August 21, 2025 • 20 mins
In this episode, Tom Varghese, MD, FACS, is joined by Timothy Pawlik, MD, FACS, from The Ohio State University. They discuss Dr Pawlik’s recent article, “Association of Discharge Against Medical Advice with Surgical Outcomes and Healthcare Cost,” in which the authors found that discharge against medical advice (DAMA) among surgical patients is associated with increased 30-day readmission, complication, fragmented care, and higher healthcare cost. DAMA patients were younger, socioeconomically vulnerable, and often had substance use or psychiatric disorders.
Disclosure Information: Drs Varghese and Pawlik have nothing to disclose.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:03):
You are listening to The Operative Word,
a podcast brought to you by the Journalof the American College of Surgeons.
I'm Dr Tom Varghese,and throughout the series, Dr Lillian
Erdahl and I will speak with recentlypublished authors about the motivation
behind their latest researchand the clinical implications
it has for the practicing surgeon.
The opinions expressed in this podcast
(00:25):
are those of the participants,and not necessarily
that of the American College of Surgeons.
Hello, loyal listeners,
welcome to another episodeof The Operative Word,
the official podcast of the Journalof the American College of Surgeons.
I'm your host for today's episode,Tom Varghese, a thoracic surgeon
at the University of Utahand also the editor-in-chief
(00:47):
for the Journal of the American Collegeof Surgeons.
I am joined today by the absolutely
brilliant Dr Tim Pawlik from OhioState University.
And I'm going to let Dr Pawlikintroduce himself to the listeners.
Tim, go ahead. Tom, thanks so much.
I don’t know how absolutely brilliantI am, but, I'm a surgical
oncologist at, The Ohio State,
(01:09):
where I also have the honor and privilegeof being the departmental chair.
Beautiful.
Well, for the listeners today,we're going to be discussing the article
where Dr Pawlik is the senior author,
and the title of the article
is called “Associationof Discharge Against Medical Advice
with Surgical Outcomesand Health Care Cost”.
(01:30):
Dr Pawlik is the senior author,Dr Azza Sarfraz.
Sorry, Sarfrazis the first author of this article.
It's published onlineand will be officially out in the November
issue of JACS.
Dr Pawlik, any, relevantdisclosures, relevant to this work?
I have no disclosures.
(01:50):
Perfect. So,
for me personally, I thought thatthis was a very timely article.
I mean, we've all heardabout the topic of discharge against
medical advice and,you know, the official,
you know, stats that are outthere is that,
and this is in the introductory paragraphto Dr Pawlik's article highlights,
(02:11):
“Discharge against medical advice posesa substantial challenge
to the healthcare system, representingroughly 1 to 2% of all inpatient
hospitals with over $800 million of annualassociated healthcare costs.”
And, Dr
Pawlik, getting right to the meat of this.
(02:32):
Why did your group embark on this?
I mean, most of the studies to datehave really looked at,
you know, the medicine population.
But was that the biggest driver
that we've never studied this beforein a surgical population?
Yeah.
Thanks again.
Tom. So, just to start off,I really want to acknowledge
my entire research team.
(02:54):
I'm here talking about the papertoday.
Yet the first author, a researchfellow, Dr
Azza Sarfraznow really deserves all the credit.
And she did a wonderful jobputting this together.
So, want to acknowledge her.
So. Yeah. So,you know, this topic came up.
So I think, like, most good clinical,
(03:16):
outcomes papers it comes from livedexperience as clinicians.
I'm sure all of us in our lifehave had, you know,
someone who's,you know, left against medical advice.
And, you know, I think it's a problemin medical patients.
Obviously,
in surgical patients, it's differentbecause there has been an acute event.
Someone's had a big operation.
(03:37):
And then if they leave againstmedical advice right after, you know,
a big event like that,it can have much different implications
than if they were admitted, let's say,for congestive heart failure
or some other chronic conditionthat acutely flared.
So yes,we specifically wanted to look at it
within, surgical, patient populationto see how common it was
(03:59):
to see if there were certain patientpopulations that were at higher risk,
and then also wanted to seewhat the impact, was on,
outcomes, as well as, clinical outcomesas well as healthcare cost outcomes.
