It's Galling: diagnostic dilemmas and the gallbladder

I finished the previous post with the sad story of my patient, illustrating diagnostic difficulties at the fringes of biliary disease. And I began the series by stating that the vast majority of gallbladder problems are straightforward, with surgery leaving patients happy and symptom-free. In the time it's taken me to write these things, I haven't changed my mind: surgery on the gallbladder is typically gratifying all the way around. But a few patients defy understanding and can end up miserable.

Doctors have a few diagnostic categories that, in my opinion, are over-called, and under-stood. Fibromyalgia. Chronic fatigue syndrome. And, in the current context, biliary dyskinesia and sphincter of Oddi dysfunction. I'm not a primary care doc, so I include the first two on the list in this sense: I know it's nice to have a fancy name to toss out when you have no idea what's going on. Having a disease or two up your sleeve the diagnosis of which is fuzzy, the description of which is plastic, the treatment of which isn't fully worked-out, isn't always a bad thing. Gets you off the hook for a certain grace period. (In the case of "biliary dyskinesia," for example, there seems to be confusion even over the meaning of the term: to some ((me, included)) it means a problem with how the gallbladder works. To others, it encompasses the whole pantheon of pre- and post-op bile-related difficulties.)

These diseases all fit that category, to some extent. I'm pretty sure there are plenty of people out there who have them; yet I have no doubt each handle is too frequently grasped. But here we'll stick to the gallbladder (the colon often does, after all, and we know of what it's full.) The treatment for these conditions is surgical, so the stakes are high.

"Biliary dyskinesia" is the term for uncoordinated muscular contraction of the gallbladder (it also sort of slops over, as I said, into the concept of sphincter of Oddi dysfunction ((SOD)), but let's keep them separate for the purposes of this series); it's sort of like irritable bowel syndrome (should have included that on the above list. Too late now.) For the gallbladder properly to empty when it squeezes, the muscles at its opening need to relax while those in the body of the bag contract. If not, it's like having a stone in the way: the muscles squeeze against a blockage (in this case, an un-relaxed muscle) and cause pain.

If a person has pain very suggestive of gallbladder origin but has no stones, biliary dyskinesia is properly suspected. To what extent there's a reliable test for it is a matter of opinion. It always has been, and remains, first and foremost a "diagnosis of exclusion," meaning once you step into that arena, you need to go through the long list of other possibilities and rule them out. Then you do a HIDA scan with CCK (Hepatic IminoDiacetic Acid; CholeCystoKinin); ie, injecting a material that's taken up in bile, illuminating the gallbladder, then giving a hormone that makes the gallbladder contract.)

To be on solid ground, two things must happen: first, the gallbladder should not empty properly (less than 30% of its content) and, second, the injection of the contracting juice should reproduce the pain pattern in question. But it's not crystal clear: how much less than 30%? How exact is the pain reproduction (CCK causes cramps and nausea in lots of people.) It's always made me a bit nervous to operate on people with the diagnosis, but the fact is that when the emptying (ejection fraction) is very low (say 10%) and when the pain syndrome is clearly evoked, cure of symptoms is very high (90%, thereabouts.) Would that it were 100% -- but in life, what is? (Funny story: prior to my discovery of blogging, I used to spend some time answering questions on a couple of online medical fora -- in fact, it's where I first "met" Kevin, MD, who was official on one to which I just interloped. In googling aspects of biliary dyskinesia for helpful links, I came upon -- quite high on the list -- several of my answers on the subject. So I might have referenced myself to support my post. Should have gone into politics...)

Sphincter of Oddi dysfunction is iffier, in my experience/opinion. That's what my patient in the previous post was presumed to have. The concept is that the valve at the southern end of the bile duct doesn't open properly, allowing bile pressure to build up in the system, causing biliary-type pain, maybe some nausea, cramps. It makes sense. But the problem is the test: pass a scope down the throat into the gut (which usually requires sedation which can affect the muscles of gut function), then pass a pressure-measuring tube into the bile duct, across the very structure whose function you're trying to measure. "Uncertainty principle" anyone?

Some people get better when SOD is diagnosed and treated. My patient didn't. She's not alone. The sad truth is that absent proven gallstones, or clear signs of inflammation of the gallbladder, our ability to be certain what's going on is imperfect at best.

In the olden days, you heard a lot (if you were a surgeon) about "cystic duct syndrome." It referred to people who continued to have their pre-op symptoms after gallbladder removal, and in whom the tube (cystic duct) between the gallbladder and the main bile duct (common duct) was left intact. We were taught to remove that whole duct along with the gallbladder, right down to the common duct. I never stopped doing it that way. With the advent of laparoscopic gallbladder removal, however, and the attendant increase in surgical injury to the common duct, lots of surgeons decided it's ok to leave the cystic duct long -- which reduces risk of other ductal damage. What you don't hear about is an increase in the syndrome (ever have a professor pronounce it "SIN droh me"? I have. Like "SAHN tih meeter for centimeter.")

I admit to having operated on a couple of patients whose evaluation showed a long cystic duct after operation by another surgeon and who persisted with pain. One got better. Objectively, I'd say there's no real science behind it; just a few papers with small numbers of patients and somewhat mixed results.

It's clear that some people have gallbladder trouble without having stones ("acalculous cholecystitis", which means inflammation without stones): it's not at all rare to see a patient with an inflamed, tender -- even infected -- gallbladder that's completely free of stones. That's not a diagnostic or therapeutic problem: at some point in the course of the illness -- acutely if not improving, or after resolution -- the gallbladder gets removed. It's not so clear what the mechanism of the problem is: presumably in at least some cases it follows from a "dyskinetic" episode.

There's another category of therapeutic vagary: the person who has symptoms and stones but who doesn't get better with surgery. The group has its own name: "post-cholecystectomy syndrome." Included are a wide variety of unfortunate folks: those whose preoperative symptoms evidently weren't in fact due to their stones (stones are often asymptomatic. Not every belly-ache in a person with gallstones is due to the rocks); those who develop side-effects from losing their gallbladder (most don't. Those that do generally get cramps or diarrhea, especially after eating fatty foods); those who have that mysterious SOD. All I can say is I hate it when it happens; I know from experience that a significant number of those people will never get complete satisfaction.

The good news: when I've been absolutely certain that symptoms are due to stones, I've had only a very tiny number fail to improve with surgery. I've had a few with diarrhea problems, almost all easily controlled with diet. And I've had some failures of therapy -- like the patient in the last post -- who fell through the cracks of understanding. If you read those medical fora to which I referred above, you'd think everyone who ever had his/her gallbladder out is miserable. The happy ones, obviously, don't complain. And -- take my word if you can -- they outnumber the problems by a huge margin.

Next I'll write about operative considerations, just for the heck of it. Taking out a gallbladder can be a lark, a walk in the park, pure fun. Or it can be the hardest thing you've ever done, scary as hell, suborning self-soilage...

Slippery Stones: more about the gallbladder

"If you don't have a pretty good idea what's going on with your patient after a thorough history and physical," I was told in medical school, "you probably never will." It's a wise -- if a little dated -- statement. Most of the time, diagnosis isn't all that hard. Rare things are rare. Common things are common: another med-school pearl of wisdom. Figuring out the problem in those outlier situations can be frustrating on each side of the white coat and, in the case of surgery, can lead to errors in both directions: doing operations that don't help, or deferring ones that otherwise might. The gallbladder has been the source of more than its share of such scenarii.

Delicate and robin's-egg blue, the normal gallbladder is startlingly beautiful. Out of place among the muted earthiness of the rest of the abdominal anatomy, it peeks above the lower edge of the right lobe of the liver, demure, nearly luminous; typically you see only the top of it, the rest hidden by the colon and omentum. It's as if the body is shy about revealing such surprising and incongruous loveliness. Aiming to remove it, seeing that color signals a likely easy time; hoping to help a person with grey symptoms, finding a blue bag makes you wonder what you're doing. With significant chronic gallbladder disease, the organ generally is thick and reddened, although in between attacks it can resume its avian amiability.

