The redefinition of aging in American surgery.

CONTEXT: Adults aged sixty-five and over account for a large fraction of all surgeries performed in the United States each year. While historical growth in rates of surgery in this population is commonly attributed to financial incentives and technological innovations, the shifts in thought that underpinned the spread of surgery among the U.S. elderly remain largely unexplored. We examined changing perspectives on aging over time in American surgery through two case studies: the expansion of general surgical procedures among older U.S. adults between 1945 and 1965, and the spread of coronary artery bypass grafting (CABG) among the U.S. elderly between 1975 and 1995. METHODS: For this article, we used close readings of historical journal articles, textbook excerpts, survey reports, and government documents related to surgery and aging. FINDINGS: Similar perspectives on aging informed the spread of both general surgical procedures among older adults after World War II and CABG in the elderly from the mid-1970s onward. In each case, surgeons argued against earlier views that surgery was contraindicated in old age using rhetoric that negated the relevance of age to medical decisions. Furthermore, surgeons elevated other types of information-such as the presence or absence of chronic diseases-to supplant age as an explanation for the high operative mortality rates seen among older patients. By stressing the modifiability of operative risk in the elderly, surgeons' arguments positioned old age itself as a new surgical "frontier." CONCLUSIONS: Surgeons' arguments for the expansion of surgery among the U.S. elderly over time worked to negate the relevance of age to medical decisions and to portray the wider use of surgery in the elderly as uniformly beneficial. While potentially promoting broader access to surgical care, such perspectives may also have contributed to ongoing health policy challenges by normalizing surgery at any stage in the life-course, with implications for current patterns of surgical utilization and medical spending.

What we talk about when we talk about risk: refining surgery's hazards in medical thought.

CONTEXT: Current efforts to improve the cost-effectiveness of health care focus on assessing accurately the value of technologically complex, costly medical treatments for individual patients and society. These efforts universally acknowledge that the determination of such value should incorporate information regarding the risks posed by a given treatment for an individual, but they typically overlook the implications for medical decision making that inhere in how notions of risk are understood and used in contemporary medical discourse. To gain perspective on how the hazards of surgery have been defined and redefined in medical thought, we examine changes over time in notions of risk related to operative care. METHODS: We reviewed historical writings on risk assessment and patient selection for surgical procedures published between 1957 and 1997 and conducted informal interviews with experts. To examine changes attributable to advances in research on risk assessment, we focused on the period surrounding the 1977 publication of an influential surgical risk-stratification index. FINDINGS: Writings before 1977 demonstrate a summative, global approach to patients as "good" or "poor" risks, without quantifying the likelihood of specific postoperative events. Beginning in the early 1980s, assessments of operative risk increasingly emphasized quantitative estimates of the probability of dysfunction of a specific organ system after surgery. This new approach to establishing surgical risk was consistent with concurrent trends in other domains of medicine. In particular, it emphasized a more "scientific," standardized approach to medical decision making over an earlier focus on individual physicians' judgment and professional authority. CONCLUSIONS: Recent writings on operative risk reflect a viewpoint that is more specific and, at the same time, more generic and fragmented than earlier approaches. By permitting the separation of multiple component hazards implicit in surgical interventions, such a viewpoint may encourage a distinct, permissive standard for surgical interventions that conflicts with larger policy efforts to promote cost-effective decision making by physicians and patients.

Explaining Michigan: developing an ex post theory of a quality improvement program.

CONTEXT: Understanding how and why programs work-not simply whether they work-is crucial. Good theory is indispensable to advancing the science of improvement. We argue for the usefulness of ex post theorization of programs. METHODS: We propose an approach, located within the broad family of theory-oriented methods, for developing ex post theories of interventional programs. We use this approach to develop an ex post theory of the Michigan Intensive Care Unit (ICU) project, which attracted international attention by successfully reducing rates of central venous catheter bloodstream infections (CVC-BSIs). The procedure used to develop the ex post theory was (1) identify program leaders' initial theory of change and learning from running the program; (2) enhance this with new information in the form of theoretical contributions from social scientists; (3) synthesize prior and new information to produce an updated theory. FINDINGS: The Michigan project achieved its effects by (1) generating isomorphic pressures for ICUs to join the program and conform to its requirements; (2) creating a densely networked community with strong horizontal links that exerted normative pressures on members; (3) reframing CVC-BSIs as a social problem and addressing it through a professional movement combining "grassroots" features with a vertically integrating program structure; (4) using several interventions that functioned in different ways to shape a culture of commitment to doing better in practice; (5) harnessing data on infection rates as a disciplinary force; and (6) using "hard edges." CONCLUSIONS: Updating program theory in the light of experience from program implementation is essential to improving programs' generalizability and transferability, although it is not a substitute for concurrent evaluative fieldwork. Future iterations of programs based on the Michigan project, and improvement science more generally, may benefit from the updated theory present here.

