How to Describe Hoarseness?

At heart, physicians are science geeks. And when it comes to a raspy voice, one can go truly bananas in how exactly to describe how a raspy voice sounds.

For the layperson, when asked to describe a hoarse voice, one often gets imprecise answers to a question most feel ridiculous... I often get a blank look with an answer that goes something like "You know... raspy... it's not clear." Unfortunately, such a description is inadequate. Even when using more descriptors like deeper/higher than normal, onset delays, pitch breaks, breathy, click, tight, etc, more information is needed.

There are 2 fundamental ways to more precisely convey the characteristics of how a raspy voice sounds and to document change (better/worse) over time.

Method #1 - Perceptual Tests

Developed by Dr. Robert Bastian, I personal prefer this method as it is more intuitive and replicable by anybody including the patient.

1) Maximum Phonation Time (MPT) - How many seconds can a single note be sustained for with a single breath? This test provides a rough measure of lung capacity and how "breathy" a voice is. The more breathy a voice is, the lower the MPT.
2) Pitch Range - What is the lowest and highest note a person can say/sing (I use a piano keyboard). Provides information on how much vocal cord swelling and length is present (the more swollen the vocal cords are, the deeper the pitch just like a violin string). I also typically like the patient to glide up and down from their lowest and highest note as it provides some additional information on neurological/muscular control of their voice depending on how smoothly it is performed.
3) Swell Tests - Essentially, the test involves singing a song (I use Happy Birthday) very quietly an octave higher than your normal pitch. If onset delays or pitch breaks are heard, does suggest the presence of a small bump (nodule, cyst, polyp, etc) on the vocal cords.

One can also add documentation of yell, cough, throat-clearing, and speaking voice.

Method #2 - Objective Tests

This type of testing can only be performed with the help of instruments and provides "numbers" that can be documented. It is more difficult to "hear" the voice looking at just these numbers, but does provide a more rigorous way to actually "measure" the voice quality. There are now even iPhone apps that can obtain such data.

The basic measures include:
1) Shimmer - Measures how much variation in loudness is present. Think of a volume knob being turned up and down slightly. Normal is less than 3%.
2) Jitter - Measures how much variation in pitch is present. Think of going up and down on the equalizer slightly. Normal is less than 1%.
3) MPT is also measured.
4) Fundamental frequency (f0) - Measure of how high/low a person's voice sounds (pitch).

One can go crazy and also add intensity, glottal noise, ratio, tremor, spectrum, EGG-pitch, EGG-intensity, EGG-jitter, EGG-shimmer, EGG-noise, CQ, CQ perturbation, CI, CI perturbation, opening rate, etc.

Regardless of the method, with this type of information, the actual degree and characterization of the vocal quality can be measured, documented, and tracked over time. Also, when communicating with other health professionals, such measures provide for an efficient and understandable way to describe a patent's voice with a colleague.

Of course, from the patent's perspective, they "just want to sound better," but this is how professionals do it.

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ENT Doctor iPhone App Games

This was bound to happen sooner or later… thanks to @hobsonent who brought this to my attention.

This Nose Doctor iPhone app game basically is to try and remove nasal hair as well as boogers from different characters' noses using different instruments.

Another iPhone app game is Ear Doctor which deals more with ear problems (obviously).

Although these iPhone apps makes a game out of it, do ENT doctors actually professionally remove boogers, earwax, and nasal hair? We do… Regularly… For real… We are indeed professional ear and nose-pickers.

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Life-Saving Emergency Trach Performed in Restaurant

On Sept 23, 2013, a physician performed a life-saving emergency tracheotomy in a restaurant on a patron who was choking on a piece of meat. [link]

While eating dinner at The Mark Restaurant in California, Dr. Royce Johnson, an infectious disease doctor affiliated with UCLA, performed this procedure on Pauline Larwood, a female supervisor and a community college trustee.

Dr. Johnson saved this woman's life using a pocket knife and the hollow cylinder of a pen after a Heimlich maneuver failed to work.

Interestingly, Dr. Thomas Frieden, director of the CDC, who was also present in the restaurant assisted in the care by monitoring Larwood’s pulse during the incident.

Also present in the restaurant witnessing the emergency procedure were:

• Francis Collins, MD (director of NIH)
• Farming and business moguls Lynda and Stewart Resnick
• Rep. Kevin McCarthy, R-Bakersfield
• Assemblywoman Shannon Grove, R-Bakersfield
• State senator Jean Fuller, R-Bakersfield

Although typically surgeons are the individuals trained to perform tracheotomies, bravo to Dr. Johnson who took the initiative in spite of the fact that he probably has never performed one.

I should also add that though media reports state that an emergency tracheostomy was performed, it is probably more likely that an emergency cricothyroidotomy was performed instead which is easier and less "bloody."

Source:
Dramatic dinner rescue involves knife, UCLA doctor and CDC chief. The Bakersfield Californian 9/24/13

CALIF. DOCTOR SAVES CHOKING DINER WITH KNIFE. The Associated Press 9/25/13

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Malpractice Lawsuit for Nerve Damage Sustained After Neck Cyst Excision

Earlier this month, a malpractice lawsuit resulted in a $4 million dollar award to the patient plaintiff who suffered permanent nerve damage after a family practice physician excised a cyst from the neck. [link]

Briefly, the patient visited the family physician in July 2009 for a lump in his left neck. The family physician recommended that the mass be surgically excised which was subsequently performed by the same family physician (not a surgeon) in the office. After the procedure, the patient experienced a weakened left arm and shoulder and had difficulty picking things up with that arm or moving the arm more than 90 degrees. Subsequent evaluation by an orthopedic surgeon and neurosurgeon determined that the spinal accessary nerve was cut at the time of the neck mass excision.

So what probably happened?

The spinal accessory nerve (also known as cranial nerve XI), is a major nerve that comes off the spinal cord and supplies motor function to the shoulder and arm (red arrow below pointing to the nerve which is yellow).

Image Modified from Wikipedia

I suspect that in this case, the mass was located in the same area denoted by the red arrow above. Now assuming that media and court documents were correct that it was truly a cyst that was excised, the cyst must have laid right below the skin, but on top of the nerve.

Careless excision of the cyst would have resulted in this nerve being cut especially during dissection on the mass's deepest aspect, especially if the physician did not hug the mass during dissection. Using an analogy, good surgical technique is like peeling an orange without puncturing the yummy orange underneath. Poor surgical technique would be peeling the rind and taking bits of the edible orange as well... or leaving some nasty rind on the fleshy orange itself.

Often, novice surgeons take large cuts around a mass with the tip of the scissor or scalpel extending beyond visualization. Also, thick layers of tissues are cut rather than thin transparent amounts. Furthermore, when a mass is grasped and pulled, anatomic structures like a nerve can get pulled out of its usual location along with the mass which can lead to unintentional damage. 

As such, experienced surgeons know when to cut big (no important structures are around) and when to cut in tiny microscopic degrees (important nerves and blood vessels are around).

The neck has a large number of important blood vessels and nerves in a highly compacted area making surgery in this part of the body potentially fraught with peril. However, there are certain "safe" areas where no significant important nerves or blood vessels are found. Such a "safe" zone from a nerve perspective is right under the chin extending down over the voicebox. Of course, there are other important structures located in this area that could get damaged even if nerves aren't a concern.

Source:
Montco jury awards Hatboro man $4M for nerve damage. Phillyburbs 8/27/13

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Unhappy with Your Appointment Day/Time with your Doctor?

A common complaint for patients is how long it may take to get in to see a medical specialist. A new patient appointment may be 1-2 weeks away when an earlier appointment may be desired.

What to do?

Of course, one can call around to every single specialist office in the region to see who has the next earliest appointment.

Other options which may work just as well include the following:

• Do NOT limit yourself to a specific day of the week and time. Always use the phrase "the very next available appointment whenever that may be."

• Ask your regular doctor to call and make an appointment for you. Be aware that if you resort to this option, you will have to accept whatever day/time you are given. Do not use this option if you will most likely end up changing the appointment to suit your schedule, otherwise risk being given an appointment far into the future.

• Although in theory, there are appointment wait lists you can put yourself into, it only works if the medical office checks it regularly... which typically does not happen. What works better is to call everyday! On a daily basis, there are ALWAYS cancellations that occur. In my office daily, there are usually 1-2 new patient appointment cancellations and double that in established patient appointment cancellations. Such cancellations usually are called in by 10AM for that afternoon or 4PM for next day cancellations. So call around that time to see if any appointment slots have opened up that you can slip into. This is why medical offices beg patients to always call if you are not going to show up and even charge a fee if you fail to inform in advance. It is to help other patients who desperately want to be seen and who could have been scheduled into your appointment slot that ended up being wasted.

Based on a study by ZocDoc, here are other appointment related trivia:

• Tuesday is the most popular day for doctor appointments; it's also the day with the most last-minute openings.
• For pediatricians, the most popular day for doctor appointments is Monday
• The most popular appointment of the week is Friday at 10AM, followed closely by Friday at 2PM.
• Thursday has the longest wait time.

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Medical Translator Commercial...

I'm sure many patients would like a medical translator like this one shown in this humorous commercial. In case you haven't seen it yet...

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Scam Tracheostomy in Hospital Leading to Arrests

Image from Wikipedia

A Chicago hospital owner and a few doctors were arrested in a horrific scandal involving deliberately over-sedating patients thereby ensuring a patient will not be able to come off the breathing machine leading to the excuse needed to perform a tracheostomy [link]. All done in the name for greater profits.

This scandal is particularly notable given it has come right at the heels of a New York Times story which reported that hospitals often profit from surgical errors, though in this criminal case, it was deliberate rather than unintentional errors.

Tracheostomy is typically performed whenever a patient is on a breathing machine for a prolonged period of time and there is a low likelihood of recovery.

However, prior to tracheostomy consideration, sedation is turned off so that the patient is allowed to wake up and try to breath on their own. If able to breath on their own with machine assistance, the breathing tube may be removed thereby avoiding a tracheostomy.

However, according to the lawsuit, the hospital and physician colluded to over-sedate patients thereby ensuring the patient is "ventilator-dependent" for which a tracheostomy is (erroneously) "justified".

