Tuesday, July 31, 2007

Times Two


Sunday's New York Times had a couple of features of medical/surgical interest. The first was a very long article on the variations in cancer treatments at various centers in the US, focusing on a young woman with colon cancer. She was diagnosed at Stage IV, meaning it had spread to her liver; in her case, very extensively. It was evidently only by her own perseverance that she finally ended up with intense chemotherapy and radical liver surgery which, statistically speaking, has a low probability of long-term benefit but which, for now, has left her overtly disease-free. Orac posted extensively on the subject, making anything I'd say mostly overage. But it is a very significant issue, even if the article -- as one would expect regarding a very complex topic -- has certain shortcomings. That there are variations in approaches to many illnesses -- in this case cancer -- and in the skills and philosophies of the doctors rendering the care is a problem for which there will never be a perfect solution. But it speaks for the creation of (and agreement upon!) well thought-out protocols covering a wide range of possible expressions of the disease, and is an argument in favor of something about which I have mixed feelings. Namely, "centers-of-excellence." Suffice it, for now, to say that I agree that for certain complex problems a team approach is ideal, and finding ways in which to evaluate the outcomes of such teams is laudable; but what I've seen of it leaves a certain amount to be desired. For example, I know of a place designated a center of excellence not far from where I am, in a field with which I have professional familiarity, that seems anything but. If the idea is a good one, the execution is what it's all about. Nor did the article address the even more difficult question of cost-benefit. Tough stuff, all of it.


The other commentary decried the fee-for-service model of physician reimbursement, in the context of running up costs because doctors get paid to do things. In part, the article, by Alex Berenson, says:

"Americans generally do not seem to mind the fact that doctors are well paid. In public opinion surveys, doctors usually rank as the most trusted professionals. Congress has repeatedly blocked Medicare’s efforts to reduce the amount it pays for each procedure doctors perform, even though overall Medicare payments to doctors are soaring and the cuts are legally required to keep the program’s budget balanced.
[Ahem. Sorry to interrupt, Alex: whereas it's true that in the past couple of years, some fees have been allowed to rise a couple of percentage points (hardly "soar"), that's only after having cut reimbursement by around two-thirds, steadily, over several previous years.] The way that doctors are paid may be an even more significant factor driving up costs and may lead to unnecessary care, said Dr. Peter B. Bach, a pulmonary physician at Memorial Sloan-Kettering Cancer Center and a former senior adviser to Medicare and Medicaid. In the United States, nearly all doctors are paid piecemeal, for each test or procedure they perform, rather than a flat salary. As a result, physicians have financial incentives to perform procedures that further drive up overall health care spending. Doctors are paid little for routine examinations and very little for “cognitive services,” such as researching different treatment options or offering advice to help patients get better without treatment. “I don’t have a view on whether doctors take home too much money or not enough money,” Dr. Bach said. “The problem is the way they earn their money. They have to do stuff. They have to do procedures.”

Primary care doctors and pediatricians, who rarely perform complex procedures, make less than specialists. They are attracting a declining percentage of medical students, and some states are facing a shortage of primary care doctors. Doctors are also paid whether the procedures they perform go well or badly, Dr. Bach said, and whether they are crucial to a patient’s health or not... “Almost all expenditures pass through the pen of a doctor,” he said. So a doctor may decide to perform a test that costs a total of $4,000 in order to make $800 for himself — when a cheaper test might work equally well. “This is a highly inefficient way to pay doctors,” Dr. Bach said....

....Private insurers like H.M.O.’s are more aggressive than Medicare in second-guessing physicians’ clinical decisions, and they will refuse to pay for imaging scans or other expensive new procedures. Now Medicare and private insurers are moving cautiously to change the current system. Recently, they have proposed pay-for-performance measures that would give doctors small bonuses if their care meets the standards set by national medical organizations such as the American Heart Association. But all those measures are a minor fix, said Dr. Alan Garber, a practicing internist and the director of the Center for Health Policy at Stanford University. Instead, he argues, the United States should move toward paying doctors fixed salaries, plus bonuses based on the health of the patients they care for..."


I get it. It's easy to think -- and it's not entirely false -- that some doctors make treatment decisions based in part on how much money they'll make. (Being as honest with myself as I can, I don't believe I ever did. I know I rejected operating on lots of folks who were all teed up for it by their referring docs. But if someone pulled all the data out my brain -- what's left of it -- and ran some sort of algorithm or other, maybe it could show some cases...) And it's probably true that if doctors were all on salary, overall health costs would go down. But the questions are 1) why, and 2) what would it look like?