To leave or to lie? Are concerns about a shift-work mentality and eroding professionalism as a result of duty-hour rules justified?

CONTEXT: Medical educators worry that the 2003 Accreditation Council for Graduate Medical Education (ACGME) duty-hour rules (DHR) have encouraged a "shift work" mentality among residents and eroded their professionalism by forcing them either to abandon patients when they have worked for eighty hours or lie about the number of hours worked. In this qualitative study, we explore how medical and surgical residents perceive and respond to DHR by examining the "local" organizational culture in which their work is embedded. METHODS: In 2008, we conducted three months of ethnographic observation of internal medicine and general surgery residents as they went about their everyday work in two hospitals affiliated with the same training program, as well as in-depth interviews with seventeen residents. Field notes and interview transcripts were analyzed for perceptions and behaviors in regard to beginning and leaving work, reporting duty hours, and expressing opinions about DHR. FINDINGS: The respondents did not exhibit a "shift work" mentality in relation to their work. We found that residents: (1) occasionally stay in the hospital in order to complete patient care tasks even when, according to the clock, they are required to leave, because the organizational culture stresses performing work thoroughly, (2) do not blindly embrace noncompliance with DHR but are thoughtful about the tradeoffs inherent in the regulations, and (3) express nuanced and complex reasons for erroneously reporting duty hours, suggesting that reporting hours worked is not a simple issue of lying or truth telling. CONCLUSIONS: Concerns about DHR and the erosion of resident professionalism resulting from the development of a "shift work" mentality likely have been overstated. Instead, the influence of DHR on professionalism is more complex than the conventional wisdom suggests and requires additional assessment.

Bioethics, raw and cooked: extraordinary conflict and everyday practice.

This article explains the emergence, growth, and institutional anchoring of bioethics in both policy and clinical arenas. Under the heading of principlism, bioethics developed a public language for resolving disputes that allowed it to transform disputes involving sacred matters into profane work routines. At the same time, having principlism as a common language for solving practical disputes allowed "ethics work" in health care to be separated from moral theorizing as a practical activity. Two issues--the right to die and the protection of research subjects--serve to illustrate the process through which bioethics established a large institutional footprint in health care.

Plus ça change: Renée Fox and the Sociology of Organ Replacement Therapy.

Rereading Renée C. Fox's "A Sociological Perspective on Organ Transplantation and Hemodialysis," published in 1970, one is likely to be struck more by continuity than by change. The most pressing of the social, policy, and ethical concerns that Fox raised remain problematic fifty years later. We still struggle with scientific and clinical uncertainty, with the boundary between experimentation and therapy, and with the cost of organ replacement therapies and disparities in how they are allocated. We still have an imperfect understanding of transplant immune responses. We still debate when a potential donor "actually" dies, and we still seem to think better empirical criteria could harmonize the diverse religious, cultural, and socioeconomic values of patients, providers, third-party payers, and policy-makers. Organ transplantation was for Fox both a particular case unfolding in time and an entryway for discussing the difficult moral questions presented by many new medical technologies in a context of high demand and limited resources.

The personal is political, the professional is not: conscientious objection to obtaining/providing/acting on genetic information.

Conscientious objection (CO) to genetic testing raises serious questions about what it means to be a health-care professional (HCP). Most of the discussion about CO has focused on the logic of moral arguments for and against aspects of CO and has ignored the social context in which CO occurs. Invoking CO to deny services to patients violates both the professional's duty to respect the patient's autonomy and also the community standards that determine legitimate treatment options. The HCP exercising the right of CO may make it impossible for the patient to exercise constitutionally guaranteed rights to self-determination around reproduction. This creates a decision-making imbalance between the HCP and the patient that amounts to an abuse of professional power. To prevent such abuses, professionals who wish to refrain from participating have an obligation to warn prospective patients of their objections prior to establishing a professional-patient relationship or, if a relationship already exists, to arrange for alternative care expeditiously.

A comparison of 2 surgical site infection monitoring systems.