"Well, doc, whenever I eat freedom fries, few minutes later I get this horrible pain right here [pointing just below the right rib cage]. Goes right through me into my shoulder blade. Hurts like hell. I get to writhing around, puking my guts out, can't stand up, can't sit down. After twenty minutes it starts to go away, and I'll feel fine again. Oh, and my doc asked me to bring you these [shows me ultrasound images of his gallbladder, full of stones.]" No brainer. Textbook stuff. That man is going to love me for liberating him from the clutches of his gallbladder. The preceding, by the way, is a classic description of "biliary colic," resulting from a stone plugging up the outlet of the gallbladder when it's trying to empty itself of bile. It differs from "acute cholecystitis," which is a more severe situation, resulting from the stone lodging in the outlet and not letting go. Instead of just hurting like hell for a few minutes, the gallbladder gets inflamed, swollen, sometimes infected. It's potentially more dangerous than colic. The distinction, I'd have to say, is often lost on non-surgical medical doctors. But I digress.

"Well, doc, whenever I eat french fries..... [repeats the above story including handing me the ultrasound, which is entirely normal.] That's a diagnostic problem. Or this: "I get heartburn a lot. Sometimes I'm nauseated for no reason. [Shows me repeat of the first ultrasound, stones aplenty.] I've heard variations on those themes countless times, and it's a dilemma. Many tests follow, but explanations remain elusive. Operations may or may not ensue. The sad saga of one of my patients is illuminating. Since it's complicated, maybe I'll just tell the story straight through, and consider the implications later.

I'd operated on her for another reason in the past. Now under the care of docs at a hoidy-toidy medical center, she came back to me when surgery was recommended. She'd been through an extensive workup for abdominal pain, not typical of gallbladder origin, but conceivably so; her gallbladder was, by all measures, normal. At the mecca of medical mastery she'd undergone a test on the basis of which it was decided she had problems with the valve at the end of the bile duct (sphincter of Oddi dysfunction -- more about that little gem, later) and she'd been advised to have her gallbladder removed. I called her gastroenterologist: why, I asked him, had he not cut the valve (the usual treatment) when he was there with his scope? Wasn't taking out her gallbladder attending to the wrong end of the stick? Removal of the gallbladder, he said, was curative sometimes (for unknown reasons); and it was their protocol not to cut the valve (papillotomy) in people who hadn't had cholecystectomy (official and impressive term for gallbladder removal). OK, I said. You're the professor.

The operation went fine. (I've always said unnecessary surgery gets a bad rap: it's easy, and people recover faster than when they're actually sick.) Her pain persisted. From her Meccanized professor, she then got her papillotomy, after which she in fact felt better for a while. When her symptoms recurred, a scope showed the sphincter had scarred down, so it was re-cut, after which she was better again, but for a shorter time, after which it was again scarred small. At that point her gastroenterologist recommended surgically cutting the sphincter; that made sense to me, because it seemed the "medical" cutting had helped, and I knew the surgical approach was more definitive and permanent, if a bigger deal. So I did it, a major procedure involving opening the duodenum and carefully (so you don't cause a leak) slicing the end of the bile duct and tacking it open with sutures. Once again she seemed to have been improved, for a while. When her pain returned, her umpteenth scope Xray showed my operation to be wide open, but her doc had her see Supersurgeon at the mecca. He recommended going back in and cutting her pancreatic duct where it joined the bile duct, figuring that in some way I'd compromised its drainage with my operation. I hadn't. (Below is a diagram that shows the relationships. Ignore the stone, in this case.)



Had I somehow interfered with drainage from the pancreas, and were that a cause of her problem (which didn't make sense, since her symptoms were the same as those before any of these procedures were done), that duct would be seen to be dilated on Xrays. It wasn't. My patient wanted me to do the operation if it was do be done, but that's where I drew the line: for one thing, it made no anatomic sense to me in her situation, and for another, I'd never done it -- at least not that way. I told her both reasons. So Supersurgeon did it, finding no operative evidence of a problem, but soldiering on.

When there was no improvement at all, so my patient later told me, and when she had another scope-Xray to check it out, the surgeon entered the exam room, walked past her to the Xray, looked it over, said "Well, my operation isn't the problem," turned on the heel of his bootie-covered shoe, and walked out without ever having said hello.

I tried everything remaining: wound injections and scanning for hernias, pain clinic referral, obtaining opinions from all sorts. The best I could do, at some point, was to assure her that whatever else was true, it was possible to be sure there was nothing going on that was dangerous to her. She continued to visit the clinic, and finally found some sort of equilibrium with her pain. In my next post, I'll try to deal with some of the issues raised. (The assholery of the surgeon will have to stand on its own, addressed no further...)

Tony Snow. And a story.

I'm interrupting the gallbladder series for a moment, at the news of Tony Snow's discovered metatstatic colon cancer in his liver. As I said about Elizabeth Edwards a couple of posts back, when famous people get sick, it's an opportunity to learn. If nothing else.

In the case of colon cancer which has spread to the liver, the outlook is not good. On average, survival is in the range of six months (as with all cancers, there are variations in both directions). There are exceptional circumstances, for instance when it appears that only one tumor nodule is growing in the liver, in which case removing it and giving chemotherapy may prolong life. Unfortunately that's rare: in most cases when it's discovered, it's widespread. Response to drugs is usually brief. Some data suggest improved response when the drugs are infused directly into the artery to the liver (in the linked diagram, the images are of experiments in rats. The one on the right is sort of like what happens in humans).

In my practice I had one patient who defied the odds so dramatically that I hesitated to mention him when I talked to others in whom I'd discovered the disease. My desire was to be candid and realistic, but, at least early on, to encourage a trial of treatment. Compared to some, the drugs used for liver metastases of colon cancer are usually well-tolerated. Response is not great overall, but once in a while.... So I'd generally suggest giving it a try, but I didn't want to raise expectations inappropriately.

My patient was in his forties and feeling healthy until he started noticing blood in his stools. It wasn't until he started having frequent cramps that he decided to see his doc, at which point, unsurprisingly, he was found to have a large tumor in his sigmoid colon. His CEA (a blood test related to colon cancer, the usefulness of which in terms of diagnosis and treatment remains controversial) was the highest I've ever seen, consistent with the amount of tumor in his liver. Nevertheless, to prevent impending obstruction, and to stop his bleeding, I operated and removed the tumor. After rapid recovery, I sent him to an oncologist who began chemotherapy. I didn't see the man again at that point, although I got the occasional office note copied from the oncologist, noting dramatic drop in the CEA levels. Eventually the man dropped out of my consciousness.

Until about eight years later, when he accompanied his wife on her appointment to see me for gallbladder surgery (see, maybe I'm not really interrupting the series after all). He looked like a million bucks. Is it wrong to act surprised to see someone alive? "Wow!" I blurted. "How great to see you! Look at you... [I figured you'd be dead by now.]"

In such a dramatic and nearly singular situation, you have to wonder if it was the drugs or if somehow his tumor had mutated in such a way as to allow his immune system to recognize and destroy it. There's no way to know. But, wanting to present a glimmer of hope in terrible circumstances, I did mention this man to subsequent patients. Until there's evidence to the contrary, I'd say, it makes sense to hope for the best while preparing for the worst. That's what I'd tell Tony Snow.

Addendum 3/28: Orac has a post on the subject, in which he says with the addition of anti-blood-vessel-forming therapy the median survival of liver metastases from colon cancer is 20 months, while five-year survival remains uncommon. I'd take his word over mine; he's active in the field, I'm an old guy. Ironically, I've been asked to move my blog to Scienceblogs, where his is. I'm debating with myself if I'm enough of a science guy to belong in the club. Maybe not.

Rocks in a Bag: what I know about gallbladders

Finally I'm getting around to writing about the gallbladder. Don't know what took me so long, seeing as how, next to hernias it's the thing upon which I operated most (if you don't count breast biopsies). And I liked it. When a person came to see me with a clear-cut gallbladder problem -- which was the case at least 90% of the time -- I could be quite confident that I was going to make him or her happy and, most likely, have a little fun while doing it. But there's the rub: it's not always a Tenantoid "slam dunk," nor is it always fun. A mysterious little bugger is that bag of bile: perhaps more than any other organ it's able to elude or confound diagnosis despite such apparent simplicity. And more than any other category, I sent people home from my office without surgery despite being referred with the idea of separating them from their gallbladders. Rocks get in your head.

First, some basics.

