Medical Studies

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How Effective is Arthroscopic Knee Surgery?

May 11, 2012 in Medical Studies | 1 comment

For patients with osteoarthritis, the answer is not at all.

A paper in the New England Journal of Medicine examined 180 patients 75 years old or younger, that had osteoarthritis of the knee, and reported at least moderate knee pain on average despite medical treatment.  The researchers randomized this individuals into three groups:

  • Surgery Group #1 (Lavage): The joint was lavaged with at least 10 liters of fluid. Anything that could be flushed out through arthroscopic cannulas was removed. Normally, no instruments were used to mechanically débride or remove tissue.
  • Surgery Group #2 (Débridement): The joint was lavaged with at least 10 liters of fluid, rough articular cartilage was shaved (chondroplasty was performed), loose debris was removed, all torn or degenerated meniscal fragments were trimmed, and the remaining meniscus was smoothed to a firm and stable rim.through arthroscopic cannulas was removed. Normally, no instruments were used to mechanically débride or remove tissue.
  • Placebo Procedure: To preserve blinding in the event that patients in the placebo group did not have total amnesia, a standard arthroscopic débridement procedure was simulated. After the knee was prepped and draped, three 1-cm incisions were made in the skin. The surgeon asked for all instruments and manipulated the knee as if arthroscopy were being performed. Saline was splashed to simulate the sounds of lavage.

The authors compared patient pain levels in these three groups before the surgery and after the surgery at regular increments (2 weeks,  6 weeks, 3 months, 6 months, 1 year and 2 years.)    The authors found that “At no point did either arthroscopic-intervention group have greater pain relief than the placebo group.”

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Are you depressed?

November 22, 2011 in Medical Studies | No comments

That is the question that that clinicians often have to ask.  Depression certainly operates along a scale and it is often difficult to quantify either i) if a person is depressed or ii) how depressed they are.

One option to assess patient depression is the PHQ-9.  The assessment asks patients nine questions regarding their mental health status.  The patient’s depression level can be quantified on a scale from 0-27 and practitioners can use this information to provide a tentative diagnosis.

The PHQ-9, like many assessment, relies on patient self-reports which depend on the communication skills of the patient.  Further, depression can be transitive in some cases; thus additional PHQ-9 questionnaires will need to be conducted over time.  Still the PHQ-9 can be a useful tool for physicians assessing patient depression.

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The History of Medicine: A Very Short Introduction

September 30, 2011 in Books, Contagious Disease, Medical Studies | 1 comment

I recently finished reading a great book by William Bynum called The History of Medicine: A Very Short Introduction. The book does just what it says: provides a great introduction to the history of medicine.  It is concise and interesting throughout.  The contents are divided into six chapters:

  • Medicine at the bedside
  • Medicine in the library
  • Medicine in the hospital
  • Medicine in the community
  • Medicine in the laboratory
  • Medicine in the modern world.

This chart explains the differences between the first five kinds of medicine.

There are many interesting nuggets of information from this book and picking out a few is difficult.  I’ll settle for two which discuss the unintended consequences of the invention of anesthesia and antibiotics:

“Giving surgeons more time to operate made conserving tissues easier, but the longer exposure of the open wounds to the air also increased the possibility of post-operative infection.  Consequently, anaesthesia enlarged the range of operations surgeons could perform, but not necessarily the changes of a patient’s surviving the ordeal.”

“The causative agents of malaria, tuberculosis, and HIV have all developed resistance to many of their conventional treatments, complicating these major world diseases.  The hospital has not ’caused’ this phenomenon; human agency has.  But drug-resistant pathogens are now so common that modern hospitals sometimes lose their desired epithet, as ‘houses of healing,’ and revert to that old one, ‘gateways to death.’”

Here is Amazon’s summary of the book:

Taking a thematic rather than strictly chronological approach, W.F. Bynum, explores the key turning points in the history of Western medicine-such as the first surgical procedures, the advent of hospitals, the introduction of anesthesia, X-Rays, vaccinations, and many other innovations, as well as the rise of experimental medicine. The book also explores Western medicine’s encounters with Chinese and Indian medicine, as well as nontraditional treatments such as homeopathy, chiropractic, and other alternative medicines.