Furthermore, patients who have undergone tracheostomy were intentionally made to stay in the hospital longer than required ("28 days") in order to earn as much money as possible in insurance reimbursements for the hospital.  [link: paragraphs 123-142]

According to media reports, this scam has so far involved 28 patients... 5 who ultimately died within 2 weeks. The most recent unnecessary tracheostomy was performed on March 1, 2013.

Because of the trach and subsequent prolonged hospitalizations, the hospital received up to $160,000 for each patient from Medicare and Medicaid.

There's more... there was a massive kickback scheme whereby the hospital paid doctors to refer cases to the hospital (clear violation of Stark Laws), doctors ordered unnecessary ER visits, and fraudulently referred patients to nursing homes and ambulance services which the hospital had a relationship with.

This awful scam was brought to light by hospital workers (administrators, physicians, and nurses) who secretly worked with the FBI and other federal investigators.

Sources:
Feds raid Sacred Heart Hospital, arrest owner and doctors. Chicago Sun-Times 4/16/13.

United States of America Criminal Case Record. 4/15/13

Hospitals Profit From Surgical Errors, Study Finds. New York Times 4/16/13

Relationship Between Occurrence of Surgical Complications and Hospital Finances. JAMA. 2013;309(15):1599-1606. doi:10.1001/jama.2013.2773.

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Do Surgeons Swear When Operating?

Surgeons, whether deserved or not, have a reputation of being mean-spirited and foul-mouthed as a group overall. It does not help that TV shows and movies perpetuate this reputation.

Well, a study was actually carried out to see if surgeons are truly foul-mouthed or not and published their findings in the British Medical Journal in 1999.

Using a grading system based on how bad the swearing is, researchers secretly tallied how often surgeons used profanity in the operating room.

The observation was carried out over 100 operations totaling 80 hours and 30 minutes of operating time.

What they found was that orthopedic surgeons were found to be the most foul-mouthed with an overall score of 41 (zero being no swearing at all).

ENT surgeons had the best score of 2 when one surgeon exclaimed "bugger" during one case.

Here's the chart...

Taken from BMJ

Reference:
Surgeons swear when operating: fact or myth? BMJ 1999; 319 doi: http://dx.doi.org/10.1136/bmj.319.7225.1611 (Published 18 December 1999)

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Forbes Critical of Patient Satisfaction Ratings of Physicians

Forbes on January 2, 2013 published a story critical of Press Gainey and other companies that obtain patient satisfaction scores.

Please note that the following is a reprint of prior blog articles (2/19/12 and 6/8/12) written on this subject by Fauquier ENT.

Indeed, much has been made about improving patient satisfaction in the healthcare industry in the belief that greater patient satisfaction equates with better health. To this end, patients are routinely asked to complete a survey based on their impressions on the care they received at a medical office, hospital, and/or emergency room.

BUT... does greater patient satisfaction actually result in or is the result of better care???

According to a recent study... higher patient satisfaction actually resulted in:

• Greater inpatient hospitalization
• Higher overall healthcare utilization
• Higher prescription usage
• INCREASED RISK OF DEATH!

The one and only measured benefit of higher patient satisfaction scores was decreased ER use.

Why would there be an increased risk of death with higher patient satisfaction scores?

Well, if a doctor always does what the patient wants, that would tend to lead towards higher patient satisfaction... EVEN if it's the wrong thing to do.

For example... when a patient sees a doctor for a perceived sinus infection, it is not uncommon for a patient to expect to leave with an antibiotic.

Unfortunately, many sinus infections are actually viral URI for which antibiotics is the WRONG course of action.

Inappropriate antibiotics lead to drug-resistant infections which lead to deaths.

However, if a doctor resists a patient's desire for an antibiotic, that would lead to a decrease in patient satisfaction.

Such medical decisions do not apply to just antibiotics, but also tests, procedures, and hospital admissions.

This example and others may oversimplify a very complex issue, but it does suggest that one interpretation of higher patient satisfaction scores are that doctors and hospital systems may choose to do the wrong thing in order to get a better score.

And that gets into the problems with how the surveys are obtained in the first place...

The Problem With Surveys

What if I told you 100% patient satisfaction scores were due to a survey of only two people... that I personally picked?

Welcome to the big bad world of patient satisfaction scores.

Often (well... pretty much all the time), I come across an article, bulletin posting, or meeting where patient satisfaction scores are announced... but no background information to back it up. HOW many people completed the survey? HOW were the people selected? WHO administered the survey?

HOW many people completed the survey?

The number of patients who actually completed the survey is very important. Mainly, because of the variance that may occur month-to-month as well as ease in manipulating the results.

Let's assume only TWO people completed the survey. The first month, both give me a thumbs up giving me a score of 100%.

However, the following month, another TWO people completed the survey, but only one gave me a thumbs up giving me a score of 50%.

NEWSFLASH!!! "Patient satisfaction scores plummeted 50% over a 1 month period of time!"

In order for meaningful interpretation of patient satisfaction scores, enough survey results MUST be obtained, especially when comparing scores across time.

HOW were the people selected?

Let's pick on the emergency room...

If I wanted to "pad" my results, I would tend to provide surveys to patients who had simple problems and who were seen quickly.

Child with an earache? Let's seem them immediately in Fast-Track ER. [Look in the ear! There's an ear infection.] Here's some antibiotics. Can you also complete this survey?

As opposed to...

55 year old narcotic-addicted patient with fibromyalgia demanding a prescription for 500 percocet pills for his chest pain. I would probably not want this patient to fill out the survey. Neither would the patient as he would probably toss it.

Granted these are extremes, but if performance bonuses are provided to departments with the best patient satisfaction scores and the ER staff were the ones providing the surveys, one can easily manipulate the results in their favor.

WHO administered the survey?

As mentioned above, survey results can be manipulated depending on who provides or gives the survey, ESPECIALLY if money is involved based on the results of the survey.

In order for survey results to be meaningful, a third uninvolved party should be the one to administer the test.

Survey Fatigue

Now even if the survey was done dispassionately and adequate number of surveys were completed, there's still the problem of survey fatigue...

What's that?

I don't know about you all, but I get about 3-4 letters per week and at least one phone call per day asking me to complete a survey on my car, toothbrush, tater tots... etc. You name it... there's a survey for it now.

Now add how many questions are asked... Hopefully one so it's quick.

But also HOW the questions are asked (yes/no versus a scale of 1-10).

As a person completing a survey, if I had my way, there would only be one question that is a yes/no question.

The more questions there are and if they are scaled rather than yes/no, the less likely I'm going to do it.

Now add if you are sick and in pain... How likely are you going to actually complete a 50 question survey on a scale of 1-10???

Probably not...

In fact, it's probably only going to be healthy individuals who tend to give better scores giving a skewed result.

Also, given the survey fatigue I and I bet most people have, it will be a rushed completion without much thought given. The default being five stars all the way down (I may not even bother to read the questions).

A decent way to look for survey fatigue is to have 2 randomly buried questions where rather than 5 stars being the best, 1 star is the best. Surveys where everything is 4 or 5 stars INCLUDING the reversed scale questions should be thrown out.

Summary

If surveys are accurately administered with statistical power and used in such a way that financial incentives are not so tightly linked to the outcomes, than potentially all stand to benefit.

However, performed the way they are currently, whether good or bad, patient satisfaction scores can be VERY misleading if not completely wrong...

I should also add that whenever money is involved, NO test is going to be 100% accurate due to cheating that is bound to happen one way or another... even if cheating occurs by providing healthcare not due to medical reasons.

I predict that this problem is going to get MUCH worse because health insurances will soon base how much reimbursement hospitals and physicians get based on patient satisfaction scores. We are talking about millions and millions of dollars.

Just read about the "no-child left behind" from the Bush era where student test scores influenced teacher pay leading to teachers allowing cheating on tests.


Sources:
Why Rating Your Doctor Is Bad For Your Health. Forbes 1/2/13

Greater Patient Satisfaction At Expense of Better Care? Fauquier ENT 2/19/12

100% Patient Satisfaction Scores. Fauquier ENT 6/8/12

Patient satisfaction: When a doctor’s judgment risks a poor rating. JAMA 11/26/12

Reference:
The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality. Arch Intern Med. Published online February 13, 2012. doi:10.1001/archinternmed.2011.1662

Patient Satisfaction and Patient-Centered Care: Necessary but Not Equal. The Journal of the American Medical Association, July 11 (jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2012.7381)

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HIPAA Compliant Text Messaging (for Free)

Let's face it...

Physicians love to text message given it is fast, easy, and convenient. However, regular instant messaging (SMS, MMS) that comes with your smartphone is not secure, saved unencrypted on a server somewhere (forever), and most importantly not HIPAA or HITECH compliant.

Enter the encrypted and HIPAA compliant messaging services.

Though most of these services cost a nominal fee per month, there are a few and growing number of services which offer free and secure instant messaging. Even better, pretty much all these services including the free ones allow sending messages with unlimited characters, pictures, video, and audio along with text.

Regardless of the service, there are two elements that allow for encrypted SMS and MMS.

1) Userid and Password
2) All your secure contacts must also be using the same service (ie, they all have to sign up before using)

The best free HIPAA-compliant messaging services that's out there that I'm aware of are qliqConnect which is geared towards health professionals and Wickr which is geared towards anybody.

There are pros and cons to both.

qliqConnect is available for use on the desktop, iPad, iPhone, and Android. Wickr is available only on the iPhone (Android coming soon).

Wickr offers complete self-destruct of messages after a certain period of time (all metadata with pictures, video and audio files, like your device info, your location, and any personal information captured during the creation of those files). qliqConnect does not.

No email is required with Wickr. qliqConnect does.

Wickr also states that messages are secured using military grade encryption that exceeds HIPAA standards and unencrypted messages are NEVER stored on any server. It is unclear whether qliqConnect offers similar level of security.

Depending on your needs, one of these free services may be more suitable than the other.

Of course, the weakest link for full adoption is that everybody you want to securely message with also needs to sign up for the same service.

In the end, if I'm a betting man... Wickr will probably win out in the end, especially once they have software available for platforms beyond the iPhone.

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Is Social Media Bad for Doctors?

I was recently asked to participate as a speaker in a panel discussion on social media next year in Canada and while preparing my thoughts on this subject, I was pondering several big questions regarding the why and pitfalls of social media for healthcare professionals.

There's the obvious "WHY" a physician should participate in social media.