Among the many functions your liver performs for you (in addition to feeling neat) is the manufacture of bile, which is a clarified-butter-yellow liquid of complex composition and which serves to help with the absorption of fatty substances into your bloodstream. (The ancients believed it had something to do with emotions: "melancholia" means, literally, "black bile.") About a quart of bile per day is produced and flows from the liver through a tube called the bile duct, entering the duodenum just below the stomach. Of that quart, a few tablespoons are sidetracked into a pouch that hangs under the liver, and is called the gallbladder. It doesn't make bile; it stores a bit of it, with the intention of squirting a dose into the intestine once in a while, particularly after eating a fatty meal. (The picture to the left, by the way, is not to scale. It makes the gallbladder look much huger than it usually is.) There's some complicated anatomy involved, particularly since the south end of the bile duct passes through the pancreas, where it's joined by a duct therefrom, carrying digestive enzymes made therein. We'll get around to the implications thereof, later.

Here's my theory: the gallbladder evolved before refrigerators, when people might starve for a day or two or three while they hunted their next meal. After a kill, they'd gorge on a big greasy meal, at which point a supplemental blast of bile was useful. (During starvation, the gallbladder can get impressively large and full of bile.) Compared to those days, we eat more or less constantly: two, three, four meals a day, a few snacks. Bile remains a necessary component of digestion, but storage isn't really called for. Our food sort of steadily drips into the intestine, so constantly dripping bile works fine. Which is why the vast majority of people who have their gallbladder removed never miss it at all.

Bile is composed of many chemicals which are supposed to remain dissolved in the liquid medium. In some people, for various reasons (genetic, diet, certain prior operations, certain blood diseases, etc) one or another of the components of bile are in too high a concentration to remain dissolved, and they precipitate out, forming crystals, which tend to grow larger and larger -- like sugar candy on a string. Stones. Trouble.

Well, not always. Some people have gallstones all their lives and never hear from them. It's muscular contraction of the gallbladder that sends the bile into the bile duct. If a stone happens to be near the opening of the gallbladder when it squeezes, it clamps down and cramps up on the stone, gets plugged up, and that hurts or causes other problems. If the stones are out of the way during the squeeze, there may be no symptoms at all. Which means not everyone with gallstones needs surgery, a decision made easier with the use of a crystal ball. I'll see if I can do justice to that, and other concepts, in the next few posts...

[UPDATE: many readers who find this post by a web-search may be unaware it's the first in a series. The others are here, here, here, and here.  Answers to remaining questions might turn up within them. Please check them out.]

Thinking About Elizabeth

Reading about Elizabeth Edwards' breast cancer recurrence brings my own patients to mind. On any given day in my practice, the greatest number of office visits were women (and the occasional man) with breast problems. The majority of those who saw me for cancer appear to have been cured, but many weren't. It took a long time for me not to see them as personal failures, and in some sense I think I still do. For everyone involved, there's enough pain to go around. My patients came to me wanting cure, expecting it. My hope was to be a part of that. Yet no matter how expeditiously, how skillfully I did my job, cure did not always result. That it wasn't my fault (had I delayed diagnosis, done the wrong operation, failed to coordinate surgery with other needed treatments, it would have been) didn't change the fact that I saw myself -- and assumed the patient did, too -- as having let them down.

When such a public figure deals with serious illness, people learn a lot. One important fact that I've heard countless times in the past couple of days is that breast cancer that has spread to bone is still breast cancer, not bone cancer. We name cancers by their organ of origin, and it's important because breast cancer, for example, behaves as breast cancer no matter where it ends up. In other words, the response of a type of cancer to particular treatment depends more on what kind of tumor it is, than on where it's found. Mrs. Edwards' treatment options depend on the type of breast cancer she has (there are several variants, with different general behaviors and responses to drugs: in particular, some respond to hormone manipulations and others don't). Cancers, however, can change: it's a laboratory of "unnatural" selection. Any cancer is made up of millions of cells, not all of which are equally responsive to particular treatment. You may wipe out all those that are, leaving others that aren't. That's one reason why most treatments combine several drugs.

I suppose it's just semantics, but I object slightly to the notion that her cancer has "returned." It never left. And that gets back to my opening statement about guilt. Our ability to cure cancer depends on a fortuitous coming together of happenstance and science. If the woman looking back at me with fear in her eyes has had her cancer discovered before it's spread from her breast, or if the cells that have escaped are few in number and sensitive to the drugs she'll get, she will be cured. If that's not the case, then treatment will most likely prolong life -- often very significantly -- but it won't wipe out the tumor. It will stay there, somewhere.

On NBC news last night, when Brian Williams reported on Elizabeth Edwards, he said (probably not an exact quote) "her cancer is back, and it's malignant." By definition, cancer is malignant. The ability to spread is, more than any other criterion, what distinguishes a malignant tumor from a benign one. "Tumor" means a group of cells -- the patient's own formerly normal cells -- that have undergone a change such that they grow at a faster rate than necessary to replace the natural turnover of their cell type. Skin cells, for example, die off at a certain rate: that's why we flake. New cells are constantly formed to replace them. If a cell changes -- mutates -- randomly, or as a result of sun exposure, or for whatever reason, in such a way as to increase the rate of division, all its "daughter" cells will carry on that change. A tumor is the result. If slow-growing, without the ability to insinuate itself into surrounding tissues -- getting into blood vessels or lymphatics, or locally infiltrating like a weed -- we call it a benign tumor. If it includes those dangerous abilities, it's malignant.

The important thing is this: it's all about timing. No one really knows -- particularly for any given person's tumor -- how much time is needed from the time the first cell or cells change to the point at which they slip beyond local control. But most people agree -- for "solid" tumors anyway (as opposed to tumors of the blood cells) -- that that window exists. You read reports that mammograms don't save lives, that breast self-exam doesn't help. In this, I'm a denier. I can rationalize that there's poor standardization of those studies among various types of mammograms and of the quality of interpretation; I can say self-exam is done better by some than others. Whatever the reason, I've never been convinced by those nay-saying studies. I've had too many patients who came to me because they found a lump, or because their routine mammogram discovered something, and who went on to be cured, for me ever to tell women to abandon regular self-exam and screening Xrays. And I've wondered from the beginning whether Elizabeth Edwards put off seeking attention because she had other things on her mind.

Hard Fact

In my para-previous post, I referred to an injury to my medial digital nerve. Because our bodies are movable, it's necessary to have standard terminology in reference to positions; when your hand is palm up, medial and lateral are the opposite of when it's palm down. Thus, the "Anatomic Position," the reference posture by which, among other things, medial and lateral are determined. This guy is in it.

And here's something amusing. In addition to medial/lateral we refer to "dorsal" and "ventral." In the anatomic position, ventral is the front, and dorsal is the back. We're seeing this guy's ventral surfaces. So what? Well, there are these things called the dorsal veins of the penis. And whaddya know? In the specimen standing there at the top of this post, we're looking at the surface on which those veins run. But it's ventral! So there's only one explanation: in the anatomic position, the penis is erect! Those anatomists! Wonder what goes on in their labs...

[Short post. Long series coming up.]

Comment, Alley-view

Damn. I screwed up. I was wondering why, for the first time, my previous post had garnered zero comments. Was it something I said? And then I noticed: somehow the post was marked "don't allow comments." Too late, I fear, but I fixed it. So, if anyone had anything to say, it's now possible. Doggone it, anyway!

Swan Thing or Another

I played rugby in college; that's me in the picture. We were a damn good team -- East Coast Champions a few times, played in tournaments in the Bahamas over Spring Break (yes, we did play.) The only time I got hurt was when I returned to Amherst during my freshman year in med school. It was a rugby weekend, and the opposing team was short one man, so I played for them, against my former team. Bad karma, I guess: in a desperation tackle, I collared a guy and my grip was stronger than the flexor digitorum profundis tendon on my right ring finger. After the game, when I tried to make a fist, the finger wouldn't flex. Bummer. Especially for a future surgeon. So I had it operated on.

Stupidly, rather than seeking out a hand surgeon (there were a couple there of great renown, including one with a fabulous name: Kingsbury Heiple. During one of our orthopedic exams, one of the students had written on the blackboard "Kingsbury Heiple is not a flavor of ice-cream.") I went to the student health service, who referred me to their default surgeon. And, rather than having the decency to send me on, he did the operation himself. Why not? He'd never fixed one before, and wanted to give it a shot. In my career, taking on an operation about which I couldn't honestly feel I was as skilled as anyone was something I never ever did. Back then, the concept didn't compute, and I never thought to ask the man if he knew what he was doing. He did, I found out later, ask ol' King how to go about it.