I've mentioned before, and I should reiterate here: many doctors -- including, amazingly enough, some surgeons -- are (or sometimes act like) human beings. Incentives and rewards are as likely to be important to them as to actual people. Working hard for its own sake, striving for excellence without any tangible recognition will be seen in some -- but hardly most-- doctors if they go on a salary. Because, unsurprisingly (or maybe surprisingly, to pundits) that's not how it works in real life. I've been in the military, and I've worked at VA hospitals. Try getting a case on after three p.m. Try getting a lab test or Xray thenabouts. Work another patient into a crowded schedule? Stay through lunch, after hours, come in early? Sorry. That's what ERs are for. If Alex is ok with it, so am I. Sleep, I've discovered, can be a pleasant thing.

In "my solution (here and here)" I suggested the opposite of salary: in fact, I argued that paying every doctor the same for a given item of work was counter-productive; that finding ways to incentivize and reward higher quality would lead to lower costs and better results. The NYT article suggests salary plus "bonuses based on the health" of their patients. Can you say "can o' worms?" Might some doctor-humans prune their practices of difficult patients? Could those willing to take on the very sick be penalized? And, to tie the two Times articles together, in a a world of salaried physicians, my crystal ball says the lady in the first piece would have an even harder time getting the care she got.

Breaking ranks with the majority of my peers, I've said a single-payor system makes sense to me. But salary doesn't. It will indeed lower costs, because people simply won't bust their asses any more. I did significantly more than twice the average number of operations per year than the typical general surgeon (and because I was in a large (enormous) clinic with very high overhead for specialists, I made
less than the average surgeon in the country, by a depressing amount); I did it because people needed the care. But I'm pretty damn sure I'd have cut my hours back to what everyone else was putting in if I'd been on a salary. If we go there, wait times will go way up. There'll be waiting lists. In training, at the VA, there were people waiting for every sort of operation: as Chief Resident I could have simply made up schedules based on what I wanted to do, maybe never getting around to some. And let's be real: as I've also said before, if you take away reward for hard work and excellent product, you'll find a very different sort of person -- on average -- choosing to become physicians. If that's not seen as a problem, so be it.

To use the Rumsfeldian/Socratic method here: Is the system broken? Yes. Does it need major overhaul? Sure as hell. Is the solution to put doctors on salary? NFW. Not unless we are, as a nation, willing to accept longer waits for more mediocre care. That old human thing, once again.


Monday, July 30, 2007

The Old Man and the C




I expressed this particular opinion on another medical site, and was -- gently -- told I was an old guy, of a generation that was out of touch. It could be true. But having treated many hundreds of women with breast cancer (I lost count a long time ago) and having been (so I was told) more sensitive to the horror and fear than the "typical" surgeon, I feel qualified to express myself. My thoughts are based in the reality I saw in my practice. So here it is: though not opposed, and having participated in many cases of it, I'm not a big fan of immediate breast reconstruction after mastectomy.

As I recall, the thread in which I commented on that other site was regarding yet another study showing that surgeons had a poor record of offering reconstruction to their mastectomy patients. Of that I was never guilty. I think it's wonderful that it's available. It's a timing thing, to me. To my patients undergoing mastectomy, I always brought up breast reconstruction; among other things, I made sure they understood it was not considered "cosmetic," and was (by law!) covered by insurance. I discussed both immediate and delayed reconstruction, and did not try to talk women out of the former choice if that's what they preferred. But I was glad when they didn't. At the risk of being misunderstood, let me try to explain.

The blanched face, the terrified glaze of the eyes, the tears. The jumbled words cascading past a trembling jaw, the grip of hand upon hand, fingers compressed white and shaking. Witnessing thoughts tumbling almost visibly through the mind, randomly, out of control, one, two, three after another, splashing through pools of panic. Endlessly, I've seen it, over and over, to the point of hating it above all, to the point of looking at my schedule and feeling a physical tightening in my gut when I saw such a consultation there. That's the reality in which such conversations take place. No matter how carefully, how gently or insistently; despite taking time, providing reassurance that we can deal with it, handing out personally-written booklets; my attempt at informing, explaining, supporting the woman and her family to whom I give the news often feels futile, as I try to breach the wall of stunned disarray.

Mastectomy is always a treatment option for breast cancer. As understanding has evolved, it's uncommon that it's the only one. By far the majority of women undergoing treatment for breast cancer have the option of breast preservation, via lumpectomy and radiation therapy. For reasons I've dealt with before (here, plus 1, 2 , 3 , 4 following), some choose -- or need -- mastectomy. More than any other cancer, I'd say, there are branching decision trees to be understood, choices to be made: lumpectomy vs. mastectomy, how and where radiation fits in, when and what kind of chemotherapy is used, the need for lymph node sampling, when and if full axillary dissection would be used instead of or in addition to sentinel node biopsy. And for women who will undergo mastectomy, the issue of prosthesis vs. reconstruction: what type -- among many varieties -- and when. It's a lot to assimilate.