That's brilliant.
And and the database that you chose was
the Nationwide Readmissions Database.
(04:20):
Tim, any thoughts about the,the pros and cons of
using that databasefor study, of this magnitude?
Yeah.
I think that, you know,
for any, research like this, you know,we're using administrative databases
that necessarily weren't createdto answer the questions that we're asking.
Right?
We're kind of co-opting these datain in particular, the
(04:42):
this database is a readmissions database.
And we're not askinga, you know, readmission question per se,
although that was one of our outcomes.
So I think that has to be kept in mind.
All of the data are based on codes
here, you know, ICD-10 codes.
And so there's always a chance of, coding
(05:05):
inaccuracies, miscoding, missing data,
and variations in coding practicesat different hospitals.
In addition, the database,you know, didn't capture information
on race or geographic region
or even hospital quality metrics.
(05:26):
So we couldn't look at dischargeagainst medical,
advice relative to these, factors.
And then again,like most administrative databases,
you know, there's a certain lackof granular clinical detail,
that's availablebecause we're looking at billing codes.
So we didn't have information on,
(05:48):
you know, specific medication use or,you know, whether there was consultation
for mental health services,social work services, things like that.
So all of that needs to be takeninto consideration.
You know, this these type of, papers,I think are more
directional in natureand highlight associations.
(06:11):
But causal inferences need to be tempered.
Absolutely.
And, and,
it's amazing,that Dr Pawlik immediately goes in
and shows you how humble a person he is,he immediately goes to the limitations.
Let's talk about the positives.
I mean, I think that you and I both knowthat the advantages of the nationwide
readmissions databases,you know, it's nationally representative.
(06:34):
It's all payer data, large sample sizes,
standardized data, you know, it gives youthat flexibility for analysis.
And I think that, probably, we'll be going
towards this is,you know, health policy implications.
I think that that'swhere this database is really useful for.
But you're absolutely correct.
(06:54):
Tim, I think that I appreciate you get,you know, acknowledging the limitations,
but getting into it.
So the years that were covered by this,the analysis was 2016 to 2020,
the Nationwide ReadmissionsDatabase, specifically,
that the group, you know, referenceda, a previous,
you know, literature that defined
(07:15):
a kind of a stratified samplingof major operations as coronary artery
bypass grafting,
abdominal aortic aneurysm repair,esophagectomy, hepatectomy, pneumonectomy.
Pancreatectomy and colectomy.
And I think I loved how you did thatbecause it was anchored in previous
literature but also broad representationacross multiple services
(07:36):
and complexities, as well.
And, Tim,
I think that's what I'd love to be ableto do is go right, right to the results.
You know, the primary outcome was indeedthe temporal trend in discharge
against medical advice incidenceamong patients undergoing major operation.
The secondary outcomes included,
you know, 30-day post-operativecomplications, 30-day readmissions,
(07:59):
in-hospital mortality during readmission,fragmented care, and then the risk
factors associated with dischargeagainst medical device advice,
as well as differences in 30-dayhealth care expenditures.
Brilliantly,I mean, this looked at the sample size.
I mean, again, that's the advantageof the nationwide inpatient database.
And the sample sizewas 1,768,752 individuals.
(08:27):
And then the group went on and said,you know, for example, triple
A repair was 15% of that group,and so forth.
Your thoughts about the findings?
Tim, was anything surprising to youor was this kind of like,
this is kind of whatthe hypothesis that the group had going in
and this is kind of what you expect?
I was reflecting on, your analysis.
Now, what would we say that the bigtakeaway points are from your perspective?
(08:52):
Yeah.
So one, I think you know, a study likethis is probably only possible through use
of large administrative databases.
Because one thing that surprised me, mea little bit was just the overall,
incidence of discharge
against medical advicein the surgical cohort was relatively low.
You know, of over 1.7 million patients,
(09:12):
only about 4000 patients, or about 0.2%
with discharge against medical advice.