My important recollections about the peri-operative time are these: in the recovery room I must have moaned, because a nurse stabbed me in the thigh with some demerol. My thigh hurt much longer than my hand. I had one more shot of demerol the next day. It felt so good I told myself "never again!" I was casted to above the elbow, and had to take a pathology final that way: having trouble operating my microscope I asked if anyone would "come over and twist my knobs." I passed. The tendon was held in place via a wire looped through it, the finger-bone, and my nail. Removing it later hurt like hell. Probably would have been worse, had the surgeon not accidentally cut the medial digital nerve, making half my finger numb.

Which brings me to the climax: the surgeon had been so excited by the operation and the mechanism of injury that he told me he planned to publish an article about it. After the several weeks it took to get my finger mobile again, we ran into each other in the hospital and he had a look. No article ensued.

The finger, in repose.


The scar, following the course of the digital nerve.

A classic swan-neck deformity. Undesirable.

The tip is permanently bent, too. It moves, but not all the way up. Once in a while when grasping an instrument with thumb and ring finger through the holes, I have to try twice to let go of the damn thing. Not a big deal. They say you should find the good in the bad: for a long time the side-numbness of the finger bugged me bigly. I'd find myself constantly rubbing it, for some perverse reason drawn to (if that's what it was) the weirdness. When I touched that part of my finger to something else, it sort of creeped me out. A year or so later it occurred to me that I was no longer noticing. My brain had bought the feeling as normal and no longer brought it to my attention.

Which gave me a perfect demonstration to patients on whom I was planning axillary node dissection (most often for breast cancer): there's a possibility of a numb spot on the upper inner arm. It could bug you for a while, I'd tell them, but eventually you'll stop noticing. And then I'd show them my ridiculous finger, proving I knew of what I spoke.

Knot Really

Of all the strongly-held beliefs imparted to me in training (and the list is long, indeed), using which suture under what circumstance may be at the top of the list. Emphasis on "strongly" as the operative criterion. That various surgeons had widely divergent views on the matter didn't diminish the near religious intensity of those beliefs. Woe be to the trainee who even questioned it: and forget about actually making up your own mind. If you were working with Doctor X, you used his/her preferred suture. At some point, it's likely you'd hear each one's reasons. Everyone had an understandable basis, I suppose. It's just that it turns out most of them were wrong. Some stuff never really made any sense; other things changed as materials improved, so I guess the old guys should get a pass.

Before getting to the meat of the matter (I could make it a pretty long and ultimately boring post if I enumerated all the examples), here's one thing I'd bet each surgeon has had etched deeply into his/her sensibility: how long the "tails" ought to be when cutting suture. As if giving the most precious of gifts, generous beyond the call, the senior surgeon would allow a new intern to cut the suture he'd just tied. In tern, the young fellow/fellowette would tremulously apply the scissor beyond the knot and snip, knowing with near-certainty that the move would be followed by the loudly-declared "That's too long!" or "That's too short!!" In fairness, too short could lead to a knot untying itself (at least if poorly tied and/or finished off with too few throws [another imprint: how many throws is just right?]). The result, over time, is a stone-carved sense of proper appearance of those two little ends, variation from which can cause a physical sense of unease. It took me many years to realize: the suture may have been placed, for example, around a munch of muscle in closing an incision such that its entire length is well over an inch, maybe two. What possible difference can it make if the ends are a couple of millimeters "too long?" And now, I can tell you, tying and cutting knots laparoscopically -- which gives a very close and magnified view -- can distort one's sense of proportion beyond repair. But enough of minutiae.

The only time I've used wire suture on my own patients was on the trauma service at the county hospital. There, our chief of service insisted on it: wire suture was strong as hell and, more importantly for traumatic and therefore typically contaminated wounds, it was highly unlikely to become a nidus for infection. Despite the fact that tying it many times a day literally rubbed the ulnar aspect of our palms raw and often bloody, and that the knots tended to be uncomfortable (even though we carefully bent them downward) under the skin of the patients and frequently required later removal, it's what we used. Period. Embedded in my brain, the need to close such incisions with wire extended briefly into my early practice days until I was convinced (didn't take much) that the new strong-as-steel but soft and comfortable dissolving materials worked just fine. To his credit, the chief (one of my heroes!) later published a paper confirming the efficacy and he abandoned wire.

At our weekly conference wherein the chief residents on all the various surgical services presented their data, including all complications, one of my friends was profoundly excoriated for brazenly flaunting the party line and closing a long midline abdominal incision with a single running suture in the muscle layer. With no exceptions -- no matter the size and material of the sutures -- no one, NO ONE, closed that layer in any way but with single interrupted stitches, placed and tied one at a time, laboriously, plentifully. Having read some papers on continuous closure, Jerry thought it made sense and gave it a go. Sadly, being at the VA hospital, he unwittingly used nylon material that had been sitting around in storage, left there by George Washington not long after he'd crossed the Delaware River. Brittle and aged, it broke, resulting in a rather dramatic (but ultimately devoid of long-term consequences) reappearance of the man's innards, not in the operating room but in his bed. Yuck. The professors, on hearing the report, went ballistic: the stupidest thing they'd ever heard of. Reckless, idiotic, no understanding of wound healing. Righteous yada yada, indignant. Poor Jerry. Now an internationally respected and universally admired and loved academic surgeon, that was a bad day for him. Suffice it to say, very shortly after finishing training I came to close nearly all of my major incisions with a running suture and never -- not once -- had a reason to regret it. Not only does it save significant time, studies have shown healing is facilitated and pain is less. Who knew?

Wounds heal between sutures. In other words, the tissue actually grasped by the stitch, being squeezed, often doesn't get adequate circulation. More so, the tighter the stitch, the smaller the bite, the more closely placed to the neighboring one. Individually placed and tied sutures, in other words, potentially provide innumerable micro-zones of ischemia. With a running suture, there's essentially no crimped zone. You can, of course, screw anything up. The important thing, in my opinion, is to take larger bites than most people take, and to cinch up the suture gently, getting the edges just together. Otherwise, if I were letting an intern do it, I'd holler "too loose," or "too tight!!"

(Only the very hip will get the photo-pun. And I'm nothing, if not hip.)

Focus

Referring to the idea that, like athletes, surgeons are engaged in demanding physical work, I wrote recently about having an "off-day." Another side of the same coin is having a tough day: as distinguished from not being on one's game, here I mean to describe what it's like to face an exceedingly difficult and danger-filled situation. Notwithstanding having one's faculties and wits gathered and finely honed, as in command of yourself as you can possibly be, it may test and demand everything you can bring to bear. All the antiperspirant in the world wouldn't suffice. I've been in war, when I feared daily for my life. It's not pleasant, but in some way you can get used to it. In my situation, at least, the odds were with me, so it wasn't too hard to ignore. Fearing for the life of someone in my charge, having to forge ahead knowing the next move could literally be fatal, while knowing I have no personal risk at all -- that's unique at least insofar as I can figure at the moment. Harder than being a soldier, a cop, a firefighter? Surely not. But distinctly different, I'd say. You're in the position of making that fatal move, as opposed to responding to one made at you. I've been in situations where I've failed to save a severely injured person. It feels terrible. I've not made a move that killed someone. But I could have.

On one occasion during my internship, I was holding retractors while a professor was trying to extirpate a large pelvic tumor. I don't remember the details -- probably the ensuing river of red washed them out of my brain. What I clearly recall, as if I were carrying the picture in my wallet, is the shock at how fast the field filled with blood. That's the way it is when the iliac vein is breached: it's big, it's flimsy, it doesn't hold a stitch very well. And it's connected immediately to the vena cava, the biggest and bluest of them all. Whenever you approach it -- as is the case with any big blood vessel -- you want to have wide access to it. You need "proximal and distal control," meaning the parts of the vein north and south of where you plan to work need to be readily available, cleared, and ready for clamping. Dissected out, maybe slung with rubber loops. With a big tumor blocking view, ain't no way. So the surgeon worked his way around the mass while, I'd have to assume, aware and worried about what lay beyond. Whether he lost his way, didn't anticipate the anatomic distortion, or just came up snake-eyes, I can't say. But when he lacerated the vein during dissection blood poured out like a prison break, and the tumor blocked any possibility of controlling the flow upstream. Blindly placing sutures, frantically replacing blood -- whatever was done, it didn't work. The patient bled to death in the operating room, one of the rare times I've seen it happen. Watching such a thing leaves one deeply affected.