IMPORTANCE: Surgical site infection (SSI) has emerged as the leading publicly reported surgical outcome and is tied to payment determinations. Many hospitals monitor SSIs using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), in addition to mandatory participation (for most states) in the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN), which has resulted in duplication of effort and incongruent data. OBJECTIVE: To identify discrepancies in the implementation of the NHSN and the ACS NSQIP at hospitals that may be affecting the respective SSI rates. DESIGN, SETTING, AND PARTICIPANTS: A pilot sample of hospitals that participate in both the NHSN and the ACS NSQIP. INTERVENTIONS: For each hospital, observed rates and risk-adjusted observed to expected ratios for year 2012 colon SSIs were collected from both programs. The implementation methods of both programs were identified, including telephone interviews with infection preventionists who collect data for the NHSN at each hospital. MAIN OUTCOMES AND MEASURES: Collection methods and colon SSI rates for the NHSN at each hospital were compared with those of the ACS NSQIP. RESULTS: Of 16 hospitals, 11 were teaching hospitals with at least 500 beds. The mean observed colon SSI rates were dissimilar between the 2 programs, 5.7% (range, 2.0%-14.5%) for the NHSN vs 13.5% (range, 4.6%-26.7%) for the ACS NSQIP. The mean difference between the NHSN and the ACS NSQIP was 8.3% (range, 1.6%-18.8%), with the ACS NSQIP rate always higher. The correlation between the observed to expected ratios for the 2 programs was nonsignificant (Pearson product moment correlation, ρ = 0.4465; P = .08). The NHSN collection methods were dissimilar among interviewed hospitals. An SSI managed as an outpatient case would usually be missed under the current NHSN practices. CONCLUSIONS AND RELEVANCE: Colon SSI rates from the NHSN and the ACS NSQIP cannot be used interchangeably to evaluate hospital performance and determine reimbursement. Hospitals should not use the ACS NSQIP colon SSI rates for the NHSN reports because that would likely result in the hospital being an outlier for performance. It is imperative to reconcile SSI monitoring, develop consistent definitions, and establish one reliable method. The current state hinders hospital improvement efforts by adding unnecessary confusion to the already complex arena of perioperative improvement.

Medical sociology as a vocation.

This article extends Weber's discussion of science as a vocation by applying it to medical sociology. Having used qualitative methods for nearly 40 years to interpret problems of meaning as they arise in the context of health care, I describe how ethnography, in particular, and qualitative inquiry, more generally, may be used as a tool for understanding fundamental questions close to the heart but far from the mind of medical sociology. Such questions overlap with major policy questions such as how do we achieve a higher standard for quality of care and assure the safety of patients. Using my own research, I show how this engagement takes the form of showing how simple narratives of policy change fail to address the complexities of the problems that they are designed to remedy. I also attempt to explain how I balance objectivity with a commitment to creating a more equitable framework for health care.

Are attendings different?. Intensivists explain their handoff ideals, perceptions, and practices.

PURPOSE: What is known about physician handoffs is almost entirely limited to resident practice, but attending physicians ultimately determine care plans and goals of care. This study sought to understand what is unique about attending intensivist handoffs, to identify perceptions of the ideal content and format of intensive care unit (ICU) attending handoffs, and to understand how ideal and reported practices are aligned in the delivery of care. METHODS: Intensivists in active practice in U.S. adult academic ICUs were purposively sampled and interviewed over 9 months in 2011 to 2012. MEASUREMENTS AND MAIN RESULTS: Thirty attendings from 15 institutions in nine U.S. states were interviewed. Subjects' specialties included anesthesiology, emergency medicine, internal medicine, and surgery. The "perfect handoff" was described as succinct, included verbal plus written communication, and took place in person. Respondents believed that the attending handoff should be less detailed than resident handoffs. Most attendings participated in handoffs at the end of each ICU rotation (n = 26). Standardized handoff practice was rare (n = 1). Media used for handoffs included combinations of telephone conversations (n = 25), in-person communications (n = 11), e-mail (n = 9), or text message (n = 2). Handoff duration varied from 10 to 120 minutes for 5 to 42 patients. Five of 30 respondents had undergone formal training in how to conduct handoffs. CONCLUSIONS: A national sample of academic intensivists identified common ideal attributes of attending handoffs, yet their reported handoff practices varied widely. Ideal handoff practices may form the basis of future interventions to improve communication between intensivists.

Assessing the effects of the 2003 resident duty hours reform on internal medicine board scores.