Which is lower,
than what is reported in thethe medical literature,
which again, may not be that surprisingbecause one would surmise that patients
who have hadwho just, just had a big operation
(09:32):
may be a little bit less likely to,you know, leave against
medical advice than someone who's beenadmitted, admitted for a medical problem.
So that was a little bit surprising.
Relatively low incidence.
I think the other thing that was,
I surprised just increased trend,
in dischargeagainst medical advice over time.
(09:53):
You know, it's hardto completely explain that,
some of that, I think may be associatedwith just some overall,
you know, trends in, disenfranchisementfrom the kind of medical establishment,
if you will, and then, you know, growing,
trend perhaps in mentalhealth and substance abuse disorders.
(10:16):
We did note that in those subpopulations,
they were at higher risk, for,
discharge against medical advice.
And, so I think thatthat was also interesting,
that increased trend over time.
And then I think the other thing that was
(10:36):
interesting was that, you know,this idea of recidivism.
So there was a subset of patientswho were discharged and discharged
against medical advice.
Then they were readmitted,and then perhaps again, not surprisingly,
but then they againleft, after, against medical advice.
So you have these people who are kindof specifically inclined to leave,
(10:58):
against medical advice.
So how can we engage a patient populationwith caseworkers, social work?
Because when they do leave against
medical advice,they are at higher risk for readmission,
fragmented care, increasedcomplications and adverse outcomes.
So we really need to target interventions
(11:20):
to better understand whythey're leaving against medical advice.
And, and help them, help them stay,and get the treatment that they need.
No, I, I'm smiling on this side, Tim,because I think that you
guys have captured it in some verypowerful sentences in the article.
So, for example, let me read one sentence.
And this is, I think, almost a reminder
(11:41):
for the C-suite and senior administration.
This this sentencereally resonated with me.
It says, “Whiledischarge against medical advice
may seem like a cost-saving optionto patients by shortening hospital stay,
the cumulative financial burdenfrom increased readmissions and prolonged
hospital utilization ultimately outweighsany perceived
(12:03):
short-term savings.”I think it's just like a timely,
you know,you and I when we were in training, like,
what was the that old adagethat was drilled into us from our mentors
and our, you know, our,you know, those who came before us,
that was that
the best surgical care is always thatwhich is delivered correctly the
first time.
Right.
It's just and dischargeagainst medical advice is ultimately
(12:24):
I mean, however you look at it, ultimatelyit is a failure in some respect.
Right? We haven't completedthe care that they needed.
And for whatever reason, they left.
And then it's just that spiral.
I love the way that you capturedthat, as well.
I guess, you know,when you have studies like this
and you've clearly documented as like, sosurgery is not exempt from this problem.
(12:47):
I mean, yes,the incidence may be lower, but,
you know, the costassociated with surgical care are higher.
So again, big impact of that.
I, I'mthinking more, Tim, about next steps.
You know, it's like I encourageall the listeners to read this article.
Like I said,I think this is going to be a touchstone
for many of us as we tackle thisor try to come up with interventions,
(13:07):
but is it really more about startingto pilot test, local interventions?
Tim.
Is it more about working with ourstakeholders, including policymakers?
What do you what are your thoughts, Tim,about next steps?
Like,what do we do now that we studied this?
Where do we go from from there?
Well, I think one area of focus onthis is individuals
who have mental health conditionsor substance use disorders.
(13:29):
If you know from the paper,the patient population with the highest,
odds of being dischargedagainst medical advice
are those individuals who had substanceabuse disorders.
And sadly, that may be relatedto patients wanting to leave the hospital
to self-medicate,with alcohol or other substances.
(13:51):
And thatkind of dovetails into another paper
that we just recently published in JACSabout alcohol withdrawal syndrome.
Yeah.
And, that problemin the post-operative setting.
So I think, you know,people are leaving for a reason.
It may not be a reason
that we understand, right, butthat they want to get their medical care.
But, you know, they may leave againstmedical advice because, you know,
(14:13):
they have, an alcoholuse disorder or substance abuse disorder.
And, and they're leavingbecause they're trying to self-medicate.