I've been there. Working deeper into the pelvis when the view is distorted by a huge tumor, stuck to the sidewalls, the bladder. Forced to do something about a nearly undecipherable mass of indeterminate origin, causing obstruction in multiple parts of bowel stuck to it. Wanting a bailout way of avoiding opening the door to disaster, but finding none. "OK," I'll say. "We could get into big trouble here. Let's take a minute to get everything ready." I suggest to the anesthesiologist that he/she start another couple of IVs. Send blood to the blood bank and get them working on crossmatch. Be sure they've got a bunch of O-negative blood available (In a pinch, you can give it to anyone). Get the cell-saver in here. Open up some vascular clamps. Wait till it's all there. And, because when I want to focus everything I have, I like to open an emergency pack of silence, I tell everyone in the room to stop loose talk, and to shut off the music. (Subject for a future post? Music on the OR. I like it, usually. Except in deep and deepening shit.)

There are other disaster scenarios, but the iliac vein/pelvis thing is especially evocative for me, having seen what I saw those many years ago. I'm sure it's not unique to surgeons, or to physicians. In some things, our approach is shaped by the memory of a single impactful event. I'll say this: it has a way of marshaling all of one's faculties. As frightening as it is, in some measure it's also thrilling to experience oneself become so focused, literally to blot out everything else in the world, and like a living lens to direct all input to a single centimeter of space, to have time become meaningless and imperceptible. Perhaps paradoxically, despite sensing breathing speed up, aware of rising pulse rate and of drips of sweat sluicing down my sides -- even needing to pause for the ultimate cliche, the wiping of one's brow by a nurse (I've dripped sweat into the occasional wound -- and flushed it away with lots of saline) -- my hands don't shake. But yes, dissecting my way into the area as carefully and clear-headedly and patiently as I know how, at some level I'm scared as hell. And although while in the maelstrom there's confidence you can carry on as long as necessary (like sound and extraneous thought, physical discomfort shrinks into insensibility) when the tense part is over, physical exhaustion can well up with surprising suddenness and depth. Neck stiff, bent back and hyper-extended knees sorry and sore.

I guess there's a sense of accomplishment, but it's more like having dodged a bullet, of having lucked out. Knowing it easily could have gone in another direction, feeling like you never want to do that again, it's hard to feel pride. Only relief. As much as I believe that the way to handle complications is to avoid them in the first place, and as hard as I work to follow that path, the feeling -- even when pretty sure there was no option -- is one of second-guessing whether I missed an alternative to skating on such thin ice. I couldn't do it every day.

Walk and Water

Ambulation and hydration; the most important parts of post-operative care. Time was, people were kept flat in bed for a couple of weeks after major abdominal surgery. I've always assumed it was because in the days of crummy suture material, there was fear of people tripping over their guts if they got up. I can see where that'd be counterproductive. Send the wrong signal, as they say.

In any case, pneumonia and blood clots -- the handmaidens of bed rest -- were just part of the deal for those subjected to it, and they claimed a lot of lives in the surgical patients of yore. I'm old enough that in my training there was at least one surgeon old enough to require his patients to stay supine for days on end (he's the one, in my book, over whom I fantasized about a beating in the parking lot. He was so frail I think I could have taken him.) Anyhow, I obsessed over getting people up and watering them down. On the one hand, I thoroughly believe it played a major role in the fact that my major surgical patients tended to recover smoothly; on the other, I think I drove the nurses crazy.

"Ambulate q.i.d. (walk four times a day) starting this evening" was part of my routine post-op orders. Realizing nurses had more to do than escort my patients, I figured if I said four times, they'd be gotten up at least twice. And I'd check the IV rates and the recorded input each shift, having generally written for a comparatively high-volume amount. For a patient already in the hospital, and scheduled for surgery, I'd write an order for ambulation twice around the halls before going down to the OR. When patients were significantly behind on their IVs (no one but surgeons understands the enormous fluid requirements of the early post-op patient: inadequate replacement predisposes, among other things, to clots), or if they weren't being walked around, I let people know. These are by far the two most important things in a patient's recovery, I told them. Most of the nurses -- especially the ones that had been around a while -- bought into it.

One thing that facilitated early ambulation was that I used a ton of long-acting local anesthetic in all my incisions, no matter the size or location. For that reason, my patients were pretty close to pain-free for eight to twelve hours after they woke up. That's when I wanted them first up and out of bed. The added benefit -- beyond that for their lungs and legs -- is that it got them off to a good psychological start (no data here: just a really strong impression that starting recovery off painlessly sends a very positive message): hey, whaddya know, I'm walking four hours after giving up half my colon! Parenthetically, I think it's much easier to maintain comfort starting from the painless state, than to achieve it starting from misery. When I started doing the wound-injecting for general anesthetics, no one else I knew of was doing it; in fact, some scoffed when I recommended it. Until the recovery room nurses kept asking them "how come Dr Schwab's patients are always so happy post-op, and yours aren't?" Whereas it's probably not universal, I think most surgeons numb their wounds before finishing up, nowadays. (I also toyed with, but didn't pursue, leaving a catheter in wounds for continuous infusion with local. There are now systems for doing just that.)

Today, most major-surgery patients are getting low-dose blood thinners right before the operation, and many are fitted with pneumatic pumps on their legs during and often after surgery to prevent blood clots. It's a step forward. But the incidence of blood clots had already gotten way low by the simple measures of getting up and watering down. Pneumonia right along with it. Life is really simple sometimes.

(The dog is Dutch, our grand-dog, a sweet and beautiful Chocolate Lab. He considers everything that moves a potential friend, and everything that doesn't a potential meal.)

Fielder's Choice

I watched a bit of the Pac - 10 tournament final the other day. A player for the Duckies was so "in the zone" it seemed anything he threw up went in. It was simply magical; I'd guess even some USC fans were mesmerized by what they were watching. You've seen something like it, I'm sure. A no-hitter where the pitcher has such control that he can do anything he wants with the ball; a running back who seems to move through the opposition as if they were paper posters; the gymnast who scores 10 after 10. A diver; a swimmer.

It's another of those things that probably can't be studied, but it seems pretty clear: on some days for some people in some situations, there's a coming together of mind and body in such a way that leads to a level of control far beyond the ordinary -- even when "ordinary" for these extraordinary athletes is beyond anything the rest of us could even dream of. And, likely as not, another day not soon thereafter, those same people can't hit a shot, get the ball over the plate, stick a landing to save their lives.

Of course, they're not actually saving lives. In the operating room, you need to pitch a no-hitter, sink all your threes, stick your landings every time. But is it a reasonable expectation, given that -- not unlike sport -- it's an intensely physical undertaking, translating very specific intention into very particular material result? If everyone else loses it once in a while, why not a surgeon?

In sports -- even professional sports -- the default presumption is "very good." "Perfect" is the exception. No problem if you don't go four-for-four. Give up a home run? Hey, at least no one was on base. And, of course, that's as it should be. I happily admit hitting "nuthin' but net" time and again is harder than placing a row of stitches. It is, however, interesting that whereas having an off-day is entirely expected with an athlete, it's never even mentioned as an issue for surgeons.

I don't know how analogous it is; I certainly don't argue that standards for surgeons ought to be as malleable as they are for sportspeople. Yet, being humans in the midst of an intense physical undertaking (probably shouldn't invoke "undertaking" and "surgery" in the same breath), it seems logical to assume that surgeons, on any given day, might have less perfect command of their skills than on another day. Doesn't everyone?

Even intellectual skills, or artistic, would seem to wax and wane. The writer who can't get a word on a page one day, who can't type fast enough on another; the painter who paints over her work and can't stand to look at it now, but who later gets mind onto canvas as if no hand were involved; don't these things happen all the time, perfectly expected? Well, guess what? I've had off-days and I'd bet every surgeon would admit -- at least inwardly -- that he or she has, too. Shouldn't it go without saying? And if so, shouldn't it scare the crap out of you? Well, maybe not. The scary part, anyway. Because "off" doesn't mean "offed."

