CODE speaking with Dr. Thomas R. Vetter, MD, MPH at the 4th Interdisciplinary Conference on Orthopedic Value Based Care 2020

Session Topics:

  • Myth busters in Anesthesia and Orthopedics
  • Standardization of preop testing criteria

Interviewee: 
Dr. Thomas R. Vetter, MD, MPH
Professor and Director of Perioperative Care
Dell Medical School at The University of Texas at Austin

Breanna Cunningham:
Hi there. Bre Cunningham here with CODE Technology. I have the pleasure of interviewing Dr. Vetter. Dr. Vetter currently serves as the Director of Perioperative Care and the professor of surgery and perioperative care at Dell Medical School, which lots of amazing progress and papers have been coming out of that campus as of late. I’m here at the OVBC conference 2020, it is the fourth annual.

So, Dr. Vetter, it’s a pleasure. Thank you for being here.

Dr. Vetter:
Thank you, likewise. Appreciate it.

Breanna Cunningham:
So you’ve given two talks thus far at the conference, both were excellent. The first one was on myth busters and anesthesia in orthopedics.

Dr. Vetter:
Right.

Breanna Cunningham:
The second was real-world cases standardization of preop testing. So as we’re on the subject of value-based care, what I found really fascinating during your talk was the lack of standardization. So, can you kind of sum up your talk for us and where you’re seeing the waste or lack of standardization and what we should do, particularly in this country, what we should start looking at as it relates to preop protocols?

Dr. Vetter:
Well, I think clinicians, physicians, I’ll speak specifically to, are kind of creatures of habit and we’re kind of all products of our own upbringing, professional upbringing. My colleague, Karl Koenig at Dell Medical School, commented that many of us practice kind of anecdotal medicine. We tend to base our reactions or how we’re going to do something today based upon something that may have occurred as recently as yesterday, or a bad case that we had or a bad outcome that we had.

So, evidence-based medicine as a tenant or as a field has been around for 25 or 30 years. The reality is though that the amount of evidence that’s been published, high-quality evidence to support any number of the things that we do on a day in, day out basis is unfortunately not that strong. Part of the reason for that is studies that are needed to be able to demonstrate strong evidence for a particular practice pattern is expensive.

The National Institutes of Health and other funding agencies, both here in the United States and abroad, have not made perioperative care, perioperative medicine, a hot or high topic for them. They’ve tended to focus, and this is not meant as a judgment, but they focused a lot on basic science and so-called translational research, and not as much on health services research or on outcomes research. That’s gradually changing.

So what you have is a gap in funding and without funding, and therefore undertaking these large scale studies that are needed to try to demonstrate that standardization for instance, of certain preoperative testing efforts, it’s difficult to do. In the current constrained environment, a department chair has to decide, “Well, how am I going to spend what margin I may have on worthy or laudable research projects?” So if you picked a topic and you wanted to look at say when should you get a complete blood count or a CBC, there are studies that have looked at-

Breanna Cunningham:
On every patient?

Dr. Vetter:
Well, just-

Breanna Cunningham:
I’m just kidding.

Dr. Vetter:
Right, on every patient. Right, right.

Breanna Cunningham:
As a pre-op nurse, every patient got a CBC.

Dr. Vetter:
Everyone got a CBC. In my lifetime, every patient, and there are some surgeons who still do it, they get a chest X-ray and they get an EKG and they get a battery of tests. When you ask them, they’re really not completely sure why they do it. But I think the nagging concern is that there’s something that might be going on with that patient that’s not been recognized. If I don’t uncover that problem through an EKG, a chest X-ray, a CBC, pick your test of choice, that it may come back to cause a complication.

Physicians won’t readily admit it, but many of us do practice defensive medicine. The attitude is no one’s going to hold us harmless if for some reason we didn’t uncover something that exists in a patient.

Breanna Cunningham:
Especially for an elective case, right?

Dr. Vetter:
That’s true. That’s true, for sure.

Breanna Cunningham:
There is a heavyweight there.

Dr. Vetter:
There is. If you’re going to take someone to surgery and replace their knee, replace their hip, operate on their spine, in the absence of an immediately life-threatening condition, there is a lot of responsibility that goes with that. That’s why I have tremendous respect for my surgical colleagues that do perform surgery on a daily basis.

But now as you look at say a CBC, you can say, as a nurse, “We get CBCs on everybody. Well, what’s the purpose?” I think now as you’re bringing it into closer focus, which is what the emphasis of my talk was, we do uncover things like preoperative anemia. So that’s actionable. I don’t think you should order any laboratory or diagnostic test, unless it either is actionable, that you plan to do something about it rather than just documenting it. Two, if it’s going to change the patient’s management, and that includes the patient’s decision about whether they should proceed with this elective surgery.

So those are, I think, kind of well-supported now, particularly in the British literature. I think the national health system in the UK is probably 10 or 15, 20 years ahead of us in the United States. One could argue forever about the value and the advantages and disadvantages of a single-payer system. Hard to say if that’ll ever come to pass, at least in my lifetime here in the United States. But they do move towards standardization because they have a single-payer system. The closest thing we have here would probably be Kaiser in the quasi-private sector and then the VA because the VA is a single-payer system. Yeah.