And if you look at the literature,you know, other literature
would suggest that,you know, patients who have,
substance use disorders or mental healthissues are at higher risk.
So that that I think provides some areas
(14:35):
for next steps about,you know, how can we, you know, address,
you know,
screening for these, problemsin the preoperative period.
How can we better address themin the inpatient setting?
So patients aren't going to leave,
because of these, behavioral healthdisorders or substance use disorders?
(14:57):
How can we have, better integratedbehavioral health
interventions,inpatient withdrawal management
and more, you know, structured discharge
planning in social work intervention,
for these high-risk individuals.
So I think that's a reallyimportant point, that I took home,
(15:19):
from this research.
That's absolutely brilliant.
In the few minutes that we have left, Tim,what I'd like to do
is take the prerogative of the fact that,you know, as a very experienced
researcher and,somebody who's seen a lot over the years,
you know, our current climateright now is a lot of people.
(15:39):
There's a lot of negativity out there.
Right?
It's there's a lot of negativity about,oh my God, there's so many problems.
And the the sky is falling.
And, why should surgeons even do researchand things like that?
We're we're seeing a lot of chatteron social media.
We see these type of thingsat the time of this recording,
your perspectivesof seeing brilliant research
(16:00):
scholars who work with your groupand start tackling these tough, topics.
And the track record in the productivitythat your group has had over the years.
What what's some timely advicethat you have for all of us in terms of,
you know, hey,how do we navigate these turbulent waters?
And, you know, where some,spotlights of success or, you know,
(16:23):
bright
spots that we can kind of gravitatetowards or aim towards, some thoughts?
Yeah.
I mean,I think there's a lot of external forces,
that are challenging,those external forces,
maybe at a particular high pitch
now, yet they have been there always.
Throughout history,there are always, you know, social,
(16:45):
economic, other, you know,
forces, that are working against usand sometimes for us.
And then there's internal factors.
And I try to focuson, you know, some of the internal factors
without being tonedeaf to the external factors.
Regardless of what is happeningexternally, science is still
(17:08):
incredibly invigorating,you know, and it is fun to be curious.
Right?
Like, I think surgeons are inherentlycurious people.
We are always asking questions,and we are seeking to answer questions
to solve problems in ultimately,
at the very crux of things,that is what research is about.
(17:30):
And, you know, you know,you joked about this at the beginning.
I'm a brilliant... I'm not.
You know what I mean?
It I find things that I encounterin my everyday clinical life,
like people leaving againstmedical advice, someone going into alcohol
withdrawal, you know, seeing someonefrom a socially vulnerable neighborhood
(17:51):
who has a poor surgical outcome,not because of surgical technique,
but because of the environmentthey live in.
And then trying to apply
some type of scientific method,and research methodology
to answer those questionsin a more quantitative and rigorous way.
That's what I try to do for my clinicals,research perspective.
(18:13):
Other people do it from a basic science
perspectiveor a clinical trial perspective.
And I think, you know, we just needto keep feeding that curiosity.
And as mentors, we need to continue to,
you know, show that excitement and sharethat excitement with our trainees.
Because that's what I enjoythe most is work on my research team.
(18:33):
And that's why, you know, Dr Azza
Sarfraz is, you know,she deserves all the credit.
You know, she did all the work.
You know, we talked about this idea,but that's what's fun is to see her
take something,build it, grow it, write it, become
successful and become, you know,the next generation of leaders in surgery.
That's what it's about.
Absolutely amazing.
(18:54):
Couldn't have said it better myself and,
Dr Pawlik, like, I mean,thank you from the bottom of my heart
for all that you do.
I mean, it's just, you know,not only, projects like this that,
we had the privilegeof publishing in JACS, but,
you know, building that better worldfor all of us,
to, you know, explore,satisfy our curiosity to advance science.
(19:15):
Thank you for joining us todayon, this episode of The Operative
Word, the podcast for the Journalof the American College of Surgeons.
Tim, thank you for everything you doand looking forward to your next projects.
Thanks so much for joining us today.Thanks, Tom.
Really appreciate your leadership of JACSand the opportunity to chat
with you today.