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Why do doctors adopt an innovation?

September 20, 2011 in Medical Studies, Networks | No comments

You’re a researcher.  You just came up with a new medical treatment that is far superior to the previous treatment.  How do you get physicians to adopt your method/technology?

Most researchers believe that providing the physician with evidence of the new treatment superiority is the number one factor driving adoption.  In a presentation at this year’s AHRQ’s 2011 Annual Conference, I found out this is not the case at all.  Evidence is important.  Physicians, however, are much more likely to adopt a new technique/innovation if it has three characteristics:

  • Low cost
  • Simplicity
  • Compatibility

In reality, all three of these factors deal with cost.  The first examines the acquisition cost, the second deals with the time cost to learn to use the new procedure, and the third describes the cost of integrating the new technique within existing operations.  These costs generally can be accurately estimated for most innovations.

On the other hand, most evidence cites benefits for patients or other stakeholders.  Even if an innovation claims to be cost-effective from the provider’s perspective, physicians must risk that these promises will not come to pass.

The seminal technology adoption study examines the spread of hybrid corn in Iowa.  Although there was significant evidence that hybrid corn was better than the status quo, there was still significant risk to the farmer since the hybrid corn was much more expensive than regular corn.  It took the adoption of a thought leader for hybrid corn adoption to truly spread.  This is why pharmaceutical companies spend so much money to get respected docs to endorse their products; it leads to more rapid spread of their drug than can even be accomplished by direct-to-consumer advertising.

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Improving Placebo Effectiveness at Kaiser

August 16, 2011 in Medical Studies | 1 comment

I went to my first physician appointment as a member of Kaiser.  I received a primary care visit and got lab work done within 30 minutes.  The whole process was incredibly efficient.  I notice the Kaiser docs and nurses followed best practices.  Further, the check-in process was very organized and my doctor could access my medical record electronically.  Further, the next day I could access my lab results online.  Overall, it was a very efficient experience.

The process as completely different from the alternative medicine described in a recent Atlantic article, ‘The Triumph of New Age Medicine‘.  Consider the case of a 60-year-old retired firefighter who had come in for an acupuncture treatment.

“His wife, a nurse, urged him to try acupuncture, and in February, with the blessing of his doctor, he finally met with Lao, who had trained in his native China as an acupuncturist. Their first visit had lasted well over an hour, Corasaniti says, time mostly spent discussing every aspect of his injuries and what seemed to ease or exacerbate them, and also other aspects of his health—he had been gaining weight, he was constipated, he was developing urinary problems. They talked at length about his diet, his physical activity, his responsibilities and how they weighed on him. Lao focused in on stress—what was causing it in Corasaniti’s life, and how did it aggravate the pain?—and they discussed the importance of finding ways to relax in everyday life.”

Does acupuncture work?  Depends by what you mean by ‘work’.   This study found that acupuncture worked no better than a ‘sham acupuncture’.  However, acupuncture does work.  Although acupuncture is equally effective as sham acupuncture, sham acupuncture actually does help improve health.  Further, acupuncture is more effective than taking a sugar pill placebo.  Thus, the quality of the placebo–in terms of perceived cost and ritual surrounding the placebo–does improve health.

What can Kaiser learn from these findings?  Combining best practice medicine with better placebos such as more elaborate rituals of patient-provider interaction may improve the quality of care provided.

Creating a warmer, placebo-filled environment could put the patient in a better state of mind and better allow the patient to use positive thinking to heal themselves.

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Surgical Complications and Mortality Rates

December 16, 2009 in Hospitals, Medical Studies, Surgery | No comments

Mortality during surgery is dependent on two factors.  The first is the probability of having complications during surgery.  The second is the probability of dying conditional on having a complication.  One would expect that hospitals with low mortality rates would have both fewer complications and lower probability of death conditional on a complication.  

A paper by Gheferi, Birkmeyer, and Dimick (NEJM 2009) shows that this may not be the case.  After risk adjustment complication rates were not significantly higher in high mortality hospitals.  However, conditional on there being a complication, mortality rates were much higher in high mortality hospitals than low mortality hospitals.  

