Learning New Things from a Patient Encounter

July 11, 2011

Peter K. Kim, MD, on why he thinks conventional preoperative bowel prep is unnecessary, and possibly harmful.

"One very important aspect of motivation is the willingness to stop and to look at things that no one else has bothered to look at."
-Edward de Bono

At 7:30 in the morning my patient looked terrible. "Mr. Chung, what is wrong?"

"I … finished … my … bowel prep," he replied in a soft, weak voice.

I am a general surgeon, and this 65-year-old patient with colorectal cancer displayed overt tachycardia from dehydration. My patient felt wiped out from something I told him to do - drink a gallon of a foul tasting liquid, lose a good night's sleep because he had to sit on the toilet all night with induced diarrhea, wake up at 4:30 a.m., and to come to the hospital. The problem was that Mr. Chung had rectal cancer and was scheduled for a five-hour surgical resection, the physiological equivalent to running a marathon. I discussed the situation with my anesthesiology colleague and cancelled the operation.

Two weeks later, I performed the surgery without preoperative bowel preparation, and the patient did fine. I had looked into the literature and found 10 years of Cochrane Reviews that demonstrated performing colorectal surgery with or without preoperative bowel preparation made no difference in outcomes, and the data suggested the process might be harmful. Well, no surprise if your patient gets no sleep before a major operation and arrives dehydrated. Also anesthesiologists are taught to reflexively "catch up" and compensate for the bowel prep in the operating room by immediately bolusing patients with two liters of crystalloid intravenous fluid. There are numerous, well-designed studies that demonstrate the immunosuppressive effects of normal saline and Lactated Ringer's solution.

"Thud, thud, thud, thud." That was the sound of the jaws of my surgical partners hitting the ground when I announced at Morbidity and Mortality Conference that I no longer do bowel preps on my patients who need elective colorectal operations. Pitchforks and torches were brandished as I, the most junior partner, was shown the virtual doorway to the "Surgical Crazy-Guy Room."

"Why not?" I said. "The last 10 years of literature and Cochran Reviews all support evidence that bowel preps are unnecessary and may be harmful." I saw the door to the Surgical Crazy-Guy Room open wider, and a large hook appear to reach for my waistline. Evidence-based surgery died a noble death. Only when I mentioned that a few other notable local surgeons had also stopped using bowel preps did the thumbs typing on the Blackberries and iPhones stop, but only for a few seconds.

This patient encounter happened three years ago, and I no longer tell my patients to drink a four-liter plastic box of Golytely (what a misnomer!) the night before intestinal surgery. Stool encountered in the colon has not hindered my ability to handle the bowel or perform anastomoses that do not leak. I have not been able to convince my partners, but I know of a few other surgeons at the university hospital who have developed the same practice. I heard somewhere that it takes 18 years for a medical practice that gets reported in the evidence-based literature to enter into the mainstream, regular practice. Much of what we do in medicine, and particularly surgery, is shrouded by the thick mists of the sentiment, "That's how I was taught to do it in my residency and fellowship." Change in surgery, even in the age of tweeting and EHRs, is slow, and it took a special patient to make me think about what and why I do what I do. I guess that is what makes medicine and surgery so interesting.

I recently completed a Clinical Quality Fellowship Program sponsored by the Greater New York Hospital Association and the United Hospital Fund. The program trained 15 doctors around New York City in the meaning of quality improvement. This is another topic that immediately rolls the eyes of most physicians, particularly surgeons. The reason is that I spent those 15 months in bi-weekly sessions thinking, reading, and still unable to answer the simple question, "What is Quality?" For example, how do you know your surgeon is a good surgeon or not? Who do you ask? Can you trust websites that rank your surgeon, her department, and her hospital with a Healthgrades.com score? What if your surgeon is not even ranked? Does that make your surgeon a bad surgeon, or maybe an excellent surgeon?

And how do we improve the care we provide to patients? These are tough issues that the government, the public, and yes, President Obama is demanding of hospitals and physicians. We can't even agree on bowel preps, so I wondered how do we improve quality care for surgical patients.

Aware that we cannot let administrators alone tell us how to practice medicine, when the chairman of my department asked me to get involved, I agreed to form a Surgical Infection Task Force. I gathered friends and colleagues from the departments of infectious disease, medicine, pharmacy, nursing, risk management, and microbiology. We met every two weeks and started with the task of improving empiric antibiotic therapy for patients with skin and soft tissue infections caused by methicillin-resistant Staphylococcus Aureus (MRSA).

This is not a sexy topic, but over 12 months we improved appropriate empiric coverage from 65 percent to over 90 percent. Our group branched out and addressed two outbreaks of surgical site wound infections after colorectal surgery, an event reportable to the New York State Department of Health. After reading Harvard surgeon Atul Gawande's books entitled "Complications” and “Better," I became a fervent disciple of the idea that we can improve complex processes by making checklists. Based on a checklist Dr. Gawande reported in the Annals of Surgery, I made a checklist for colorectal surgery and distributed the guideline to the surgeons in my group. The guidelines were posted in the operating room and regularly challenged at Morbidity and Mortality Conferences. Eyes rolled but infection rates came down coincidentally. I had left the issue of bowel preps off the guidelines.

Newsflash: we are being watched. One day an administrator came to my operating room uninvited to observe how I prepare a patient for colon surgery. She wouldn't tell me who sent her for this "observation." Instead of angrily kicking her out of a place she had never stepped foot, I welcomed her and showed her the checklist I had made. I went through it in detail like I always do, and she seemed satisfied.

I like the idea that medicine, and specifically surgery, is not a science, but rather, a craft. Craftsmen build things, and occasionally new tools are acquired. Or maybe somebody teaches us that we can use the tools we have in a different way. In my hospital, there isn't much difference in the outcomes of patients who have their appendix removed laparoscopically or by an open technique. Some surgeons only do one or the other, and the patients do just fine. Nobody tells them to change, but they can if they feel it is better for the patient. Freedom to change is what makes medicine pleasurable, and I hope that the future engineers of the Affordable Care Act can keep that in mind.

Peter K. Kim, MD, FACS is a general surgeon who practices in the Bronx, New York. He is an Assistant Professor of Surgery at the Albert Einstein College of Medicine. He lives in Pelham, NY, with his wife and two sons. He may be reached at editor@physicianspractice.com.

This article originally appeared in the July/August 2011 issue of Physicians Practice.