Are the Rituals Behind the Surgery as Important as the Scalpel?

A BETTER OPTION? In a 2014 study comparing elective surgical interventions to sham surgeries, 51% showed the effect of the placebo did not differ from that of surgery.

Studies of so-called sham surgeries suggest the pre-operative rituals a patient goes through may be as effective in curing a patient's ills as the surgery itself. Put another way, the healing power of surgery may have more to do with the rituals leading up to the moment of incision than with the scalpel and the hand that wields it.

Consider the elaborate and seemingly spiritual pre-operative rituals facing every surgical patient: fasting (NPO); donning ceremonial garb (a hospital gown); altering consciousness (undergoing anesthesia); anointment (having the surgical site prepped); and, finally, giving oneself over to a masked healer (the surgeon). Faith in these rituals can create a powerful placebo effect, say researchers who have studied sham surgery, the controversial practice in which patients are led to believe they underwent a surgical procedure — including anesthesia and incisions — when in fact they didn't.

In a recent example, ophthalmology patients who thought they were receiving YAG laser vitreolysis to treat symptomatic vitreous floaters reported a 9% improvement in symptoms 6 months after surgery. Of the 16 patients who received the sham surgery, 5 (31%) reported a 20% to 60% improvement in their floater symptoms, which the authors of a new study published in JAMA Ophthalmology attribute to a placebo effect.

Patients who undergo actual surgery may fare no better than peers who undergo sham surgery. A 2014 study of 53 trials comparing elective surgical interventions to sham surgeries found that 51% showed the effect of the placebo did not differ from that of surgery. Another study of patients suffering from chronic lower back pain found virtually no difference in patient self-rated outcomes between those who received spinal fusion and those who received multidisciplinary cognitive-behavioral and exercise rehabilitation.

Orthopedic surgeon and author Ian Harris, MD, says most surgeons believe they may be doing the right thing by electing for surgery, but only because they lack sufficient evidence arguing against it for certain surgical interventions. In his book, Surgery: The Ultimate Placebo, Dr. Harris says the dearth of high-quality studies "allows surgeons to do procedures that have always been done, those that their mentors taught them to do, to do what they think works, and to simply do what everyone else is doing."

Bill Donahue

Abhorrent Conditions at VA Hospital

NONE WORSE "I have never seen a hospital run this poorly," says whistle-blower Stewart Levenson, MD.

Fly-infested operating rooms, rusty (or bloody) surgical instruments, total failure to address treatable cervical myelopathy, undiagnosed tumors, copying and pasting patient records for years without updating them — these are just some of the atrocities attributed to the Manchester (N.H.) Veterans Affairs Medical Center, and detailed in a recent Boston Globe "Spotlight" report.

Shortly after the article appeared, hospital director Danielle Ocker, RN, BSN, MBA, and chief of staff James Schlosser, MD, were removed from their posts by David Shulkin, the Secretary of Veterans Affairs, who ordered a "top-to-bottom" review of the facility.

Numerous physicians and hospital employees had contacted both a federal whistle-blower agency and the Globe to accuse the facility of endangering patients, and the U.S. Office of the Special Counsel has found a "substantial likelihood" of legal violations, gross mismanagement, abuse of authority and a danger to public health.

Doctors at the "4-star" (as rated by the VA) facility were furious with management, says the Globe, asserting that they had no say as to how the hospital was run, that they didn't have the tools they needed to do their jobs, and that patient care was chronically deficient. The administrators, they say, seemed more concerned with performance ratings than with treating the roughly 25,000 veterans per year who visit the facility for outpatient care and same-day surgery.

"I have never seen a hospital run this poorly. Every day it gets worse and worse," Stewart Levenson, MD, one of the whistle-blowers, tells the Globe, adding that he tried to go "through the [hospital] system and got nowhere."

Ms. Ocker and Dr. Schlosser had told the Globe they were surprised so many members of the staff had reported the hospital's problems. They said the hospital was addressing shortcomings and that patient safety had not been compromised.

Jim Burger

CMS Looks to Slash Payment for Off-campus Services by Half

SITE SPECIFIC CMS wants to slash payments for off-campus hospital outpatient services by another 25%.

For the second straight year, CMS wants to cut by half what Medicare pays for services provided at medical facilities that are owned by hospitals but located off their campuses — from 50% of the outpatient prospective payment system for 2017 to 25% of OPPS rates for most services in 2018.

The proposed plan would affect such services as pain management, some X-rays, radiation therapies and some behavioral health services.

"CMS believes that this adjustment will encourage fairer competition between hospitals and physician practices by promoting greater payment alignment," the agency said.

Hospitals groups strongly oppose the proposed rule, saying the proposed Medicare reimbursement cuts would decrease patient access to care at the facilities, especially in underserved areas.

"This proposal appears to have a questionable policy basis and is yet another blow to access to care for patients, including many in vulnerable communities without other sources of health care," says Tom Nickels, executive vice president of the American Hospital Association.

Bruce Siegel, MD, MPH, president and CEO of America's Essential Hospitals, says the proposal would disincentive hospitals from opening or operating new off-campus provider-based locations.

"Hospitals that otherwise would seek to enhance access by establishing clinics in healthcare deserts will not do so if they determine this damaging payment policy makes new outpatient centers economically unsustainable," says Dr. Siegel.

Comments on the proposed rule change are due by Sept. 11.

Daniel Cook

InstaPoll: How Do You Typically Read Surgical Publications?

Tell us in this week's InstaPoll how you prefer to read your favorite surgical publications, such as Outpatient Surgery Magazine: in print or on an electronic device?

More than half (54%) of the 261 respondents to last week's InstaPoll prefer face-to-face interaction at work. The results:

How do you prefer to communicate at work?

  • text 14%
  • email 29%
  • talk in person 54%
  • talk on telephone 3%

Dan O'Connor

News & Notes

  • Persistence pays off for Iowa surgeon in long-running CON dispute It took 5 attempts, a decade of frustration and a federal lawsuit, but ophthalmologist Lee Birchansky, MD, finally earned the certificate of need required to re-open an existing outpatient surgery center next to his Fox Eye Laser & Cosmetic Institute in Cedar Rapids, Iowa. Although the center had been dormant for several years, Dr. Birchansky previously performed surgeries there in a partnership with a nearby hospital. He was forced to shutter the center when the hospital terminated the rental agreement to build a surgery center of its own, at which point the Iowa Supreme Court declared that he needed to obtain a CON. He did so but was summarily denied 4 times. The situation drew the national spotlight last month, when Dr. Birchansky and other plaintiffs filed a federal lawsuit arguing that "unconstitutional" CON laws stifle competition by letting hospitals and other established healthcare centers oppose newcomers.
  • Fujifilm recalls duodenoscopes for upgrade Fujifilm Medical Systems USA is recalling all ED-530XT duodenoscopes and will upgrade them in accordance with a new design recently approved by the FDA. The upgrade consists of replacing the forceps elevator mechanism, including the O-ring seal, and the distal end cap. The company will also issue new operation manuals. The call for an improved design was prompted by outbreaks of antibiotic-resistant infections linked to duodenoscopes made by Fujifilm and others.
  • Are antibiotics overkill before lap choles? Antibiotic prophylaxis doesn't appear to be needed to lower the already low risk of infection following elective laparoscopic cholecystectomy, even though the practice is commonly used, according to a new study in the journal Surgical Infections. Researchers who studied the outcomes of 570 patients who underwent lap choles between March 2007 and February 2010 found the SSI rate was 1.2% with no difference among patients who received placebo or first- and second-generation cephalosporin.