We're unable to sign you in at this time. Please try again in a few minutes.
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Invited Critique |

The Spectrum and Cost of Complicated Gallstone Disease in California—Invited Critique

Jack Pickleman, MD
Arch Surg. 2000;135(9):1027. doi:10.1001/archsurg.135.9.1027.
Text Size: A A A
Published online


When first asked by the editor to submit a critique of this study, I was supplied only with the title, and armed with this, I was confident I could trash and burn the work sufficiently to justify the editor's confidence in me. Alas, my generally feisty mood rapidly dissipated on the review of the data that unarguably show the increased cost, in human and financial terms, of the delayed treatment of symptomatic gallstones. This is not the first study that has shown that physician delay, either rooted in medical ignorance or mandated by bureaucratic indifference, can lead to a higher incidence of complications in a group of patients who should sustain very little morbidity and negligible mortality if treated expeditiously at the onset of symptoms. These California data demonstrate that the cases of 44% of the patients treated for gallstones were complicated by the presence of acute cholecystitis or other sequelae of untreated gallbladder disease and that half of this number had premonitory biliary colic; therefore, almost one quarter of all patients could have been treated electively by laparoscopic cholecystectomy if early operation had been undertaken. If the California figures can be assumed to be representative, hundreds of millions of dollars and countless lives could be saved nationally by earlier intervention. One disturbing piece of data noted by the authors was that 25% of all elective cholecystectomies in California are still being performed as open procedures. In my opinion, this is an unacceptably high number which I suspect reflects a lack of expertise in performing laparoscopic cholecystectomy by a substantial number of surgeons practicing in that state. These data presented here throw down the gauntlet to physicians and surgeons, virtually demanding earlier laproscopic intervention in all symptomatic patients. The medical and medicolegal implications of these data should be fully understood by practicing family physicians, internists, and gastroenterologists. Also, it should give pause to those politicians advocating a single governmental payer system in the United States as this will inevitably give rise, as noted by our friends north of the border, to rationing of care and long waiting lists for medical services. The accompanying article clearly shows that this represents inappropriate medical care for patients with symptomatic gallstones.

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

First Page Preview

View Large
First page PDF preview





Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.


Some tools below are only available to our subscribers or users with an online account.

0 Citations

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles