform such skills in non-standard conditions.

Photo courtesy of Dr Gregor Prosen

Quality of care
Skills and expertise of EMTs and physicians reflect in quality of care. A large number of studies show a significantly better first hour and first day survival rate, a better functional outcome, as well as less time spent in intensive care unit in trauma patients; as well as survival of patients with acute myocardial infarction and respiratory diseases when treated by physicians. These results may reflect the higher level of expertise and the more profound knowledge of the physicians, as well as their ability to make clinical decisions and use aggressive treatment on scene. Studies have, however, found a difference in survival even when standard procedures were followed by both physicians and EMTs, such as in cases of cardiac arrest. Physicians administer a higher number of drug dosages per minute, they have shorter hands-off intervals and pre-shock pauses, and intubate a greater proportion of patients.

Issues
One of the biggest problems of maintaining a physician-based EMS is the financial “loss”. Is it worth overcrowding the Accident and Emergency (A&E) waiting rooms with myriads of “minor” patients who EMTs have to bring in, rather than clearing the A&E departments and allowing the staff to treat the more serious cases requiring advanced hospital equipment? Looking at the larger picture, survival of patients after CPR may be less costly in the Franco-German model than in the Anglo-American model. A study showed the expense of 0.7 euro per patient after CPR in Birmingham, compared to 0.17 euro in Bonn. Another problem, arguably more evident in the Americas than in the Europe is the litigious concerns. Many physicians who volunteer or work in ambulance services in the USA have malpractice insurance, which only covers their practice at their respective facilities, not in the pre-hospital environment, making them vulnerable to malpractice law suits. Some hospitals have overcome this problem by rewriting their insurance policies to include pre-hospital coverage for physicians working in those capacities.

While I support the involvement of physicians in pre-hospital emergency care, there remains a question of which physicians should be sent on the scene. Not all countries have enough physicians or adequate finances to allow all ambulances to be manned by anesthesiology or emergency medicine specialists, and instead send out newly qualified doctors with little experience. The right answer may lie between the two extremes: the use of both physicians and EMTs. For example, in Portugal dispatchers communicate with patients and decide whether to dispatch an emergency vehicle, as well as whether to man the vehicle with a physician and a nurse, or two EMTs.

Sources:
1 Timmerman A, Russo SG, Hollmann MW. Paramedic versus emergency physician emergency medical service: role of the anaesthesiologist and the European versus the Anglo-American concept. Current Opinion in Anaesthesiology 2008; 21:222-227.
2 Fischer M, Krep H, Wierich D, et al. Comparison of the emergency medical services systems of Birmingham and Bonn: process efficacy and cost effectiveness. Anasthesiol Intensivmed Notfallmed Schmerzther. 2003 Oct;38(10):630-42.
3 Garner A, Crooks J, Lee A, et al. Efficacy of prehospital critical care teams for severe blunt head injury in the Australian setting. Injury 2001; 32(6):455-60.
4 Osterwalder, J. J. Can the “golden hour of shock” safely be extended in blunt polytrauma patients? Prehospital Disaster Medicine 2002; 17(2):75-80.
5 Apodaca A, Olson CM Jr, Bailey J, et al. Performance improvement evaluation of forward aeromedical evacuation platforms in Operation Enduring Freedom. J Trauma Acute Care Surg 2013; 75(2 Suppl 2):S157-63
6 Katz SH1, Falk JL. Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Ann Emerg Med 2001 Jan; 37(1):32-7.
7 Klemen P et al. Effect of pre hospital advanced life support with rapid sequence intubation on outcome of severe traumatic brain injury: a prospective multicentre study. J Trauma. 2006.
8 Botker MT, Bakke SA, Christensen EF. A systematic review of controlled studies: do physicians increase survival with prehospital treatment? Scandinavian journal of trauma, resuscitation and emergency medicine 2009; 17:12.
9 Dickinson ET. The impact of prehospital physicians on out-of-hospital nonasystolic cardiac arrest. Prehosp Emerg Care 1997; 1(2):132-135.
10 Olasveengen TM, Lund-Kordahl I, Steen PA, et al. Out-of hospital advanced life support with or without a physician: Effects on quality of CPR and outcome. Resuscitation 2009;80(11):1248-52.
11 Fischer M et al. Comparison of the emergency medical services systems of Birmingham and Bonn: process efficacy and cost effectiveness. Anasthesiol Intensivmed Notfallmed Schmerzther 2003 Oct; 38(10):630-42.
12 Skow G. Docs On Ambulances. EMS World, 1 October 2010. http://www.emsworld.com/article/10319194/docs-on-ambulances?page=2
13 Page C, et al. Analysis of Emergency Medical Systems Across the World. Worcester Polytechnic Institute. MIRAD Laboratory, April 25, 2013.