But perhaps even a more basic concern for a physician deciding whether to pursue social media or not is whether it may even be a bad idea.

Beyond the obvious medico-legal issues regarding private medical information (HIPAA, HITECH, etc, etc), there is perhaps an underlying fear of having their online persona hijacked by negative publicity, whether warranted or not.

In essence, as Sensei Marketing pointed out succinctly in a blog post, could social media actually create bad customers or in our case, patients???

It happened to McDonalds when their hashtag #McDStories was hijacked by a mob of angry trolls as well as real customers with negative stories.

Sensei Marketing's belief in the evils of social media was summarized quite simply:

"people deep down are bullies or at the very least indifferent to bullying."

Assuming the general populace, which includes patients, are all bullies deep down, social media allows for (borrowing from Sensei Marketing):

• No Guilt - Easy to condemn or accuse
• The Mob - If lots of people are doing it, it just makes it that much easier for an individual to justify doing it too.
• Anonymity - Being unidentifiable allows for those who ordinarily would have exercised restraint, to vocalize (or type) without fear.
• No Accountability - With anonymity, there is no repercussion or punishment 
• Streisand Effect - If an individual (or doctor) tries to combat a negative rating or comment, it just brings more attention to it. More on this effect as it pertains to physicians here.

There are already numerous doctor rating websites where patients are encouraged to critique their doctor. Doctor rating sites are also universally reviled by physicians for one reason or another.

Could social media be just another further extension of doctor rating websites, except now the physician is doing it to himself inviting another avenue for public ridicule or even attack?

The answer is yes...

BUT, a physician should not avoid social media for fear of risk. In fact, a physician should pursue social media not just for (free) marketing or informational purposes, but also to control risk! I also have a more optimistic view of human nature (we are NOT all bullies deep down).

Unlike doctor rating websites where a physician has little recourse to combat negative comments justified or not, social media CAN be controlled, shaped, and monitored by the physician.

Bullying or negative comments will occur online whether a physician likes it or not. Whether through a doctor rating website or not. Whether there is a social media presence or not.

As such, the absence of a social media presence may in fact promote physician brand negativity given there is no public competing positive voice... namely, your own.

Furthermore, even if you are a wonderful doctor without a bad word anywhere online, in this day and age... an absent presence is increasingly becoming interpreted by the public as a negative, especially when a google search, which takes into account social media presence, often decides who a patient ultimately decides to see.


Source:
Is Social Media Bad For Business? Forbes 11/11/12

Social Media is Creating Bad Customers. Sensei Marketing

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What do Earthquakes Have to do with Thyroid Masses?

I'm not sure what is going on within the Italian Court system, but in October 2012, the Italian Court convicted 7 scientists to jail terms for not accurately predicting the 2009 L'Aquila earthquake that ended up killing over 300 people.

Also in October 2012, the Italian Supreme Court ruled that cell phones caused one man's brain tumor.

Since when does the Court decide on matters of scientific validity?

And even more importantly, what does this have to do with ENT???

I'm sure people here and there will shake their heads and say how ridiculous. "Unbelievable" that the Italians Courts have made such a stupid decision.

I hate to break it to you all... but it happens ALL THE TIME, especially in the field of medicine. The Court and Lawyers have profoundly influenced how medicine (and now seismology) is practiced whether scientifically valid or not. No matter how ridiculous it may be seen in hindsight or not.

Let's go back to those poor convicted earthquake scientists...

At least in Italy, it's likely that these Court decisions will having a chilling influence over how scientists will behave in the future whether scientifically valid or not. For every single minor tremor, scientists will now have to weigh potential for jail-term if they are inaccurate with their predictions (even though everybody knows predicting major earthquakes accurately is impossible).

I can imagine them to report in the future every single minor tremor as a potential threat of a major earthquake and as such, citizens of Italy are warned to take precautions and evacuate the area for 1 month.

I wonder how Californians will react to such predictions.

In medicine, especially in the field of radiology and pathology, diagnostic dilemmas equivalent to what Italian seismologists go through are common. For fear of the Court and Lawyers, radiologists and pathologists commonly overcall grey areas leading to further testing and even surgery for ultimately reasons that were totally unnecessary.

For example, thyroid masses are one particularly thorny area for both radiologists and pathologists.

In radiology, they will report every single nodule and cyst no matter how small for fear of Court and Lawyers. In the huge majority of the time, such thyroid masses are benign and no intervention is needed. However, should one of those nodules/cysts actually end up being thyroid cancer, the radiologist may end up being sued if he did NOT report them. As such, they are all reported and the burden of lawsuit than falls upon the doctor who ordered the CT scan or ultrasound in the first place.

What does this mean for the patient? For fear of Court and Lawyers, patients will end up getting more tests done and even undergo surgical removal "just to make sure" that it is not cancerous.

Which leads to the next diagnostic dilemma...

In pathology, fine needle biopsies of such thyroid masses is common. However, making a pathological diagnosis is sometimes quite difficult, especially if cancer is on everybody's mind. So what is the pathologist to do if he is uncertain whether cancer is present or not? For fear of Court and Lawyers, he makes an ambiguous statement:

There are some atypic cells suggestive but not definitive of cancer. Clinical correlation recommended.