Breanna Cunningham:
So then back to the CBC. So based on your talk, from what I gleaned in it is that not everybody needs it preoperatively.

Dr. Vetter:
Probably not. But I say that because most of the time in the past, we’ve gotten a CBC because it just seems like everyone does it. What’s the purpose of it? It serves a purpose. Now I’ve come to realize in the older population in particular for recognizing or diagnosing anemia, because anemia unless you’re profoundly anemic, you’re not going to be symptomatic. Most of us have been trained that a well-done history and physical should uncover the vast majority of problems that a patient suffers from that they may or may not have been previously diagnosed with or that may or may not be well-controlled.

But a couple of things that don’t stand out very quickly, for instance, is hypertension. You could be walking around for the last five years with poorly controlled hypertension, and unless it reached a pretty high level, you wouldn’t have any symptoms. But it’s putting a tremendous strain on your heart, minute by minute, hour by hour. It’s putting a strain on your kidneys, likewise on a day in, day out basis. It’s putting a strain on the cerebral vasculature, increasing your risk of stroke, for instance.

So nobody would say, “Well, gosh, we should stop measuring blood pressure in our preoperative patients,” right? But we uncover patients every day in our preoperative clinic in Austin, Texas who have poorly controlled hypertension. The reasons for it can be variable. It could be that the medications they were prescribed are expensive and they can’t afford them, or the medications cause side effects, which are difficult for them to tolerate, because their hypertension is a silent killer, for lack of better words.

Breanna Cunningham:
Right.

Dr. Vetter:
So let’s come back to the CBC as a quintessential example. Patients can be walking around with low levels of anemia, they may not be symptomatic, they may not even be aware of it, okay? You can say, “Okay, that’s okay.” But they’re going to come to the surgery and the data is now pretty unequivocal, that if you’re anemic and I take you to surgery for an elective procedure, it increases the risk of you experiencing a major postoperative complication, including death.

Dr. Vetter:
If I transfuse you with a unit of banked blood or so-called allogeneic blood, even one unit, it also then even further increases your risk of postoperative complications, including death. So now the CBC takes on much greater importance because you don’t know that you’re anemic. I can look at you and say, “Well, you’re not pale. Your conjunctiva doesn’t look pale and your nail beds don’t look pale.” But maybe you’re of an ethnic diversity that doesn’t really show that those symptoms are stigmata, so we should find out whether you’re anemic.

Then one of my overarching concerns is let’s take a patient who’s 70, who’s coming to have a hip replaced and they have never had a screening colonoscopy. Well, this is perioperative population health management or population health management. You ask the patient, “Well, have you ever been screened for colon cancer?” And their answer is, “No, I haven’t ever had a colonoscopy.” Well, whoa, time out, you’re anemic. The data are pretty clear that, until proven otherwise, if you have iron-deficiency anemia, you have likely a colon polyp that’s probably bleeding. If it’s bleeding, it could very well be precancerous or actually now evolved to be colon cancer.

So now we take you to surgery, if we didn’t check your CBC, or if we did and we didn’t do something about it, in other words, it wasn’t actionable. You get a brand new hip and you go through rehab, might be a little challenging for you because you’re anemic, maybe you’re a little malnourished and you’ve got an indolent slowly but steadily growing cancer. Six months or a year from now, suddenly you’re much more symptomatic from your anemia and you go to see your primary care doctor, they send you to a gastroenterologist, they do a colonoscopy, and lo and behold, you’ve got advanced colon cancer. Well, that’s a disaster.

Breanna Cunningham:
It is a disaster. But also, I mean, as it ties back into value-based healthcare, it makes me … where are the areas that we don’t want to over-test, but using this example, we don’t want to under-test. What’s the balance, Dr. Vetter?

Dr. Vetter:
Well, I think we’ve kind of beat up CBC enough for the purposes of now.

Breanna Cunningham:
Sure, sure.

Dr. Vetter:
But let’s take-

Breanna Cunningham:
I mean in general.

Dr. Vetter:
In general. Well, again, I come back to you should only order a laboratory or diagnostic test if it’s actionable if you’re going to do something about it and it’s going to potentially change management of the patient. So let’s take an EKG or an ECG. Electrocardiograms have been around forever and you get an EKG, and you have to be prepared that if there’s an abnormal finding on the EKG, you’re going to go the distance to determine whether or not it’s significant.

My generation of anesthesiologists was trained, put the patient under general anesthesia and not push back. In other words, the surgeon is the captain of the ship, they still are the primary driver of surgical care and I have tremendous respect for my surgical colleagues.

But if you’re going to get an EKG or an ECG and you find an abnormality, let’s say atrial fibrillation or other findings that might indicate the patient has coronary artery disease, may have had a previous heart attack that was silent because they have diabetes, or they’re a woman and they don’t demonstrate traditional signs and symptoms of crushing chest pain. Well, the obligation then is that you have to say to your surgical colleague, if you’re running a preoperative assessment and optimization clinic, “We need to stop, we need to hit the pause button and we need to take this patient through further diagnostic evaluation to determine is that EKG finding real or is it just a normal variant?”