(19:37):
Thank you for listening to
the Journal of the American Collegeof Surgeons Operative Word Podcast.
If you enjoyed today's episode,spread the word on social media
by using the hashtag #JACSOperativeWord.
Subscribe to The Operative Wordwherever podcasts are available
or listen on the American Collegeof Surgeons website at facs.org/podcast.
You are listening to The Operative Word,
a podcast brought to you by the Journalof the American College of Surgeons.
I'm Dr Tom Varghese,and throughout the series, Dr Lillian
Erdahl and I will speak with recentlypublished authors about the motivation
behind their latest researchand the clinical implications
it has for the practicing surgeon.
The opinions expressed in this podcast
(00:25):
are those of the participants,and not necessarily
that of the American College of Surgeons.
Hello, loyal listeners,
welcome to another episodeof The Operative Word,
the official podcast of the Journalof the American College of Surgeons.
I'm your host for today's episode,Tom Varghese, a thoracic surgeon
at the University of Utahand also the editor-in-chief
(00:47):
for the Journal of the American Collegeof Surgeons.
I am joined today by the absolutely
brilliant Dr Tim Pawlik from OhioState University.
And I'm going to let Dr Pawlikintroduce himself to the listeners.
Tim, go ahead. Tom, thanks so much.
I don’t know how absolutely brilliantI am, but, I'm a surgical
oncologist at, The Ohio State,
(01:09):
where I also have the honor and privilegeof being the departmental chair.
Beautiful.
Well, for the listeners today,we're going to be discussing the article
where Dr Pawlik is the senior author,
and the title of the article
is called “Associationof Discharge Against Medical Advice
with Surgical Outcomesand Health Care Cost”.
(01:30):
Dr Pawlik is the senior author,Dr Azza Sarfraz.
Sorry, Sarfrazis the first author of this article.
It's published onlineand will be officially out in the November
issue of JACS.
Dr Pawlik, any, relevantdisclosures, relevant to this work?
I have no disclosures.
(01:50):
Perfect. So,
for me personally, I thought thatthis was a very timely article.
I mean, we've all heardabout the topic of discharge against
medical advice and,you know, the official,
you know, stats that are outthere is that,
and this is in the introductory paragraphto Dr Pawlik's article highlights,
(02:11):
“Discharge against medical advice posesa substantial challenge
to the healthcare system, representingroughly 1 to 2% of all inpatient
hospitals with over $800 million of annualassociated healthcare costs.”
And, Dr
Pawlik, getting right to the meat of this.
(02:32):
Why did your group embark on this?
I mean, most of the studies to datehave really looked at,
you know, the medicine population.
But was that the biggest driver
that we've never studied this beforein a surgical population?
Yeah.
Thanks again.
Tom. So, just to start off,I really want to acknowledge
my entire research team.
(02:54):
I'm here talking about the papertoday.
Yet the first author, a researchfellow, Dr
Azza Sarfraznow really deserves all the credit.
And she did a wonderful jobputting this together.
So, want to acknowledge her.
So. Yeah. So,you know, this topic came up.
So I think, like, most good clinical,
(03:16):
outcomes papers it comes from livedexperience as clinicians.
I'm sure all of us in our lifehave had, you know,
someone who's,you know, left against medical advice.
And, you know, I think it's a problemin medical patients.
Obviously,
in surgical patients, it's differentbecause there has been an acute event.
Someone's had a big operation.
(03:37):
And then if they leave againstmedical advice right after, you know,
a big event like that,it can have much different implications
than if they were admitted, let's say,for congestive heart failure
or some other chronic conditionthat acutely flared.
So yes,we specifically wanted to look at it
within, surgical, patient populationto see how common it was
(03:59):
to see if there were certain patientpopulations that were at higher risk,
and then also wanted to seewhat the impact, was on,
outcomes, as well as, clinical outcomesas well as healthcare cost outcomes.
That's brilliant.
And and the database that you chose was
the Nationwide Readmissions Database.
(04:20):
Tim, any thoughts about the,the pros and cons of
using that databasefor study, of this magnitude?
Yeah.