Now the legal burden is on the surgeon. The surgeon, for fear of Court and Lawyers, will now suggest to the patient that to be absolutely sure there is no cancer present, it is perhaps best to remove the thyroid gland.

Low and behold, many patients who undergo thyroid removal for such ambiguous findings on radiology and pathology reports end up with no cancer found in the thyroid gland. All that testing and surgery was, in the end, totally unnecessary.

The judgements of four physicians have been consecutively affected and compounded with each other for fear of Court and Lawyers:

• Primary Care Doctor who ordered the CT scan or Ultrasound of the thyroid gland
• Radiologist who reported the thyroid nodules/cysts
• Pathologist who interpreted the needle biopsies of those nodules/cysts
• Surgeon who ends up removing the thyroid gland based on the pathology and radiology results

Does this actually happen???

Absolutely. All the time.

In fact, it happened to the President of Argentina who had her entire thyroid gland removed for fear of cancer, but ended up that no cancer was found. Read more.

Read more about the surgery here or watch the video!

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Find an ENT Doctor App

If you have an iPhone or Android, get the ENTLink App... You can search for an ENT by current location or by zip code. The search can be narrowed to a specific specialty area (laryngology, neuro-otology, rhinology, etc) as well.

Of course, you can search for the same information from the website.

Download the app for iPhone and Android.

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100% Patient Satisfaction Scores

What if I told you this 100% patient satisfaction score was due to a survey of only two people... that I personally picked?

Welcome to the big bad world of patient satisfaction scores.

Often (well... pretty much all the time), I come across an article, bulletin posting, or meeting where patient satisfaction scores are announced... but no background information to back it up. HOW many people completed the survey? HOW were the people selected? WHO administered the survey?

HOW many people completed the survey?

The number of patients who actually completed the survey is very important. Mainly, because of the variance that may occur month-to-month as well as ease in manipulating the results.

Let's assume only TWO people completed the survey. The first month, both give me a thumbs up giving me a score of 100%.

However, the following month, another TWO people completed the survey, but only one gave me a thumbs up giving me a score of 50%.

NEWSFLASH!!! "Patient satisfaction scores plummeted 50% over a 1 month period of time!"

In order for meaningful interpretation of patient satisfaction scores, enough survey results MUST be obtained, especially when comparing scores across time.

HOW were the people selected?

Let's pick on the emergency room...

If I wanted to "pad" my results, I would tend to provide surveys to patients who had simple problems and who were seen quickly.

Child with an earache? Let's seem them immediately in Fast-Track ER. [Look in the ear! There's an ear infection.] Here's some antibiotics. Can you also complete this survey?

As opposed to...

55 year old narcotic-addicted patient with fibromyalgia demanding a prescription for 500 percocet pills for his chest pain. I would probably not want this patient to fill out the survey. Neither would the patient as he would probably toss it.

Granted these are extremes, but if performance bonuses are provided to departments with the best patient satisfaction scores and the ER staff were the ones providing the surveys, one can easily manipulate the results in their favor.

WHO administered the survey?

As mentioned above, survey results can be manipulated depending on who provides or gives the survey, ESPECIALLY if money is involved based on the results of the survey.

In order for survey results to be meaningful, a third uninvolved party should be the one to administer the test.

Survey Fatigue

Now even if the survey was done dispassionately and adequate number of surveys were completed, there's still the problem of survey fatigue...

What's that?

I don't know about you all, but I get about 3-4 letters per week and at least one phone call per day asking me to complete a survey on my car, toothbrush, tater tots... etc. You name it... there's a survey for it now.

Now add how many questions are asked... Hopefully one so it's quick.

But also HOW the questions are asked (yes/no versus a scale of 1-10).

As a person completing a survey, if I had my way, there would only be one question that is a yes/no question.

The more questions there are and if they are scaled rather than yes/no, the less likely I'm going to do it.

Now add if you are sick and in pain... How likely are you going to actually complete a 50 question survey on a scale of 1-10???

Probably not...

In fact, it's probably only going to be healthy individuals who tend to give better scores giving a skewed result.

Also, given the survey fatigue I and I bet most people have, it will be a rushed completion without much thought given. The default being five stars all the way down (I may not even bother to read the questions).

A decent way to look for survey fatigue is to have 2 randomly buried questions where rather than 5 stars being the best, 1 star is the best. Surveys where everything is 4 or 5 stars INCLUDING the reversed scale questions should be thrown out.

Summary

Whether good or bad, patient satisfaction scores can be VERY misleading if not completely wrong...

I should also add that whenever money is involved, NO test is going to be 100% accurate due to cheating that WILL happen one way or another.

I predict that this problem is going to get MUCH worse because health insurances will soon base how much reimbursement hospitals and physicians get based on patient satisfaction scores. We are talking about millions and millions of dollars.

Just read about the "no-child left behind" from the Bush era where student test scores influenced teacher pay leading to teachers allowing cheating on tests.

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TV Show HOUSE Exploring ENT Problems

I must clarify that I never really like TV show House for reasons explained here... but patients who love watching House have alerted me to some episodes this season that touched on ENT problems.

So... here goes...

Episode 21 (Season 8): Holding On
Diagnosis: Persistent Stapedial Artery

19 years old cheerleader was admitted after suffering from dizziness, massive nosebleed, and auditory hallucinations. It was ultimately determined that he was suffering from a persistent stapedial artery.