So my first concern is simply about overload: the need to wade through an enormous amount of information and sort it all out, at a time when you are bordering on panic. In the midst of that, adding another very thick layer of fog, requiring visits to a plastic surgeon and the full consideration of several very different options, making a realistic decision about reconstruction seems, sometimes, like piling on. First things first. Let's focus all our energy on getting through the cure. Let's know that this option awaits, and be reassured by it; and get back to it later.

I suppose that sounds condescending. Poor little women, can't handle all that stuff. Hardly. Women are tough as nails. They have to be. And let me say again: I've always brought up, and haven't tried overtly to steer women away from immediate reconstruction. (Does my mind-set affect the outcome? Could be, in some cases.) But condescension (if that's what it is) cuts both ways. At least one famous female surgeon used to go around the country claiming that the only reason mastectomy was invented was because men like to mutilate women. And, by inference, a woman who'd choose it, and not have reconstruction, was somehow succumbing to that mindset. Mastectomy is mutilation. But how one responds to it is -- and ought to be -- very individual. The time, it seems to me, to decide about reconstruction is after the enormous stresses of facing the cancer are dealt with. Many major centers publish with pride that immediate reconstruction is their standard of care, their treatment of choice. I can't help but think that many women are pushed (is that too strong a term?) into it when they'd rather just take their time.

Depending on the method, breast reconstruction is a very big deal. The operation can take several hours, and may subsequently require a couple of much smaller touch-ups. Clear-headed choice is mandatory. And here's a related issue: lying in an operating room for another four hours -- turning a forty-five minute operation into a five hour one -- anesthetized, then having one's body deal with all the required healing, while asking the body also to deal with as yet not-fully-treated cancer seems physiologically iffy. I know of one study that found no average delay in starting chemotherapy for women undergoing immediate reconstruction, and that's good. What haven't happened yet -- and likely won't, for practical reasons -- are studies that randomize women into immediate versus delayed reconstruction and follow for several years to evaluate any effect on long-term cure, segregated by stage at diagnosis. It'd be important, I'd think. Related are the delays from diagnosis to treatment that come with the need for arranging the consults and coordinating operating time. Maybe centers who promote immediate reconstruction have streamlined that part.

I don't for a second minimize the psychological effect of mastectomy. I've seen it. I know it. I've practiced through the times when reconstruction was not available; when it was technically disappointing, and when it became cosmetically fabulous; when it was done only later; and now, when it's done at the time of the mastectomy. In the pre-immediate days, I've had many patients who were very relieved to know reconstruction could be done yet who, when the time came, said they were surprised at how comfortable they were with their status and chose not to have reconstruction. (Prosthetics have also come a long way: some adhere directly to the chest so they don't need a special bra; they have lifelike texture and coloration; their nipples show through flimsy bras, if you like that sort of thing.) The numbers weren't small. From that fact, I infer that many women, under the stress of the initial diagnosis, are "encouraged" into a very big surgical deal when, given time, they'd have opted out. One can argue both ways whether that's a good or a bad thing.

Psychological well-being and body image are the bottom line issues (assuming -- which we can't quite -- no impact on survival). Studies make it clear that reconstruction serves the purpose very well, and argue for immediate reconstruction. Yet it's not simple: the "baseline" evaluations of immediate reconstruction were done in women not yet treated, who had no basis for knowing what mastectomy would be like for them; those of the women who underwent delayed reconstruction had already had mastectomy. The measured improvements were less in those with delayed surgery; but they'd had time to adjust and, in effect, raise that baseline.

I'm no crusader here. I neither expect nor desire to change minds. Recognizing that it's not clear-cut, rather than pushing a particular approach, I favor being sensitive to the individual; having feelers out to intuit what the woman sitting in front of me needs. But it appears that there's now a trend in a single direction, and that it's generated in academic centers -- the very places where, in all things, more is more. (If there's a more complicated means to an end, they find and promote it. Kidding [?]) Based on my experience, it's a steamroller for at least some women, generating what may be unnecessary anxiety and commitment to a very laborious and expensive process; forcing a quick decision at a time of great vulnerability.