I think that, you know,
for any, research like this, you know,we're using administrative databases
that necessarily weren't createdto answer the questions that we're asking.
Right?
We're kind of co-opting these datain in particular, the
(04:42):
this database is a readmissions database.
And we're not askinga, you know, readmission question per se,
although that was one of our outcomes.
So I think that has to be kept in mind.
All of the data are based on codes
here, you know, ICD-10 codes.
And so there's always a chance of, coding
(05:05):
inaccuracies, miscoding, missing data,
and variations in coding practicesat different hospitals.
In addition, the database,you know, didn't capture information
on race or geographic region
or even hospital quality metrics.
(05:26):
So we couldn't look at dischargeagainst medical,
advice relative to these, factors.
And then again,like most administrative databases,
you know, there's a certain lackof granular clinical detail,
that's availablebecause we're looking at billing codes.
So we didn't have information on,
(05:48):
you know, specific medication use or,you know, whether there was consultation
for mental health services,social work services, things like that.
So all of that needs to be takeninto consideration.
You know, this these type of, papers,I think are more
directional in natureand highlight associations.
(06:11):
But causal inferences need to be tempered.
Absolutely.
And, and,
it's amazing,that Dr Pawlik immediately goes in
and shows you how humble a person he is,he immediately goes to the limitations.
Let's talk about the positives.
I mean, I think that you and I both knowthat the advantages of the nationwide
readmissions databases,you know, it's nationally representative.
(06:34):
It's all payer data, large sample sizes,
standardized data, you know, it gives youthat flexibility for analysis.
And I think that, probably, we'll be going
towards this is,you know, health policy implications.
I think that that'swhere this database is really useful for.
But you're absolutely correct.
(06:54):
Tim, I think that I appreciate you get,you know, acknowledging the limitations,
but getting into it.
So the years that were covered by this,the analysis was 2016 to 2020,
the Nationwide ReadmissionsDatabase, specifically,
that the group, you know, referenceda, a previous,
you know, literature that defined
(07:15):
a kind of a stratified samplingof major operations as coronary artery
bypass grafting,
abdominal aortic aneurysm repair,esophagectomy, hepatectomy, pneumonectomy.
Pancreatectomy and colectomy.
And I think I loved how you did thatbecause it was anchored in previous
literature but also broad representationacross multiple services
(07:36):
and complexities, as well.
And, Tim,
I think that's what I'd love to be ableto do is go right, right to the results.
You know, the primary outcome was indeedthe temporal trend in discharge
against medical advice incidenceamong patients undergoing major operation.
The secondary outcomes included,
you know, 30-day post-operativecomplications, 30-day readmissions,
(07:59):
in-hospital mortality during readmission,fragmented care, and then the risk
factors associated with dischargeagainst medical device advice,
as well as differences in 30-dayhealth care expenditures.
Brilliantly,I mean, this looked at the sample size.
I mean, again, that's the advantageof the nationwide inpatient database.
And the sample sizewas 1,768,752 individuals.
(08:27):
And then the group went on and said,you know, for example, triple
A repair was 15% of that group,and so forth.
Your thoughts about the findings?
Tim, was anything surprising to youor was this kind of like,
this is kind of whatthe hypothesis that the group had going in
and this is kind of what you expect?
I was reflecting on, your analysis.
Now, what would we say that the bigtakeaway points are from your perspective?
(08:52):
Yeah.
So one, I think you know, a study likethis is probably only possible through use
of large administrative databases.
Because one thing that surprised me, mea little bit was just the overall,
incidence of discharge
against medical advicein the surgical cohort was relatively low.
You know, of over 1.7 million patients,
(09:12):
only about 4000 patients, or about 0.2%
with discharge against medical advice.
Which is lower,
than what is reported in thethe medical literature,
which again, may not be that surprisingbecause one would surmise that patients
who have hadwho just, just had a big operation
(09:32):
may be a little bit less likely to,you know, leave against
medical advice than someone who's beenadmitted, admitted for a medical problem.
So that was a little bit surprising.
Relatively low incidence.
I think the other thing that was,
I surprised just increased trend,
in dischargeagainst medical advice over time.