Breanna Cunningham:
Right.

Dr. Vetter:
Because if we ignore it, then we take the patient to surgery and they have a postoperative complication. This may not occur during the operating room experience, it may not even occur in the first couple of days. It may occur two weeks, three weeks, a month, two months out after their surgery and they die or they have a heart attack or they develop kidney failure, any number of problems. Everyone wonders, “Wow, how did that happen?” Well, I think we could have seen the harbingers of it preoperatively by doing some testing.

Breanna Cunningham:
Sure. So it sounds to me, naturally, in an era of value-based care, we’re very cost-cautious.

Dr. Vetter:
Right.

Breanna Cunningham:
But on that note, it really just comes down to the clinician’s discretion, and really looking at the whole picture and determining what test you’re going to order.

Dr. Vetter:
Correct. Remember, we defined repeatedly, Michael Porter was the original definer of quality. Excuse me, value is equal to quality divided by cost. You have to put safety, I think, in the numerator and as I talked about in my lecture, you need to put, not only patient family but also provider satisfaction, because of the rising tide of burnouts we’re facing.

Breanna Cunningham:
Sure.

Dr. Vetter:
So yes, I think clinicians do need to take responsibility for making those decisions. I mean, that’s what comes with being the clinician, right?

Breanna Cunningham:
Sure, sure. So my final question for you is related to this conference. So you have been a big supporter, you’ve been here year over year.

Dr. Vetter:
Four years running.

Breanna Cunningham:
Four years. What is your favorite thing about this conference?

Dr. Vetter:
The diversity of the audience. I think it would be very easy, again, for Dr. Kain, when he took the risk that he did in forming the American College of Perioperative Medicine. Kind of going off the reservation as he was viewed by some of his colleagues in our trade union, the American Society of Anesthesiologists, that he kind of went his own way. I admire his courage for that.

One of the things that Zeev was very committed to be this was not going to be just another anesthesiology conference. So when you look at the people who have attended from the very beginning, they are a diverse mix of not just anesthesiologists, but surgeons and perioperative nurses and hospital administrators and payers. I think that is the single greatest strength of this meeting.

Dr. Vetter:
After Zeev did it for two years, it’s a little bit like the Macy’s Day Parade, in my opinion. They celebrate Thanksgiving and then they start planning the next year for the Macy’s Parade, right? For the Thanksgiving parade. Well, I know Zeev is already starting to think about April of 2021.

Breanna Cunningham:
Absolutely.

Dr. Vetter:
I think that’s the sign of a great leader and that he knows that you can’t stay static, you can’t stay constant. So next year’s conference will be equally diverse and he will continue to build an iterative kind of plan, do, check act. Plan, study, act.

So what I love about this conference. The location is okay, it’s a good location. He had considered doing it in Las Vegas. I think that would have been a little distractionary perhaps because then people might have been apt to play hooky a little more often. It’s also not on the beach, which I wish it was sometimes because then you could take a walk in the evening with my beloved and better half who’s with me right now.

But that said, it’s this really diverse mix of people. So I like talking to people, I like hearing questions. I’d like to see us going forward and I’ve talked to Zeev about this, having more active audience participation. They say you only get out of something that you put into it. The rapid cycle nature of the presentations, I think, is also very important, so that we keep people’s attention. People stay throughout the entire day.

Breanna Cunningham:
Yeah. Yeah, absolutely.

Dr. Vetter:
They don’t drift.

Breanna Cunningham:
No.

Dr. Vetter:
They don’t drift away.

Breanna Cunningham:
No. No, I mean, at your talk, standing room only in the back, right?

Dr. Vetter:
Yeah, yeah. Yeah, and yesterday’s parallel session on enhanced recovery and the PSH, I gave two lectures and Zeev originally said, “Tom, there’s only 50 people. If you could run that session for me, I can then focus on the larger conference going on.” I said, “Sure.” Well, we had standing room only for the first part of it, so they rearranged the seating so that we get more people. Well, there was still standing room only and people were in the hallway.

So I think some of the fundamentals of how to execute these concepts are still really, really, really hot topics. I think we can talk about health policy, we can have all those people talk in big generalized terms, but people want to come home from a conference like this with some take-home points.

Breanna Cunningham:
Sure. Things they can implement in their day-to-day.

Dr. Vetter:
Practical things. How do I make this work in my own hometown?

Breanna Cunningham:
Absolutely, absolutely.

Dr. Vetter:
Yeah, for sure.

Breanna Cunningham:
Well, Dr. Vetter, thank you so much.

Dr. Vetter:
My pleasure.

Breanna Cunningham:
It was a pleasure interviewing you again.

Dr. Vetter:
Thank you. Okay.

Breanna Cunningham:
I look forward to seeing you next year.

Dr. Vetter:
I hope so.

Breanna Cunningham:
Thank you.

Dr. Vetter:
Take care.

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