I think it's a chicken/egg sort of thing. If a guy hits his first three, he gets pumped. If it clanks off the rim, well, not so much. There's a feedback loop. Likewise, you expect certain things to happen in surgery. Annoyances. A little bleeder here, an adhesion there. You navigate the waters. But sometimes it's one thing, then another. And another. Can't get the rhythm going; always one more little distraction making the flow elusive. So you get agitated, adrenalized. Then the hand is a tiny bit tremulous. You notice, and assume the nurse notices. You accidentally pull a stitch out. Take two or three attempts to grab something properly with a forceps. More adrenaline, more stress. Jesus! This patient is really a bleeder. One of those days. What's going on here? And so it goes. Nothing is smooth. Getting to point B from A is a series of zigs and zags.

So is that my fault? Is it just the random confluence of things in one place, like flipping up heads ten times in a row, or am I contributing to the chaos? Whatever it is, it adds up. It can get to you. On some occasions, I've literally had to step back from the table, take a deep breath, and make myself relax. Ask the circulator (the person in the room not scrubbed into the operation) to get some O.J. and stick a straw under my mask. The equivalent, I suppose, of the coach calling a time out, taking a stroll out to the mound.

The difference is you can't yank yourself out of the game. You've got to find a way. No one in the bullpen. So you do; you just do. You can't lose it, so you don't. Which is why, I think, it shouldn't be too scary to read this. It's part of being a surgeon; it's what we've learned to do.

Maybe laying down a bunch of sutures isn't as hard as laying down a bunt; but doing it no matter what -- knowing no one will take the ball from you, pat you on the butt, and call in the reliever -- that's harder, I think. No excuses; no post-game interview where you say "Just didn't have it today, couldn't suture worth a damn. Just gotta shake it off and learn from it, put it behind me. Tomorrow's another day, it's early. 'Nother patient tomorrow. Put on the ol' scubs one leg at a time. One operation doesn't make a career. I trust my stuff. I'm not worried. Trade rumors? Don't pay no attention."

Twist and Shout

The more senior of my two partners when I first went into practice was old school in the very best sense of the words. The most general of general surgeons, he still did the occasional orthopedic procedure, yanked out uteri (indeed, that operation is more of a "yank," in terms of non-anatomic dissection, than most), didn't mind drilling a burr-hole or two if called upon to do it. I'm sure he'd have been happy to deliver a baby on the proverbial kitchen table; in fact, I think he did, back a ways. Many of his patients were people for whom he provided complete care as their family doctor. Blood pressure, diabetes, pneumonia -- he managed them all. And well, far as I could see. Gentle and soft-spoken, self-deprecating, Hume was welcoming to me from the start, and set an admirable example. When he assisted me, or I him, I always learned something. And, I'm happy to say, I showed him a few things as well. If it was mutual admiration, it was lop-sided in the way of a cub and a poppa bear.

He practiced mostly in the time when doctors were nothing but highly respected, and, at least in his case, it was entirely deserved. In his forty or so years of practice, he was never sued. Here's how it was in his heyday, as he told me once: a long-time patient, on whom he'd done a colon resection several years earlier, came to see him with abdominal pain. As was standard in the days before ultrasound, Hume ordered a gallbladder Xray, which made the expected diagnosis of gallstones. "George," he told the man, "looks like you'll need your gallbladder out. And while we're in there, I'm going to remove a clamp that I seem to have left in you last time." "Sure thing, doc. Whatever you say." (Snide-comment-avoiding explication: far as I recall, it was the stones that were the problem.)

One of my favorite tricks of patient care, for which I loved to write the order because I knew it boggled some nurses and about which I was never certain it worked but wrote it anyway because it made intuitive sense even if it seemed silly so it was fun to talk my patients into it and to imagine them doing it, having had a few people get better after doing it whether they would have or not had they not done it, and which in part I ordered because it always reminded me of Hume and made me feel like a canny old-timer who had a couple of decidedly low-tech tricks up his sleeve even when I was young but kept ordering when I was old, frequently enough that the nurses referred to it as the "Schwab shake" because it was in a different town and none of them knew Hume, was a thing he taught me. (Chew on that sentence, Strunk and White!) To see any sense in it at all, you have to be able to imagine the intestine in the midst of a small bowel obstruction.

In the virgin abdomen (but not always in the abdomen of a virgin), the small intestine is free to slip and slither pretty much anywhere it wants. (In some operations, it's useful to "eviscerate" the patient by pulling the intestine as far as it will go outside of the abdominal cavity. Re-inserting them, those guts roll back in like a gang of slurpy slinkys over a soft stair, like the buttered spaghetti Momma dolloped onto your plate.) In an area of inflammation from an operation, or injury, or infections of one or another sort, a bit of intestine might become adherent to the abdominal wall or to other structures.Those areas are what we call "adhesions." If other areas remain normally slippery, it's not hard to imagine a loop or two of bowel sliding around a more fixed one, and causing a twist. And there you have it: small bowel obstruction. Typically, that means a distended abdomen as the upstream intestine fills with digestive juices, cramps as the muscular action of the gut ("peristalsis") tries to push stuff past the blockage, cessation of bowel movement or gas passage, and, most often, vomiting. In some instances, the blockage isn't complete, and there might be some amounts of stool. Diarrhea, even.

Surgery is usually the treatment for complete obstruction, and typically needs to be done within several hours, lest the twisted area die from lack of circulation (maybe I'll get into some of the subtleties in the future.) Non-surgical treatment consists of "suck and drip." Namely, a tube into the stomach to suction away the juices that are backing up, and IV fluids to replace the losses. If the patient is able, walking around is thought to be helpful, if for no other reason than to prevent secondary problems related to bed rest. But there the patient is, lying nearly continuously on her/his back, with a belly full of fat swollen intestines. If what you're hoping for is a serendipitous untwisting, lying like that with a bunch of sausage stacked on itself seems less than propitious. Thus, Hume's trick: get the patient out of bed, have him/her lean forward onto the bed, back as parallel to the ground as possible, and shake their hind end like kyphotic hula dancer. (I always demonstrated for my patients, which was generally found to be amusing.) Get them guts off of each other and move 'em around. I like it. (If the idea is sound, I thought, somersaults would be ideal. In fact, one of my friends -- a pediatrician, for whatever it's worth -- had a problem with recurring obstructions after splenectomy many years earlier. I suggested somersaults, which he starting doing at home at the first hint of symptoms, and he claims it helped. Eventually, however, I operated and fixed him for good.)

I never did a study; hard to imagine one ever being done. Several -- not all -- patients recovered without an operation after shaking it up. It's known, of course, that some obstructions resolve without surgery, so I can't claim to know whether the maneuver works or not. But all of my patients who could, did it. Whereas the long-term nurses on the surgical floor got used to the idea, I assume there were some -- especially those on the medical floors where such patients occasionally found themselves -- who thought I was nuts. Until their patients started pooping. And there's this: I was once consulted on a patient with a bowel obstruction in whom, on bedside abdominal exam, I could easily feel a particularly fat loop of bowel. What the heck, I thought: I manipulated it upward (it was remarkably easy to do) and around in some way, immediately after which the patient excused herself rapidly from my ministrations and headed to the bathroom where she produced ample evidence that the obstruction was no longer. I think Hume would have liked it.

Pigs in Shit

Reading the comments on another blog recently (the blog of the world's most dastardly lurker) I was reminded of a thing that always drove me crazy. No matter where I was, in the locker room of every OR and surgical center in which I've worked, there were guys who left their scrub clothes and towels on the floor. And their caps and shoe covers, often within an arm's reach of the receptacles into which they could easily be placed. Moreover, whereas I never risked the perversion-alert of hanging around long enough to check, I'd be willing to bet my (admittedly depreciated) left nut it was exclusively the surgeons -- as opposed to the various techs and nurses -- who behaved that way. It annoyed the hell out of me. Embarrassed me. I actually went around picking all the stuff up and putting it in the hampers, because I hated to imagine the housekeepers having to do it, surely thinking what a bunch of spoiled assholes those doctors were -- and including me in their scorn. I always wondered if they left their clothes on the floor at home as well. Based on the doctors' wives I knew, I doubted it, although a few were on their second or third. So who knows? [Disclosure: I collect a pile of socks near my bed. But when it's big enough, I wash them myself.]

One time I left a note on the bulletin board in the main locker room: Unless your mother or wife is expected soon, pick up your own goddamn scrubs. Until the sign disappeared, things looked a little better.