 

In Hospital Mortality (Gheferi et al. NEJM 2009)

How can doctors decrease mortality due to complications?  Gheferi, Birkmeyer, and Dimick recommend “timely administration of antibiotics in patients with sepsis, the rapid transfer of a patient to an intensive care unit (ICU), and the availability of interventional cardiologists during an acute myocardial infarction.”

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H1N1: Do I have it? Do I need a vaccine?

October 20, 2009 in Contagious Disease, Public Health | No comments

Two weeks ago, the U.S. government released its H1N1 vaccine to the public.  Many people have had a number of questions about whether or not they should get the vaccine.  The CDC website has a list of Key Facts and a Q&A section that is helpful.  

There are five major groups who should have priority of getting the vaccine:

  • pregnant women,
  • people who live with or provide care for infants younger than 6 months (e.g., parents, siblings, and day care providers),
  • health care and emergency medical services personnel,
  • people 6 months through 24 years of age, and,
  • people 25 years through 64 years of age who have certain medical conditions that put them at higher risk for influenza-related complications.

There are a number of people who should NOT get the vaccine.

  • People who have a severe allergy to chicken eggs.
  • People who have had a severe reaction to an influenza vaccination.
  • People who developed Guillain-Barré syndrome (GBS) within 6 weeks of getting an influenza vaccine previously.
  • Children younger than 6 months of age (influenza vaccine is not approved for this age group), and
  • People who have a moderate-to-severe illness with a fever (they should wait until they recover to get vaccinated.)

The H1N1 vaccine is prepared using the same method as used for the seasonal flu.  However, because the H1N1 vaccine was developed too late, it could not be added to the seasonal flu vaccine.  Thus there are two flu shots available now, one for the seasonal flu and one for H1N1. 

If you think you have the H1N1 illness, you can use this self assessment tool to verify whether or not you should see a doctor.

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Medical Advances

June 7, 2009 in Medical Studies | No comments

The Economist‘s Technology Quarterly reveals some recent advances in medical technology:

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Getting Naked

January 26, 2009 in Medical Studies | No comments

The physician-patient interaction can be a strange one.  Patients leave their most important possession–themselves–in the hand of strangers.  Typically conservative women will bare their naked bodies to physicians.   Although rare, the possibility exists for the physician to take advantage of this situation.  

In the U.S. “4 percent of the disciplinary order that state medical boards issue against physicians are for sex-related offenses…Seventy two percent of females medical students and twenty nine percent of male medical sudents have been victors of patient initiated sexual behavoir.”  I know of patients who slap cute medical assistants’ behind.  Physicians and patients can both act inappropriately.

How do physicians establish trust with their patients?

Atul Gawande gives some examples from around the world in Better: A Surgeon’s Notes on Performance.

  • Afghanistan: When a male physician examines a female patient, they are separated by an opaque screen with a two-inch circle cut into the screen. “Behind it, the woman is covered from head to toe by her burka. The two do not talk directly to each other. The patient’s young son serves as the go-between.” S
  • Iraq: Family members are present in the exam room whenever there is a male physician examining a female patient.
  • Venezuela: A nurse chaperone is present any time there is a breast or pelvic exam.  The exam will not take place without the presence of the chaperone.
  • England: A nurse chaperone is present any time a patient undergoes a breast, pelvic or abdominal exam.
  • Ukraine: A nurse chaperone or family member is rarely present in the examine room, but cultural mores help to maintain a professional tone.  Patients always address the physician as Dr. ____, and the physician addresses the patient as Mr. or Mrs. _____.

Gawande, Atul (2007) Better: A Surgeon’s Notes on Performance, Metropolitan Books, 288 pages.

Gawande A (2005) “Naked” NEJM, 353:645-648.

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Why do we die?

January 23, 2009 in Medical Studies | No comments

What factors predict how long we live?  What are the best ways to forestall death?

The determinants of premature death are 40% behavoiral, 30% genetic, but only 10% medical care.  It is important to remember that medical care and health are far from synonomous.

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