When I've been asked my opinion, I've given it. When from behind those glazed eyes, from obviously overwhelmed minds the words are formed, "What do you think, doctor? Should I have reconstruction right away?" I've usually said something like this: "I have no problem with it if that's what you want to do. But if you don't want to have to decide now, you will always have the option, any time, down the road. Let's set up a consultation with a plastic surgeon if you like, to hear what's involved. But for now, let's go about curing breast cancer. Let's get all that over with, and when you're recovered, feeling good, strong, we'll take that one on and sort through the options." It's self-selecting, I'm sure: if they're asking, they're hesitant. But generally, when they hear that, a quantum of tension is dissipated, the grip relaxes, and you can sense a bit of relief fill the room.



Addendum: I'm well aware that most plastic surgeons prefer immediate reconstruction, because they don't have to deal with scar tissue. It's easier. Many claim better cosmetic results (I've seen it both ways, and -- at least with tissue-transfer techniques such as TRAM flap -- can't tell the difference. Both look great, usually.) Frankly, I think their ease is part of the push for immediate reconstruction, and I'm not sure it ought to be. Patient satisfaction is another issue, and like the whole subject is iffy and tricky and subject to claims of being patronizing. Recognizing the impossibility of accurately measuring such a thing and to subject it to a meaningful prospective study, I've heard opinions expressed on both sides of the issue by plastic surgeons. Some say that comparing a reconstructed breast to the "real" one -- which is what happens with immediate reconstruction -- has a higher chance of disappointment than when it's compared to having lived with mastectomy for a time. I'd welcome comments from my occasional plastic surgeon readers. And here is an example of what we're talking about, from the right side of the bell curve:

Sunday, July 29, 2007

Friday, July 27, 2007

Disconnect



Most of them were crazy, or demented. Sometimes they were brought in by an obviously discomfited relative, a daughter, and there was always something off, something that made it, at a certain level, understandable. "I had no idea. I thought I'd been smelling something, but her whole place was so awful, and she refused any help. She'd get angry when I tried to help. One day she let me help her bathe, and I saw it... Is it bad, doctor? Is there anything you can do?" Parents embarrass their kids all the time; on the soccer field, at birthday parties. This sort of thing is beyond the familiar by a factor of ten, or a hundred. To let a breast cancer advance to that point, one's grip on reality has to have loosened. Lots of people put off seeking medical attention. With breast lumps, I heard many attempts at explanation: I didn't think it was serious; I thought it would go away; I thought it was getting smaller. Even at the point of ulceration, women would claim they just noticed it. The inappropriate smile, the sense of disconnection, a certain dishevelment. Which is why Julia blew my mind.

Dressed like a doily, hair perfectly tinted and permed in tight waves contained like the kids of a strict school-marm, she sat before me and slightly pursed her sticked-lips, which were painted precisely within the lines. She was powdered and rouged, in the manner of the ladies of elegance; subtle, tasteful. No self-mockery, no flags raised; it was by the book, and she exuded a talcumy tastefulness, smelling grandmotherly in the nicest meaning of the term. Completing the picture, she'd been -- and remained -- a bank teller for three decades. A fixture in her slice of the community. "I've found a lump in my breast," she said, quietly, eyes on her hands folded neatly in her lap, not able to meet mine. Embarrassment, not fear, was what I sensed. After perfunctory data-gathering, I showed her into the exam room and gave her a gown.

In the red and seeping crater that occupied almost the entirety of her right breast were layers of kleenex. Cut into little squares, laid orderly one upon the other like baklava from behind the looking glass, the tissues had also been lightly perfumed. By their thickness and leather-like texture, I could tell they'd been there a very long time. As had, of course, the tumor itself. Years, more likely than months.

What were you thinking? How could you let this happen? is what the mind screams. I've seen more than a few like this (though never so tidy) and have never been that blunt. In the case of Julia, after a mental in-drawing of breath, I said simply, "You're probably worried this is cancer, and I'm quite certain it is. But, you know, when they grow large like this there can be some good news. The really aggressive ones spread fast before getting this big, so it sort of declares itself a slow-grower. And we have a good chance of controlling that kind." She nodded in small and quick excursions of her head, assenting in silence to my request to shave a piece of the tumor for testing. Because tumors are devoid of pain nerves, such a maneuver is painless.

What you aim for is local control; a way of treating and extirpating the tumor in such a way as to eliminate the festering and prevent its return. What's done is done: most likely, cure is out of the question -- although as I told Julia, this indolent behavior leaves open the possibility of long-term survival. In elderly ladies, most breast cancer is very sensitive to hormone therapy, which provides a well-tolerated and home-based way to regression of the growth. I've seen large and ulcerated masses shrink and heal over with only such treatment, after which -- unless refused, or prohibited by underlying fraility -- a simple mastectomy has been followed by permanent quiescence, locally. When needed because of medical risk, I've done the operation entirely under local anesthesia. I'm certain that, given the simplicity of the treatment, some of those ladies wondered why they'd waited a lifetime to be seen.