PURPOSE: To determine whether the 2003 Accreditation Council for Graduate Medical Education (ACGME) duty hours reform affected medical knowledge as reflected by written board scores for internal medicine (IM) residents. METHOD: The authors conducted a retrospective cohort analysis of postgraduate year 1 (PGY-1) Internal Medicine residents who started training before and after the 2003 duty hour reform using a merged data set of American Board of Internal Medicine (ABIM) Board examination and the National Board of Medical Examiners (NMBE) United States Medical Licensing Examination (USMLE) Step 2 Clinical Knowledge test scores. Specifically, using four regression models, the authors compared IM residents beginning PGY-1 training in 2000 and completing training unexposed to the 2003 duty hours reform (PGY-1 2000 cohort, n = 5,475) to PGY-1 cohorts starting in 2001 through 2005 (n = 28,008), all with some exposure to the reform. RESULTS: The mean ABIM board score for the unexposed PGY-1 2000 cohort (n = 5,475) was 491, SD = 85. Adjusting for demographics, program, and USMLE Step 2 exam score, the mean differences (95% CI) in ABIM board scores between the PGY-1 2001, 2002, 2003, 2004 and 2005 cohorts minus the PGY-1 2000 cohort were -5.43 (-7.63, -3.23), -3.44 (-5.65, -1.24), 2.58 (0.36, 4.79), 11.10 (8.88, 13.33) and 11.28 (8.98, 13.58) points respectively. None of these differences exceeded one-fifth of an SD in ABIM board scores. CONCLUSIONS: The duty hours reforms of 2003 did not meaningfully affect medical knowledge as measured by scores on the ABIM board examinations.

Training for efficiency: work, time, and systems-based practice in medical residency.

Medical residency is a period of intense socialization with a heavy workload. Previous sociological studies have identified efficiency as a practical skill necessary for success. However, many contextual features of the training environment have undergone dramatic change since these studies were conducted. What are the consequences of these changes for the socialization of residents to time management and the development of a professional identity? Based on observations of and interviews with internal medicine residents at three training programs, we find that efficiency is both a social norm and strategy that residents employ to manage a workload for which the demand for work exceeds the supply of time available to accomplish it. We found that residents struggle to be efficient in the face of seemingly intractable "systems" problems. Residents work around these problems, and in doing so develop a tolerance for organizational vulnerabilities.

Remaking surgical socialization: work hour restrictions, rites of passage, and occupational identity.

We examine how a policy aimed at improving patient safety by limiting residents' work hours brought with it an unintended and unexamined consequence: altered socialization due to modified rites of passage during residency that endangered the stereotypical "Surgical Personality" and created a potential rift between the occupational identities of surgical residents who train under duty hour regulations and those who trained before they were imposed. Through participant observation occurring between June 2008 and June 2010, in-depth interviews (n = 13), and focus groups (n = 2), we explore how surgical residents training in four U.S. hospitals think about the threats that the shift from unrestricted to restricted duty hours creates for their claims of competence and professionalism. We identify three types of resident responses: (1) neutralizing statements that deny any significant change to occupational identity has occurred; (2) embracing statements that express the belief that a changed and more balanced occupational identity is needed; and (3) apprehensive statements that expressed fear of an altered occupational identity and an anxiety about readiness for individual practice.

Why is U.K. medicine no longer a self-regulating profession? The role of scandals involving "bad apple" doctors.

This article identifies the role played by a series of medical scandals in the U.K., occurring from the mid-1990s onwards, in ending a collegial model of self-regulation of the medical profession that had endured for 150 years. The state's original motive in endorsing professional self-regulation was to resolve the principal-agent problem inherent in the doctor-patient relationship. The profession, in return for its self-regulating privileges, undertook to act as a reliable guarantor for the competence and conduct of each of its members. Though sufficient to ensure that most doctors were "good", the collegial model adopted by the profession left it fatally vulnerable to the problem of "bad apples": those unwilling, incapable or indifferent to delivering on their professional commitments and who betrayed the trust of both patients and peers. Weak administrative systems in the NHS failed to compensate for the defects of the collegium in controlling these individuals. The scandals both provoked and legitimised erosion of the profession's self-regulatory power. Though its vulnerability to bad apples had been present since the founding of the 19th century profession, it was the convergence of social and political conditions at a particular historical moment that transformed the scandals into an unstoppable imperative for reform. Huge public anger, the voice permitted to a coalition of critics, shifts in social attitudes, the opportunity presented for imposing standards for accountability, and the increasing ascendancy of pro-interventionist managerialist and political agendas from the early 1990s onwards were all implicated in the response made to scandals and the shape the reforms took. Scandals need to be understood not as simple determinants of change, but as one performative element in a constellation of socially contingent forces and contexts. The new rebalancing of the "countervailing powers" has dislodged the profession as the senior partner in the regulation of doctors, but may introduce new risks.