Featured images courtesy of Dr. Gregor Prosen

Tags Ambulance, Emergency medicine

Clinical General Innovation Lifestyle Opinion

Medical Technology: Google Glass and the Future of Medical Education and Practice

Post author By Ankur Narain
Post date July 12, 2014
4 Comments on Medical Technology: Google Glass and the Future of Medical Education and Practice

Medicine is often a field at the forefront of technology. The importance of the field itself combined with the lucrative payouts seen for successful medical devices attracts many entrepreneurs and companies to the field. One of the most intriguing new technological advances is Google Glass – the augmented-reality glasses developed by tech powerhouse Google. There has been much speculation about the use of Google Glass in medicine. The possible implementation of Google Glass within the medical field raises important questions about how Google Glass may change medical education and practice.

What is Google Glass?

Google Glass is an augmented-reality system developed by Google. It is a voice-controlled, hands-free computing system that is housed in a “glasses” interface that users can wear much like spectacles. It contains an HD capable screen, 5 megapixel camera, and is Bluetooth, WiFi, and GPS enabled. The interface can sync with both Android and iOS phones for integration of information across platforms. Google Glass is currently in its “Explorer” beta phase, with a retail price of $1500. Speculation is that the upcoming retail version will be greatly reduced in cost.

What are the uses for Google Glass in Medicine?

The combination of features present in the Glass package makes it an enticing future medical tool. The main hypothesized role for Glass is in information sharing and transfer. Glass may prove useful in allowing physicians access to patient medical records, imaging studies, and pharmaceutical information in real time via the integrated HD screen. Glass may also be useful for physicians on home-call, as information about patient’s vitals and status can be relayed while the physician is en-route to the care facility. In the surgical field, Glass may help with surgical procedures by providing instant access to reference materials and real-time consults in the operating room. Finally, Glass may provide a more integrated and unique experience for medical students. Students will be able to view patient interactions and procedures with the same point of view (POV) as the physician, providing an unparalleled immersive educational experience. Furthermore, use of Glass by patients will allow students to view patient encounters from the patient’s POV, providing a perspective that many students may never have otherwise experienced.

Photo courtesy of Ted Eytan

How is Google Glass Currently Being Used?

While Google Glass is still in its infant stages, there has been some limited implementation in the medical field. Dr. Christopher Kaeding, an orthopedic surgeon at the Ohio State University, was the first physician to use Glass during a surgical procedure. The procedure was broadcast via Glass to both medical students and faculty at the university.

In terms of education, the University of California – Irvine Medical School has implemented Glass in its innovative iMedEd program. Established in 2010, iMedEd provides medical students at UC Irvine with specialized technological access and training. It started with school-issued iPads for every medical student, and later expanded to point-of-care ultrasound training and use. In 2014, the iMedEd program began utilizing 10 pairs of Glass to be distributed amongst the 3rd and 4th year medical students on the wards. It will be an interesting development to see how Glass is received amongst the students, and how they rate its effectiveness at enriching their educational experience.

What needs to happen for Glass to have widespread adoption in the medical field?

While Glass does have intriguing possibilities, it is by no means a proven entity in the medical field. I believe that for Glass to become an influential medical product two things have to happen. The first thing that must happen is that Glass must be utilized extensively in the consumer market. Many of the questions about Glass revolve around public uncertainty about privacy issues. If Glass gains a large foothold in the consumer marker, patients will become accustomed to interacting with Glass users and will feel less hesitant in a Glass-using setting. The second thing that must happen is that app developers must create useful medical apps for Glass. These apps must both provide utility to physicians and be compliant with HIPAA regulations. Much like EPIC was to electronic medical records, Glass needs companies who are willing to take on the intense regulatory scrutiny of the medical field in app development.

Sources:

Featured image:
Google Glass Dr. Guillen