Burnout: Quenching the Fire?

In two ways, I'm feeling a little guilty. First, I doubt I've provided any new insights in this burnout mini-series. And second, since I began by saying I'd heard from a few people that I've gotten them interested in a career in surgery, I don't want to have turned them off or discouraged them. So let's see what I can do about that.

In my core, I always loved doing surgery, and being surgeon to my patients. As I hope I've made clear in this blog, I was always amazed that I was allowed to do it, and awed at the mysterious beauty of it all. As much of a responsibility as it is, it's also an inexplicably wondrous honor and privilege. Those words aren't lightly written. But in a diabolical combination of being constitutionally unable to cut back, being hyper-demanding of perfection in myself and only slightly less so in those who touched my patients, mixed with a certain degree of paranoia which made me see any imperfection as an accusation, I got to a point where some sort of line was crossed. Every ring of the phone at home became a gut-shot; the emergency room was like a stalker, a heavy-breathing relentless destroyer of plans, a stealer of sleep, a wielder of a fearsome disrupter ray. Klingons, the lot of 'em.

The cold shower of new rules, the deluge of self-fertilizing forms, the insults and veiled threats of the latest memo from some bureaucrat or other, the inverted logic of convincing some insurance cubicle-denizen that I had a legitimate reason for recommending an operation she understood not at all -- I think I might have withstood all that were I better rested, had I not arranged my day for maximum continuous pressure nor added work upon work. So here's the bouquet-toss to future surgeons: don't do it like I did.* Give yourself a goddamn break. Good news: the system doesn't care if you work your ass off or not. So don't. Turns out, the world didn't stop turning, people didn't start dying left and right when I sheathed my scalpel.

That's, I suppose, the corollary of my obsession: the silly sense that I was indispensable, that only I could render proper care to my patients. Don't get me wrong: I think my judgment, my technique, and my rapport with my patients were above average (OK, OK: way above average!) But so would they have been, had I relaxed a little. I have no doubt that rounding, as I did, three, four times a day made a difference in length of stay. But it seems I was the only one who noticed. I kept office hours four (sometimes five) days a week, wanting to be there if my patients needed to be seen, hating to have someone else see them. That meant I always had pressure to get my operations done by a certain time. I could have arranged it differently. Making things worse, as much as I hated to be late I also hated to make others late. I almost never ran beyond my scheduled OR time. I almost always saw patients in the office EXACTLY at the time of their appointment. I helped move patients on and off their gurneys (I'd recommend that!), cleaned up my exam rooms, whatever it took to keep things going on time. Close to crazy. I never could say no to a request to work in a woman frightened about her mammogram, instead of making her wait a few days. Couple of days? Probably would have still been ok. As I said in the first two posts in this series, US healthcare as currently constituted is -- almost as effectively as if it were deliberate -- selecting against hard work and high quality, at least to the extent that it fails to recognize, encourage, or reward it. Consider it good news: don't kill yourself! I'm serious.

Want to have a better life? Don't schedule yourself into your office half an hour after your last case is expected to end. Cut yourself some slack, in all things. Rounding twice is enough. Letting your partners see your patients on weekends off is ok; I saw theirs, ferchrissakes! Take all the time off you're allowed. Avoid serving on any committee you can wangle your way out of. Get thrown off, if that's your only option. But be civil to the ER doc who calls at three a.m; and to the nurse who overlooks something, explain in non-angry terms how and why you think it could have been different. A "teaching moment," I believe, is what they call it. Chill. Had I done so more often, I might not be blogging.

And here's the happiest secret: there's always one place they can't get to you -- the operating room. (They can call you, of course; but they can't paper you, committee you, disallow you. Not while you're there.) If you love it, that will never change; so if you love it, go for it. The act of doing surgery, distilled to its essence, the condition of being surgeon to a fellow human being -- that will always be honorable and essentially untouchable, immutable. And wonderful. It's even conceivable that if "they" come up with meaningful ways to evaluate the quality of medical care, some sort of global, transferable, reproducible, over-arching and useful method that's neutral and rational (pretty unlikely but not unimaginable), then the piles of paperwork, reams of rules, confabulations of committees might actually become superfluous, and a doctor will once again be allowed to be a doctor. A physician. I like that word. It's almost as good as surgeon.

*Unless your patient is me.

Burnout: Fanning the Flames

In trying to understand my own burnout, "control" (or lack thereof) is a dominant theme. This is nothing new. In fact, I doubt I'm unearthing bones not already thoroughly analyzed. But I can give instructive personal examples.

For a while I was on the board of directors of my clinic, which was then and is even more so now one of the most successful doctor-owned and -managed in the US. During my tenure, we were deeply in the thrall of the managed care model as the guarantor of our future. My feelings about it were, diplomatically, mixed. If I may be allowed to say it for the ten thousandth time, providing cost-effective care has always been as much a part of me as the Krebs Cycle. I've never needed anyone to remind me of it. Nor -- take my word for it -- have I ever been a trigger-happy surgeon: many is the patient sent to me for an operation, returned to his/her referring doc with a note pinned to the shirt saying "Please excuse Johhny from surgery today. He doesn't need it." So the idea of being required to seek approval from a peach-fuzzed (or even a grey-muzzled) primary care doc (need I repeat myself?) sat, diplomatically, unsteadily in my saddle. (In fairness, some of the internists who knew me over several years filled out all the authorizations the minute they sent the patient to me. Not, however, the family docs. But I've been over that. In one sense of "over" anyway.) Frosting a burnt cake, we even agreed to pay primary care docs a "gatekeeper" fee. Perfect.

I never objected to scrutiny; in fact, I welcomed any legitimate comparisons of my work to that of others. But it was always my contention that being in a clinic was the ideal situation in which paperwork could be minimized. After all, we had a medical director whose job included oversight; we knew each other well; we worked in a closed shop. Hell, we'd even cashiered a couple of losers. Ought there not be a presumption of quality? So when one of my fellow board members -- a young family doc whom I actually admired for his practicality -- announced at one of our meetings that he'd come up with his own form (in addition to the required ones!) he was going to send to specialists along with his patients, and showed it to us (couple of pages, lots of blanks to fill in) I hit the roof. Sailed right through it. Covered the man, the board room, and myself with plaster. Lots of it. Then, still rising, I resigned from the board. The form was never distributed, but it took enough days for my pulse to return to its usual 1.5X that I figured who needs the extra aggravation.

Every few weeks the medical staff at the hospital came up with a new committee, for which it obtained members by also coming up with regulations requiring and penalties for failing to sign on. Among the three or four on which I sat was the "Blood Utilization Committee." People from the blood bank (really good people, I might add) presented quarterly data on the use of blood and blood products and we looked into any deviations from accepted indications. Without fail, the data showed near perfect compliance, with the only outliers being nephrologists buffing up their dialysis patients -- outside of "standard" indications, but within "special" protocols. If ever there were proof that doctors knew what they were doing in an area, this was it. Yet, after a couple of years on the committee we were presented, for our approval, with a blood products ordering form. What's the patient's blood count, list this lab or that, provide seven indications for the use of the product you are ordering and click your heels three times. And yeah, another roof repair job was needed. I'm happy to say the form didn't appear in charts until a year or two after I was off the committee. But appear it did.

Small potatoes, I suppose. But multiply those incidents by a number that increased every year, and pretty soon there's salmonella in the salad. It'd be easy to quantify the amount of paperwork, if I had the desire and the money to hire a hundred people to work on it. What's hard is to measure the additive effect on the psyche; especially a steadily smoldering one. If it were one or two things, I might not have ex/imploded. Had I been getting more sleep, spending more time away from the hospital, maybe some of it would have rolled off. But at every turn, literally almost weekly by the latter years of my career, I'd find myself staring numbly at another missive announcing another rule, another form, another penalty, from the clinic board, the hospital administration, from medicare, blue cross et al, the malpractice insurer. Not so numbly; more accurately, with cold and trembling hands. Seriously. If adrenaline were water, I think my adrenals could have pumped out New Orleans.