This artery is a congenital defect of the inner ear that should have obliterated during fetal development. However, if persistent, is typically found going through the stapes bone of the middle ear.

It CAN cause symptoms of dizziness as the pulsations of the artery can transmit through the stapes footplate and into the vestibule via the oval window. It can also cause auditory hallucinations by pressing against the nearby temporal lobe as well as a nosebleed. If the artery ruptures, it can only drain through the eustachian tube and out the nose.

However, if the patient presented to the ER with nosebleed and dizziness, a complete physical exam would have been performed and a clearly seen blood-filled middle ear cavity (hemotympanum) would have been seen that even a medical student would have found. That would have indicated an ear issue causing both the dizziness and nosebleed. Also, the patient would have complained of hearing loss with blood in the ear.

From that point, the differential diagnosis is actually quite small and would have been obtained relatively easily.

Episode 17 (Season 8): We Need The Eggs

Diagnosis: Amoebic Meningitis

35 years old man admitted to House’s service after he is discovered crying blood. He later develops light sensitivity, vomiting, and a stiff neck.

After suspecting meningitis, it was discovered that he was using a Neti Pot and was using tap water rather than distilled or sterilized water in order to perform saline flushes. The water happened to contain an amoeba (likely Naegleria fowleri) which caused an amoebic infection of the brain.  The culprit organism Naegleria fowleri causes a life-threatening encephalitis after passing thru the nose and up into the brain where the organism eats neurons for food.

Such brain infections have been recently reported in the news and can be prevented by using water that is boiled, distilled, or filtered.

Fortunately, it is rare.

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If Computer Security Experts are Getting Hacked, Why are Hospitals/Doctors Expected to be Better?

As anyone knows from reading the newspaper recently, major computer security firms like RSA and Verisign have been hacked. Even the pentagon!

If companies that specialize in computer security get hacked, why are hospitals and doctors who do NOT specialize in computer security held to an even higher standard?

Criminal penalties against healthcare professionals and organizations are steep for computer data breaches at $100 per record with criminal penalties that can include fines of $250,000 and 10 years in prison.

Given such steep penalties, the assumption is that hospitals and physicians must be experts in computer and network security... even better than companies that specialize in this subject area... or can purchase one.

So who should healthcare organizations hire to secure their computers to avoid getting hacked as I can certainly tell you, they are most certainly not security experts?

Google? Symantec? RSA? Verisign? The pentagon?

They've all been hacked successfully... As such, how can we trust their security products?

The answer is simple... There is no company that can be contracted to provide bulletproof security.

The only way is to NOT use a computer at all!

So here's the interesting quandary...

The government is mandating hospital and physicians to transition to electronic medical records or start facing penalties for not doing so.

BUT, the electronic medical records must have bulletproof security or else criminal penalties and even jail-time can be had for any breaches.

With these mandates, the only thing doctors and hospitals can hope for is to not get noticed by hackers. Either get punished for not using a computer or get punished for not having a security system even better than the pentagon.

Source:
Why the security industry never actually makes us secure. CNET 3/3/12
HIPAA Violations and Enforcement. AMA

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Dr. Chang a Washingtonian Top Doctor for 2012

For 2012, Dr. Chang was selected as a Washingtonian Top Doctor in the field of otolaryngology (page 120). This year's list was published in the March 2012 issue of the magazine.

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Dr. Chang a Northern Virginia Top Doctor for 2012

Northern Virginia Magazine published their annual list of Top Doctors for 2012 in their February 2012 edition. Dr. Chang was listed as one of Northern Virginia's Top Doctor in the field of Otolaryngology (page 72).

Of note, Dr. Chang was nominated by his doctor peers opposed to nomination by a small panel.

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What Makes a Successful Hospital - Where Are the Tweakers???

First off, I don't have a business degree (in fact, I'm a MBA drop-out) nor a degree in hospital administration (does chairing a hospital committee count?), but I do have an opinion (don't we all) in light of having co-founded a bioinformatics company (iCORD, LLC) in the past based on a patent developed during my surgical residency... But I also admit that the company was ultimately unsuccessful if one measures success in terms of monetary profits, but I can say I succeeded in that my now defunct company's "product" still lives on at Duke University Medical Center.

It is perhaps my mixed bag background of a few victories and even more failures that I learned a thing or two about what it means to become better... it is what I call evolutionary tweaking or to put it more bluntly... whining and doing something about it. But let's stick with the "tweaker" euphemism.

Tweakers are annoying and may be a thorn in any administrator's side, but they produce results. They tinker and tinker in an attempt to improve and better a situation they consider a problem whether it be an engine, a computer program, or an entire production system.

Based on Isaacson's biography about Steve Jobs, he had it in abundance... even on medical care and devices during his last days.

Apparently, in his very last days of life, he went through 67 nurses before he found 3 he liked. He also refused to wear an oxygen mask due to a perceived poor design until he personally reviewed 5 different mask options and picked the one he liked best.

I'm certainly not promoting a culture where every patient, nurse, doctor, and administrator should start whining and complaining about everything. The hospital would shut-down.