(09:53):
You know, it's hardto completely explain that,
some of that, I think may be associatedwith just some overall,
you know, trends in, disenfranchisementfrom the kind of medical establishment,
if you will, and then, you know, growing,
trend perhaps in mentalhealth and substance abuse disorders.
(10:16):
We did note that in those subpopulations,
they were at higher risk, for,
discharge against medical advice.
And, so I think thatthat was also interesting,
that increased trend over time.
And then I think the other thing that was
(10:36):
interesting was that, you know,this idea of recidivism.
So there was a subset of patientswho were discharged and discharged
against medical advice.
Then they were readmitted,and then perhaps again, not surprisingly,
but then they againleft, after, against medical advice.
So you have these people who are kindof specifically inclined to leave,
(10:58):
against medical advice.
So how can we engage a patient populationwith caseworkers, social work?
Because when they do leave against
medical advice,they are at higher risk for readmission,
fragmented care, increasedcomplications and adverse outcomes.
So we really need to target interventions
(11:20):
to better understand whythey're leaving against medical advice.
And, and help them, help them stay,and get the treatment that they need.
No, I, I'm smiling on this side, Tim,because I think that you
guys have captured it in some verypowerful sentences in the article.
So, for example, let me read one sentence.
And this is, I think, almost a reminder
(11:41):
for the C-suite and senior administration.
This this sentencereally resonated with me.
It says, “Whiledischarge against medical advice
may seem like a cost-saving optionto patients by shortening hospital stay,
the cumulative financial burdenfrom increased readmissions and prolonged
hospital utilization ultimately outweighsany perceived
(12:03):
short-term savings.”I think it's just like a timely,
you know,you and I when we were in training, like,
what was the that old adagethat was drilled into us from our mentors
and our, you know, our,you know, those who came before us,
that was that
the best surgical care is always thatwhich is delivered correctly the
first time.
Right.
It's just and dischargeagainst medical advice is ultimately
(12:24):
I mean, however you look at it, ultimatelyit is a failure in some respect.
Right? We haven't completedthe care that they needed.
And for whatever reason, they left.
And then it's just that spiral.
I love the way that you capturedthat, as well.
I guess, you know,when you have studies like this
and you've clearly documented as like, sosurgery is not exempt from this problem.
(12:47):
I mean, yes,the incidence may be lower, but,
you know, the costassociated with surgical care are higher.
So again, big impact of that.
I, I'mthinking more, Tim, about next steps.
You know, it's like I encourageall the listeners to read this article.
Like I said,I think this is going to be a touchstone
for many of us as we tackle thisor try to come up with interventions,
(13:07):
but is it really more about startingto pilot test, local interventions?
Tim.
Is it more about working with ourstakeholders, including policymakers?
What do you what are your thoughts, Tim,about next steps?
Like,what do we do now that we studied this?
Where do we go from from there?
Well, I think one area of focus onthis is individuals
who have mental health conditionsor substance use disorders.
(13:29):
If you know from the paper,the patient population with the highest,
odds of being dischargedagainst medical advice
are those individuals who had substanceabuse disorders.
And sadly, that may be relatedto patients wanting to leave the hospital
to self-medicate,with alcohol or other substances.
(13:51):
And thatkind of dovetails into another paper
that we just recently published in JACSabout alcohol withdrawal syndrome.
Yeah.
And, that problemin the post-operative setting.
So I think, you know,people are leaving for a reason.
It may not be a reason
that we understand, right, butthat they want to get their medical care.
But, you know, they may leave againstmedical advice because, you know,
(14:13):
they have, an alcoholuse disorder or substance abuse disorder.
And, and they're leavingbecause they're trying to self-medicate.
And if you look at the literature,you know, other literature
would suggest that,you know, patients who have,
substance use disorders or mental healthissues are at higher risk.
So that that I think provides some areas
(14:35):
for next steps about,you know, how can we, you know, address,
you know,
screening for these, problemsin the preoperative period.
How can we better address themin the inpatient setting?
So patients aren't going to leave,
because of these, behavioral healthdisorders or substance use disorders?