[photo from edinphoto.org.uk]

Thursday, July 26, 2007

Are You Experienced?



The news of the week includes reference to an article about a study of surgeons doing prostate cancer surgery. Experience counts, it reports; surgeons doing fewer than ten prostatectomies for cancer have significantly poorer results than those doing more than two-hundred fifty (now there's a hell of a range!) The researchers also conclude: if you have cancer surgery, you ought to go to a teaching hospital. They're half right.

In the early years of my practice it sometimes happened that I'd lose a patient to the big city surgeons. Typically it was for breast cancer: I'd see her, do the appropriate workup including a biopsy of some sort, have a lengthy discussion of the surgical options. Back then, given a less-than-full schedule, I even went to people's homes to break the news, sometimes. Very appreciative: "You've done a really great job, doctor. I like you a lot. But my friend had a surgeon in Seattle, and, well, he's been around a long time and, well, you know..." It took a few years before it stopped happening -- probably at least as coincident with my premature graying as with anything meaningful. But in time, for whatever reasons, the outflow stopped; in fact, there was the not entirely rare inflow from those parts...

In describing my mentors and their influence on me, I've said I thought I didn't fully get what they were trying to impart until I'd been out from under them for a couple of years. It's true. But in the context of the article in question, I'm trying to consider in what ways it's the case. Smoother; faster; more confident. An evolving sense of how I saw myself and what I wanted to be. But safer? Getting better outcomes for my patients? I'm inclined, of course, to say no; but maybe data would show otherwise. It's not the first time an article has appeared tying outcome to experience. It certainly makes intuitive sense. And yet it's not the whole story. If I could figure it out ahead of time, I'd rather be operated on by a less-experienced surgeon who does things right than one with hundreds of cases under the belt, done less well.

When I've given readings of my book, a question I'm regularly asked is how to find a good surgeon. It's a toughie, for the non medically-connected person. I begin with the idea of trusting your primary doc; if you have one you like and believe in, you ought to be able to assume she or he wouldn't steer you wrong. Other than the occasional political issue, and the fact that most primary docs don't really understand what goes on in an operating room, I think it's a good bet. Whatever else is true, they do see the patients again after they've sent them off; flesh-and-blood feedback. And, of course, credentials mean something. Training at an excellent program increases the likelihood that a surgeon knows his or her way around a body. Doesn't guarantee. Nor is the opposite true: one of the best surgeons I know trained at a pretty unremarkable place.

Not every operation I learned ended up in my armamentarium in practice. And here's the tricky part: I didn't reject certain cases just because I didn't do them often. Some operations, while complex and challenging, involve nothing but a combination of techniques I used all the time: Whipple procedure; esophagogastrectomy. Uncommon as they might be in terms of numbers, my ability to do them and do them well was not in question. Not in my mind, at least; nor in the outcomes. Other operations involved either techniques I didn't employ regularly, or had the potential for post-op complications with which I didn't deal often enough to feel like I had the breadth of judgment to bring to bear. So I didn't do them: major liver resections; colectomy with ileo-anal pouch creation. (In regards to the latter, I helped a recently minted surgeon do one and showed her a few tricks that shaved a couple of hours off her operative time and smoothed the patient's recovery.) I could do any of those; but I didn't.

What are we to do with this experience/outcome data? If we only go to experienced surgeons, at some point there won't be any, right? How do you get patients if you need to have had patients to get them? Anyone want to sign up to be fodder?

New procedures have, without question, a learning curve. It takes time to get the hang of laparoscopy, for example. One would like to think that, after several years of long days and nights and rigorous supervision, any trainee would come out the other end knowing how to operate. If you know principles of dissection, of exposure, how to handle various tissues, you ought to be able to translate that to most any operation in a way that keeps the patient safe and provides the expected outcome. Somewhere in my mind, in ways I can't entirely sort out -- yet -- it seems to be that there's more going on here than experience with a particular operation.

If there's a solution to the patients' dilemma -- knowing where to go for what procedure -- it ought to involve some sort of mentoring program for surgeons. I may not need to have done two hundred repetitions of an operation if I've received the benefit of training by someone who has. That is, of course, what residency training is all about. But there's more to it than that. My surgical life is entirely involved with a single laparoscopic procedure nowadays. Three surgeons, three anesthesiologists doing one procedure, over and over. From the point of view of smooth operation, in all senses of the word, it's a soaring pleasure. Likewise outcomes. And when other surgeons are planning to start doing that operation, they must be mentored for several cases before getting privileges to do it on their own. These guys are among those that do the mentoring. It might be ideal if for each operation there were such super-specialty centers. But is that practical? Wouldn't people prefer not to have to scatter their body parts across the country?