BUT, there should be a culture where incremental tweaks are not only allowed, but encouraged with the expectation that many ideas will fail with monetary setbacks. However, just like survival of the fittest, the cumulative evolutionary cycles of keeping successful ideas and tossing ones that aren't will lead to a better organization over time... continuously and cheaply.

Home run ideas should not be the goal. Batting consistent singles (or tweaks) are...

There are systems to describe this process: PDSA (Plan Do Study Act), Toyota Production System, Just-In-Time Production, Deming Wheel, Shewhart Cycle, Control Circle, etc.

Now I certainly am not the first to suggest this concept to hospital settings. In fact, I've seen PDSA posters tacked on a wall in hospital physician lounges in the past.

However, I have observed great variances in how different hospital systems incorporate this "controlled whining" into their culture and administration.

Some embrace this process wholeheartedly and have succeeded in abundance. Others give lip service and designate the "tweakers" as whiners to be shut-up with bureaucratic red-tape, offensiveness requiring peer-review, or worse.

Employees and staff are a hospital's greatest assets both in terms of knowledge and production services. A hospital can either embrace trying to unlock the knowledge of what it already possesses or it can stifle them by punishing those who try to "tweak" thereby sending the message to everybody else to stay in the background... passivity being the rule... or voluntarily leave (or get fired).

The long-term success of a hospital system depends on how well it utilizes ALL its resources including not only encouraging an idea a hospitalist physician may have about telephone communication (allowing for faster patient care), but also trying to discover the knowledge trapped in a janitor's head who just might know how to thoroughly clean a hospital floor in half the time (saving time and money), but is too afraid to say anything.

Adapt or perish. History is replete with immensely successful companies that failed to adapt and are now either bankrupt or nearing death... Eastman Kodak, Tower Records, Borders Bookstores, etc.

And how does a hospital adapt to avoid non-existence? Continuously tweak... even when things are going well. USE all your assets with all guns blazing rather than smothering them.

Celebrate the tweakers!!!

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Doctor Distraction Happens... It's Mandatory!

I admittedly snorted out loud when I read a New York Times article  earlier last week regarding increased physician distraction due to electronic devices, especially with the advent of the smartphone with its emails, text messages, calls, and other alerts that ping intermittently throughout a typical work day.

There is no question that electronic devices distract physicians as the article pointed out... But that's like complaining about a leaky faucet when there's a flooded basement and a hole in the roof.

The bigger problem that should be mentioned is hospital bureaucracy which probably creates just as much if not more unintended distractions for physicians and nurses.

What many patients and lay public may not realize is that there is a TON of paperwork that goes into the care of a patient. Regulatory bodies like the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) that accredits hospitals have made it mandatory in many cases though I suspect hospital administration often carries it a step above and beyond what is truly necessary.

What all this "mandatory" paperwork means is that nurses are calling physicians all the time just so they can check a box on a form... and there are a LOT of boxes to check.

Take a simple ear tube placement. A procedure that takes about 1-2 minutes to perform under sedation in the pediatric population.

It takes about 15-20 minutes to fill out all the nursing and physician forms (whether paper or electronic medical records). When the surgery actually begins, the nurse is too busy filling out even more forms rather than paying attention to the surgery... and often the surgery is already over... and the nurse is still busy filling out forms.

Talk about distraction... a registered nurse has been relegated to being a mere secretary rather than helping (or paying attention) in the care of a patient.

I recently asked a nurse how much time they spent on actual patient care versus how much time filling out forms during a typical shift.

It saddened my heart when I was told 60-70% of a nurse's time is spent on filling out forms (whether notes, chart documentation, medication reconciliation, etc) and only 30-40% on actual patient care. This time disparity was not always true in years past.

OR... ask any physician how many times they get called during a typical day because some form or paperwork was not completed or needs completion or just remind to get it completed by nurses who themselves are the main individuals who suffer under the crush of mandatory documentation in a hospital setting.

It is irritating to say the least to get a phone call during the middle of an operation, say dissecting a tumor off the facial nerve during a parotid cancer resection, by someone who wanted to remind me to sign off on a medication list on a patient I've already provided prescriptions for.

Another classic experience of mine was when the anesthesiologist had trouble intubating a patient who started to suffer a severe lack of oxygen. I was immediately called to the bedside and performed an emergency tracheostomy.

Of course, the nurse (well indoctrinated in form completion) involved in the case immediately instructed me to STOP performing the trach and to get consent as per the regulations... which is true 99% of the time... but never mind that. Heaven forbid we now can't check that little box that states "consent obtained prior to surgery." But in the interest of patient care, I did suggest that it would be better if the patient lived with an unconsented trach rather than died due to time spent obtaining consent.

Though electronic devices may be considered a "distraction" analogous to a mosquito buzz that comes and goes, one must not forget the avalanche of paperwork which is a much more pervasive and insidious distraction that DELIBERATELY takes attention away from the care of the patient. I understand the need for documentation, but at some point when the documentation itself dominates the majority of heathcare rather than the actual administration of care, there's something fundamentally wrong going on.

It's probably why medical missions are so gratifying to participating nurses and physicians where 90%+ of the time is in actual patient care.

Reference:

As Doctors Use More Devices, Potential for Distraction Grows. NYT Dec 14, 2011.

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