The NEW ENGLAND

JOURNAL OF MEDICINE

 

perspective

A Differentiation Diagnosis — Specialization and the Medical Student

If you walk through my medical school building in the evening and follow the aroma of pizza, you'll probably find your way to a dinner talk organized by a student specialty interest group. Running the gamut from surgery to psychiatry, these groups are made up of first- and second-year medical students, many of whom joined just weeks after they first donned their white coats.


poetry

Living Will

And the years fall

And the heart turns,

Releasing what it holds.

And seasons flicker,

And cities fade

As memory looks aside.

Desires, they rise

Like hope, like boats,

And the boats, they

Rock in place,

And no one knows

How the floating

Wears them down.

As darkness grows,

The heart calls out

In search of

What is lost.

Past the turn

Where quiet yawns,

It will sing

For all that comes

To break the fall

Of years.


now@NEJM and Resident 360 | selected posts

Déjà Voodoo: Readmission or Observation after the Affordable Care Act

The hospital where I work has one of the busiest emergency departments in Boston. Patients come in with everything you might imagine, from heart attacks to rabbit bites. A number of these patients, after being evaluated and treated, can be discharged home from the emergency department; others need to be admitted for further management. For still others, the plan isn’t immediately clear. Let’s say a patient has pain from a kidney stone. Can he try to pass the stone, or does he need intravenous medications and surgery? Such a patient might benefit from a short period of observation, in a so-called observation unit. If his pain improves, he could potentially return home, avoiding an admission.

While there are many appropriate uses for an observation unit, critics have raised the possibility that hospitals may be preferentially observing patients, rather than admitting them, to make their readmission rates appear more favorable. The Affordable Care Act, which was passed in 2010, introduced an initiative to reduce costly readmissions for patients recently discharged from the hospital. The Hospital Readmissions Reduction Program targeted a handful of “high-yield” conditions — heart failure, acute myocardial infarction, pneumonia, chronic obstructive pulmonary disease, and knee and hip replacements. Readmission rates, which had begun to decline before the legislation went into effect, declined at an even greater pace afterward. Was this because hospitals were using observation units to “game” the system?

The Good Word: Improving Patient Handoffs

Starting at six in the evening, the surgery residents at my hospital gather for sign-out.  This is when residents from the day shift hand over care of their patients to those working overnight.  Sign-out takes place in the residents’ lounge — a room furnished with computers, couches, and a makeshift ping-pong table — and tends to be an informal affair.  Multiple conversations happen at once, and interruptions are not uncommon, whether by phone call or passerby or stray ping-pong ball.

If you ask any of the residents, they’ll tell you this system works just fine. But as shift changes have become more frequent in recent years to accommodate work hour restrictions, there is concern that the growing number of handoffs may be leading to medical errors. As in a game of “telephone,” information can get distorted each time it is relayed. If reducing the quantity of handoffs isn’t an option, is there a way to improve the quality?

Got Skills? In Surgery, It Matters

In the science fiction film “Prometheus,” set in the year 2093, surgery is depicted as a purely automated process. A woman climbs into a capsule-shaped machine; with the touch of a few buttons, the machine sets to work preparing a sterile field, making an incision, extracting a specimen, and stapling her back up. No surgeon is required.

In today’s world, we still very much rely on surgeons. We expect them to be competent and to deliver the best outcomes possible. But surgeons aren’t machines; no two are exactly alike in experience or skill level. Does this variation matter?

A New Way to Desensitize Patients for Kidney Transplant -- Use a Bacterial Enzyme

On a recent season of the fictional television series House of Cards, the President of the United States needs an organ transplant. His chief of staff tampers with the waitlist and moves the President to the top of the list, saving him at the cost of another man’s life.

This sort of scenario plays to what most people understand implicitly to be true: When it comes to organ transplants, the demand is high for a limited supply. In kidney transplants, the supply-demand mismatch continues to grow; today, over 100,000 patients are on the deceased donor waitlist. But availability is just the surface of the problem. Nearly one third of patients on the waitlist carry antibodies against HLA or other antigens, due to pregnancy, blood transfusions, or other prior exposures. Therefore, their immune systems are likely to attack and reject any transplanted organ. Therapies to reduce this antibody count, or “desensitize” patients, have helped to mitigate the problem, but often incompletely remove donor-specific antibodies and can result in rebound antibody production. Such treatments are also expensive and can be cumbersome.

Intravenous Fluid Therapy in Major Abdominal Surgery - Less May Not Be More

Intravenous fluid therapy in major abdominal surgery is a classic Goldilocks dilemma: Too little fluid can result in low blood pressure and consequent organ damage, but too much fluid can cause tissue edema, potentially delaying recovery of bowel function and precipitating cardiopulmonary complications. What is the right balance?

Staying Abreast of Screening Mammography

Should women of a certain age be screened regularly for breast cancer?  It’s a seemingly simple question that has proven controversial to answer, as evidenced by the uproar last November over a revised recommendation from the US Preventive Services Task Force to start mammographic screening at age 50 instead of 40.

Supporters of routine screening mammography have argued that it significantly reduces breast cancer mortality. According to estimates by the US Preventive Health Services Task Force, screening mammography is associated with a 15 to 23% reduction in breast cancer mortality.  Meanwhile, the WHO has stated on the basis of several randomized trials that screening women between the ages of 50 and 69 years potentially reduces the mortality rate by 25%.

Critics, on the other hand, have challenged the validity of these findings.  Many previous trials studying the effectiveness of screening mammography used historical comparison groups, looking at mortality among current cohorts of women as compared with unscreened cohorts from the past.  Such a comparison introduces the possibility of confounding.  Were the observed reductions in mortality due to screening mammography?  Or were they due to other factors influencing breast cancer mortality that have changed over time, such as advances in treatment?