With the advent of the eighty-hour work week (which, according to many of my pals in academic surgery, is diluting the experience of trainees), such a thing becomes even more critical. If the American College of Surgeons had the resources, it would be arranged that every new surgeon, on completion of training, would be taken under the wing of one who'd been around the block a few times. Such a program would identify those that need a little more polish before being loosed on the world, would impart the knowledge that only comes (apropos that comment about the need to go to training hospitals for certain precedures -- the best surgeons I know, by far, are those in private practice) from being in private practice; and most importantly -- assuming such a thing were possible (probably not) and done in a meaningful way (conceivable) -- would give patients the confidence that they'd be getting a good product when they expose themselves to the surgeon's knife.

Tuesday, July 24, 2007

Eau d' OR


I'm reminded of something I should have mentioned in the "Body Talk" post, which also, some would say, loosely connects to the "Happy Talk" one. It concerns the, uh, humanity of surgeons and of those who work alongside them.

If it's true that at some times one needs to excuse oneself to attend to certain personal needs, it's also the case that there can be, y'know, etherial -- as it were -- evidence of that same humanness; following which -- sorry! -- odors may linger. Other than embarrassment, some tricky questions may waft into consciousness as well, particularly when operating in the belly. Could the odor indicate an overlooked hole in the bowel? How to bring it up, when the answer isn't clear but you know yourself not to be a possible, er, source. Might a fellow worker not acknowledge it and allow a worried search to continue? Or might he/she admit, "Uh, I'm pretty sure I can say it's not a hole in the bowel..." My experience: either/or. And, might I add, it's not always the case that when I'm in the OR I'm the surgeon-in-charge. I can say no more...

And, to compound the disquiet expressed by those whose questions led to the previous post: there's another suite explanation for the preceding mubble, witnessed occasionally on the occasional occasion by all of us who work therein. Without wishing further to disturb the sensibilities of my readers nor to increase their fantaworries, let me just say that the muscle relaxers given during surgery don't only relax the muscles of the abdominal wall. Nor, need it be said, do the muscles in question act only as air-valves...

Now, to lighten the load [poor choice of words?] of those who may worry about their next trip into the OR: I'm also reminded, in a somewhat non-linear way, of an old joke about the induction of anesthesia and saying stuff, about which I was writing yesterday:

Anesthesiologists like to get their patients to fill their lungs with oxygen before going off to sleep. So here's one talking to a patient, a young girl:

"Nice big breaths...."

"Yeth, and I'm only thixteen...."

Monday, July 23, 2007

Happy Talk


"Thankzzzz doc yer th greatiszz.... No, rilly man.... yer the...... zzzzz ..."

"Huh? The operation's over? No way. You're kidding, right? Bandage? Oh yeah, lookit that. Wow. The operation's over? No way. You're kidding, right? Over? You're kidding, right? Is the operation over? You're kidding. Right? Bandage? Oh yeah..."

"I robbed a bank, y'know. Had to kill a guy. Put the money in a Swiss bank. The account number is...."

I've heard it all. Well, except that last one. And I've been asked frequently: "Did I say anything when I was out?" Readers of this blog have wondered the same. Evidently it's a pretty common concern: do people reveal stuff or otherwise embarrass themselves when under the effects of anesthesia drugs? Relax, people; the answer is "no." OK, gotta be truthful: it's also "yes."

Sodium pentothal, formerly used extensively in the operating room but now largely replaced, has been referred to as "truth serum." Whereas it's true that under the influence of some drugs people can get a little disinhibited, it's not the case that they'll get all revelatory. I haven't learned any secrets from my patients. When asked, however, I'd often say, "Well, you did tell me about that Swiss bank account." Only once did that result in a worried look....

Most surgical patients get a little something to relax them before they get wheeled into the OR. It's not unlike a couple of nice martinis -- without the olives. (No solid food before surgery.) So yeah, tongues loosen a little. Giggles sometimes; rarely, tears. "Wow, this feels great..." Stories get told. Amusingly, when the story is interrupted mid-sentence by the arrival in their brain of the knock-out punch, I've seen people wake up later and begin exactly where they left off, unaware of the passage of time. And yet, I've never heard anyone say anything they'd be sorry about. Unless telling me how wonderful I am is in that category...