(14:57):
How can we have, better integratedbehavioral health
interventions,inpatient withdrawal management
and more, you know, structured discharge
planning in social work intervention,
for these high-risk individuals.
So I think that's a reallyimportant point, that I took home,
(15:19):
from this research.
That's absolutely brilliant.
In the few minutes that we have left, Tim,what I'd like to do
is take the prerogative of the fact that,you know, as a very experienced
researcher and,somebody who's seen a lot over the years,
you know, our current climateright now is a lot of people.
(15:39):
There's a lot of negativity out there.
Right?
It's there's a lot of negativity about,oh my God, there's so many problems.
And the the sky is falling.
And, why should surgeons even do researchand things like that?
We're we're seeing a lot of chatteron social media.
We see these type of thingsat the time of this recording,
your perspectivesof seeing brilliant research
(16:00):
scholars who work with your groupand start tackling these tough, topics.
And the track record in the productivitythat your group has had over the years.
What what's some timely advicethat you have for all of us in terms of,
you know, hey,how do we navigate these turbulent waters?
And, you know, where some,spotlights of success or, you know,
(16:23):
bright
spots that we can kind of gravitatetowards or aim towards, some thoughts?
Yeah.
I mean,I think there's a lot of external forces,
that are challenging,those external forces,
maybe at a particular high pitch
now, yet they have been there always.
Throughout history,there are always, you know, social,
(16:45):
economic, other, you know,
forces, that are working against usand sometimes for us.
And then there's internal factors.
And I try to focuson, you know, some of the internal factors
without being tonedeaf to the external factors.
Regardless of what is happeningexternally, science is still
(17:08):
incredibly invigorating,you know, and it is fun to be curious.
Right?
Like, I think surgeons are inherentlycurious people.
We are always asking questions,and we are seeking to answer questions
to solve problems in ultimately,
at the very crux of things,that is what research is about.
(17:30):
And, you know, you know,you joked about this at the beginning.
I'm a brilliant... I'm not.
You know what I mean?
It I find things that I encounterin my everyday clinical life,
like people leaving againstmedical advice, someone going into alcohol
withdrawal, you know, seeing someonefrom a socially vulnerable neighborhood
(17:51):
who has a poor surgical outcome,not because of surgical technique,
but because of the environmentthey live in.
And then trying to apply
some type of scientific method,and research methodology
to answer those questionsin a more quantitative and rigorous way.
That's what I try to do for my clinicals,research perspective.
(18:13):
Other people do it from a basic science
perspectiveor a clinical trial perspective.
And I think, you know, we just needto keep feeding that curiosity.
And as mentors, we need to continue to,
you know, show that excitement and sharethat excitement with our trainees.
Because that's what I enjoythe most is work on my research team.
(18:33):
And that's why, you know, Dr Azza
Sarfraz is, you know,she deserves all the credit.
You know, she did all the work.
You know, we talked about this idea,but that's what's fun is to see her
take something,build it, grow it, write it, become
successful and become, you know,the next generation of leaders in surgery.
That's what it's about.
Absolutely amazing.
(18:54):
Couldn't have said it better myself and,
Dr Pawlik, like, I mean,thank you from the bottom of my heart
for all that you do.
I mean, it's just, you know,not only, projects like this that,
we had the privilegeof publishing in JACS, but,
you know, building that better worldfor all of us,
to, you know, explore,satisfy our curiosity to advance science.
(19:15):
Thank you for joining us todayon, this episode of The Operative
Word, the podcast for the Journalof the American College of Surgeons.
Tim, thank you for everything you doand looking forward to your next projects.
Thanks so much for joining us today.Thanks, Tom.
Really appreciate your leadership of JACSand the opportunity to chat
with you today.
(19:37):
Thank you for listening to
the Journal of the American Collegeof Surgeons Operative Word Podcast.
If you enjoyed today's episode,spread the word on social media
by using the hashtag #JACSOperativeWord.
Subscribe to The Operative Wordwherever podcasts are available
or listen on the American Collegeof Surgeons website at facs.org/podcast.
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