I'm a lot of bad things, but stupid isn't one of them. And I'm enough of a realist to recognize it ain't Camelot and doctors -- myself included -- aren't perfect. (Some much less so than others.) So yes I accept that scrutiny is necessary, regulations are unavoidable. "The best of all possible worlds" is as illusory an idea as is that of a functioning Congress. But somewhere along the line -- and it happened in my practice lifetime -- the assumption changed from "doctors generally know what they're doing" to "doctors are incompetent, uncaring, unethical, and untrustworthy." Officially, anyway. Paperwork-wise. I may be more paranoid than most: I guess I took every form as a personal accusation, and it grated more deeply in me than in some of my peers. But I know it affects everyone.

I don't think it's just ego, or some inflated sense of myself. To a degree it's the opposite: I beat myself bloody over the slightest deviation from what I considered perfection, and generally knocked myself out to make amends and to prevent the next blemish. Yet I foolishly imagined that I had more control over my world than was true: why, I thought, can't problems just get ironed out? Do we really need all these committees breathing down out necks, these forms, these threats? Can't we just talk when someone thinks there's a problem? (Answer: of course not!)

Here's another example of how it works: a lot of surgeons use fluoroscopy during surgery. We don't operate the machines, but we are quite capable of interpreting what we're seeing, because, among other things, we know exactly what we're looking for when we're doing it. [Disclosure: there may be some politics at work here. Before useful intra-operative fluoro, the patient would be on a special table under which an Xray plate was slud, a hard film taken, and the radiologist would read it -- with or without the film getting returned to the OR for viewing by the surgeon. I always insisted on getting the film brought back before the radiologist saw it and generally we were sewing up by the time I got the call. With fluoro, I rarely had a hard copy made, so the radiologist never saw a film and, therefore, never got to bill for (irrelevant) reading. So the advent of surgeons reading their own fluoros was not well-received in all quarters.] Nonetheless, once upon a time I and many other surgeons were using it with no problems. Then one day a new cardiologist came to town, and used fluoro in the Xray department for some procedure or another, and someone turned him in for exposing the patient to too much radiation. OK, fair enough. But what was the response? Talk to him? Maybe even send around a little memo with information about proper use? Hell no. With no input from any non-radiologist doc who used fluoroscopy, the medical staff officers got together and made some rules. Mind you, the incident occurred not in the OR, but in the radiology suite; but suddenly everyone who used fluoro was required to take a course, get certified, fill out paperwork for each case, or have a radiologist present. For one friggin' incident, by a non-surgeon, after a gazillion proper uses!!! Here, in exact real-time replication, is how much time my Xrays took (for any radiologists out there, the image was saved until I sauntered over for a closer look): "OK, ready? Shoot. Thank you."

Burnout: Embers

The medical director of my clinic once gave me a book on burnout. I never read it. Didn't have the time or energy.

Because a young reader considering a career in surgery referred to stories he's heard of depressed and disappointed surgeons and asked for my thoughts, I'll try to address it. Parenthetically, I've heard from more than a few readers that my blog and/or book has inspired them to consider surgery as a career. Don't know whether to smile proudly, or shoot myself.

I quit my practice much younger than I'd have predicted when I went into it. In thinking about the reasons, not all of which can I distill, I can't make the claim that one ought to generalize: I speak only for myself. In some things, the themes are universal; in others, maybe more particular to me than my colleagues. As with many others, it's true that my love for my work diminished over the course of my career: yet at its core, the rewards and pleasures remained. It's just that it was harder and harder to access them, as the layers of bullshit of all sorts increasingly hid it all from view. Maybe it's like this: early in my career a day of work had ten pounds of pleasure in it. By the end, it was still ten pounds (heck, maybe even twelve), but I had to wade through fifty pounds of crap to find it. Thirty years ago, it was only five.

Surgeons my age are transitional characters. When we first dipped our toes in the pool we were touched by ripples of the good old days: regulations were minimal, the default presumption was that we knew what we were doing, most of our time was taken up with actual patient care. The occasional meeting. Serving on a committee once in a while. And we could charge what we thought was a fair price for what we did. Let's get that last concept out of the way first. (Reality check: not everything about the good old days was good, especially for the consumer. I admit it enthusiastically. It's not necessarily better now; just different.)

I've yet to meet a medical doctor of any sort who went into the profession first and foremost for the money. (For some, that came later.) Nor would I claim that doctors deserve to be the highest paid of professionals. In fact, at the time I took up the scalpel, I thought many docs -- surgeons especially (general surgeons less so!) -- made way too much money. The public health would be much more adversely affected were garbage collectors to cease to exist than if doctors did. Yet there's a truism: most people willing to work very hard, who have an ethic of excellence, who take great and justifiable pride in what they do, expect some sort of reward commensurate with and in some way proportionate to the quality of their product. And money, for better or worse, is one of the vehicles for providing that reward. Not the only one; not, maybe, the most important one. But a very tangible one. Measurable. Whereas I recognize that speaking about it at the outset risks losing any sympathy (in fact, I'm not asking for sympathy: I'm just trying to explain, and to answer an honest question), I think it's central, symbolically, to understanding the unhappiness that I and many of my cohorts came to feel.

My brother is an attorney. A very successful one; a senior partner in one of the US's bigger international firms. I gather he's really good at what he does: the accolades he's received within his profession attest to it, as do (to the extent that I can understand them) the extremely complex cases he's guided to favorable outcomes. He charges by the hour, a hefty sum which has risen steadily over the course of his career. More, I gather, than many of his peers. And, I'd wager, his clients are happy to pay it: for their top dollar, they get a top echelon lawyer who can be counted on to work his ass off and most likely prevail in their cause. To them, he's worth it. (Makes four times more than I ever did, and is probably four times better at what he does than I was at what I did -- I'm thinking there may be greater divergence among good attorneys than among good doctors.) As in virtually every other profession, you get what you pay for. Not so, any more, with medicine.

Two things have happened to physician reimbursement, and both have had a perverse and adverse effect on professional morale. First, payments have steadily declined, to about a third of where they were when I started out. Second, fees have become standardized, meaning Doctor A gets exactly the same amount to take out a colon as Doctor B, no matter how much better at it one is than the other. By law and/or contract, doctors have no ability to establish their own charges or to collect the difference. In the first instance, the effect is that doctors have to work harder and harder every year just to stay even financially; in the second, it means there's no incentive -- financially anyway -- toward excellence. If money is a surrogate for acknowledgment of a job well done, the current system says "we don't give the slightest shit about whether you are doing your job better than the next guy or girl." Take it, and shut the f@*k up. Or so it seems. You may or may not believe this: doctors are, for the most part, altruists. The real rewards come from doing right by the patient. I love the relationship I have, as a surgeon -- especially and particularly as a surgeon -- with my patients. I love (except when all hell breaks loose) being in the operating room. (Heck, sometimes even then: as long as I can bail myself and my patient out, able to tell myself I did good, and seeing the instant proof.) But (or is it "so?") it's enormously deflating every year to get the latest announcement from Medicare, or Blue Cross, or for-profit Joe the insurer and its multimillionly paid exec, of the latest cut in what they'll pay me. Similarly, the notion that they'll be paying the same amount to some guy who I KNOW is not getting the results I am (or saving them the amount of money I am, by virtue of a passion for cost-effective care and willingness to work extra hard to achieve it.) Like I said, it's perverse. And my claim is that it's having an effect on who chooses to go to medical school, and who chooses to go into the most demanding specialties. My friends in academic medicine seem to agree. It's elsewhere that hard work and excellence are valued more.

Every year I was in practice I made more than in the previous year, despite the fact that in virtually every year, reimbursement declined. The reason is obvious: I simply kept working harder and harder. Partly it's because that's who I am: I never took as much time off as I was allowed, I always took call on my own patients, rounded whether I was on or off. So here's an instance in which my behavior contributed particularly to my burnout. But the milieu was the same for everyone. And it compounds itself: as you work harder and harder to stay even, you'd like to hire some help. But anticipating further cuts, you feel you really can't afford to. As I got older I came to think I'd be happy to trade time for money; but my younger partners -- with young kids and longer futures -- didn't want to take the financial hit. And whereas they were taking the same amount of call as I was, they (perhaps wisely!) kept fewer office hours, saw fewer patients, and took more vacation. And why shouldn't they? Coming along in the new era, maybe they saw that hard work wasn't recognized and rightly concluded it wasn't worth it. Yep, you get what you pay for.

So that's a foundational background. Money isn't an explanation, but it is sort of a microcosm. I'll think some more about the rest of it, and let you know what I come up with. Next.