Generally, I enjoy operating on a patient who's awake. We talk, usually light-heartedly. Given some sort of anti-anxiety drug, the conversations can be loose, chatty, funny. People will say the same thing over and over, ask the same questions repeatedly. My goal is to keep them comfortable; if they want to ramble on, it's fine with me. Most often they doze, wake up, talk a little, doze some more. It's pleasant, not confessional. Because such talk is commonplace, even when particularly entertaining it goes out the other side of my mind as quick as it enters; my head -- and, I'd aver, those of everyone else in the OR -- is a sieve that way. Talk like that is texture, not substance.

The flip side of this is a theoretical utility. Far as I know -- and the anesthesiologists who sometimes wander by (Mitch?) might be able to amplify -- studies of suggestibility under anesthesia are equivocal. Still, I liked to give some positive thoughts to my patients as they went off to sleep and when they emerged: "We'll take good care of you. You'll going to be comfortable when you wake up." And, after it's over, "Everything went great. You're going to be glad we did this. Comfortable, no nausea." I have no idea if it had an effect or not. I always made it a point to talk to my patients when they were awake in the recovery room, not only telling them how it went but -- unless it wasn't true -- telling them I expect things to be fine, give them some positive vibes. With practically no exceptions, no matter how engaged and appropriate they were in those conversations, people never remembered what was said, or even that I'd been there. Or that they'd asked me the same thing five times in a row.

If it were possible, I'd love to see a study of people wherein within a standard time of emergence they'd receive some suggestions. Some would hear words saying they'd be comfortable, be up and out of bed soon; others would hear something neutral, unrelated to pain. The floor nurses wouldn't know who heard what. Pain medication use would be recorded. I'd like to think the former group would need less. (The problem with any sort of surgical studies is that even when operations are "the same," they really aren't. Different surgeons, different operating times, incision size; different people getting the procedure. It's really hard to standardize. Still, it'd be interesting.)

Friday, July 20, 2007

Body Talk



"Do you want a foley?" nurses frequently ask before the beginning of abdominal operations -- referring, of course, to the patient. "No," is my invariable reply. "I peed before I got here." "Hah hah." I'm guessing at least a few people wonder: do surgeons ever need to, you know.... The answer is a resounding "occasionally." Many of us, after all, are physical beings.

I've had to take a bathroom break only once or twice in a pretty long career. And it was for the other, er, number. Certain intestinal disorder, don't you know. And yes, it's embarrassing. The leave-taking, the walking past the front desk ("Done already, Dr. Schwab?" "No, uh, taking a little personal time. Be right back. Gotta go..."), the looks on faces at my return. Eyes and foreheads are pretty expressive, above surgical masks. Nurses, being decent human beings, are likely to worry, "Are you OK?" Anesthesia folk, ever witty, can be counted on to say something pithy. Nigel or Lynn, especially. "This should be refreshing. Finally you're less full of it." I can take it.

More common is flagging during an especially long, physically and emotionally taxing case; particularly late in the day, or during or after a long night on call. More than a few times I've asked for a shot of orange juice. It never tastes better, nor has more power of rejuvenation. Some poor nurse has to hie to the fridge in the lounge, scout up a straw (the bendy kind), and wiggle it behind my mask (first making an opening with a finger), while I lean toward her or him to keep from contaminating my gown, and use prehensile lips to try to arrest the tip and insert it into my mouth. Glug, glug. When it's cold, it's sesqui-orgasmic. I've also had candies digitally inserted behind my mask and guided to my lips. I always assumed the nurses didn't find it particularly appealing to do; but I've never been more grateful.

Angels of understanding, there's a couple of nurses -- ones with whom the relationship goes way back -- who've ascended a step-stool and given me a neck rub after I've stopped for the second or third time, leaned back from the table, and stretched. Oh man!! I flap my foot like a belly-scratched dog, and swear devotion till death.

Eschewing cold medicine, I've put a layer of gauze in my mask, under my nose. Drips. And, slightly off topic but nose related, I've gratefully accepted a swipe of benzoin (for its aroma) onto my mask when encountering a particularly putrid pus-pocket, or a well-rotted intestinal infarction. (Actually, I've used it pretty rarely: I've always thought draining pus was among the more noble things a surgeon does: and when it stinks up a room to the point of turning green those who must stay, and driving away those who can find an excuse to exit, there's no need to wonder if you're doing good for the patient. So, in a way, I like it. Dead bowel? Not so much.)

In the operating room, I've been poked, stabbed, cut, and cauterized. My left index finger bears the scar of a scalpeled flap, a centimeter at its base, equally tall: the result of an episode in training that sent me to the ER with a spurting digital artery, and after the sewing-up of which I returned to find my attacker/assistant (it was one of those rush-jobs: as I was ten seconds into opening the belly in the midst of a flood of blood, he reached to pinch off the aorta, banging my elbow...) happily repairing the patient's iliac artery as the attending looked up with amused eyes skrinkling above his mask.

Somewhere along the line, I converted my hepatitis antigens: probably from a needle-stick at San Francisco General Hospital, only a few years before HIV ravaged the place. Digging my way behind the rectum in a deep and narrow male pelvis, I've shaken cramps out of the palm of my hand. The backs of my knees have ached and the fronts wobbled as I leaned for hours into a tough dissection. I started wearing support hose in the OR way before middle age. Stasis dermatitis (mild) made itself known while I was Chief Resident.

If there's a point here, it's this: much as I like to emphasize on this blog that surgery is a thinking person's sport, there are times when it's all about the body.

Wednesday, July 18, 2007

Traumadramarama


When there's as much shit flying from the fan as is compatible with known laws of motion, you slash open the chest, in the emergency room. There are reasons, and there are ways. For sheer speed, you cut between the ribs and then, at the end near the sternum, where cartilage takes the place of bone, you turn the knife northward and chunk through a few of those soft ends. It makes an ugly, L-shaped scar, but it's quick, and you can reach in as if through a trapdoor. It eliminates the need for finding, opening, inserting, and cranking a rib-spreader, breaking a couple of ribs in the process. Why do it? Well, for one thing, when someone is exsanguinating into his belly, a way to slow the flow is to clamp the aorta. Accessing it through the chest means staying out of the belly until you get to the OR; open such a belly in the ER, and the victim will bleed out in a heartbeat. A few heartbeats.

As a surgical trainee, cracking a chest in the ER is one of those things you look forward to with thrilled anticipation -- and before the first, with not inconsiderable uncertainty. (In private practice, valuing order and knowing you've been there and done that, generally you hope never to be in the situation where it's needed. Although the admiring murmurs it engenders never fail to stoke certain flames. "Wow" is an ego-pleaser, too, when heard after a successful rescue.) My first was for a stab wound to the heart; with the pericardium swollen and blackened by blood, I was momentarily disoriented and unsure of my landmarks. (In opening it, you want to avoid, among other things, cutting the phrenic nerve.) It's less messy when the purpose is to find and clamp that aorta, although it's a first surprise to recall how posterior it is.

Whatever the reason, once a chest is opened it's a thrustle (I like making new words. Thrash/hustle. Did you like "snork" in the previous post? I was thinking of snore/speak) to get the patient to the OR asap. If the aorta is clamped, you've effectively cut off blood flow to the entire belly and below: kidneys, liver, guts, feet. No time for doodling. You may or may not be squeezing the heart in your hand: external chest compressions have little effect when the heart is empty, so until those people I mentioned in the previous post -- working on several IVs and pumping the tank full again -- accomplish their goal, to get blood circulating you hold that heart and work it, even as it's still beating. And you can feel the engorgement, the ventricles filling more of your hand, the more powerful squirt in response to your grasp as the blood volume is restored. Carefully, with hope, you can begin to relax your grip, keeping your hand near, sensing the more effective beats; and finally, extract your hand from the chest, while realizing for the first time how awkwardly it's been bent, reaching in from the side of the patient, through a small, tight, and bony hole. As circulation returns to the patient (at least his upper body!), so it does to your hand.

It's not over. Even with the aorta clamped, opening the belly releases the bled blood, and it gushes out under pressure as the belly deflates. Backbleeding -- depending on the nature of the injury -- can still re-empty the heart; as can the simple act of releasing the compressive pressure of the belly wall. Clearing the field of blood as fast as possible, by bailing, mopping, suctioning, you aim to find the source of bleeding hemi-instantly, hopefully to get clamps on either side of the holes and releasing -- slowly -- the aortic clamp. Another opportunity for re-crashing blood pressure: while the clamp has been on, the distal blood vessels relax and dilate. Releasing blood into that now-larger vascular space invites a big drop. So you wait until the anesthesiologist indicates s/he's caught up and then some. With luck, you may already have been able to satisfy yourself it was safe to place a clamp below the arteries to the kidneys and remove the one in the chest.

First things first and second: a missile or sharp thing that got a vessel to bleed likely punctured some bowel as well. After gaining control of the bleeding, and before repairing it, it's time to have a look around for what else is wrong. If there are intestinal holes, they need pinching off in one way or another so they don't leak until you get back to them (Babcocks and Allis's work fine. Temporary whip-stitch for a bigger gash.) And there needs to be an even number of holes. If not, you've missed something! There are lots of opportunities and places in which you can do just that.

"Running the bowel" is the term for, in an orderly fashion, slipping the entire length of the intestine through your fingers, looking for trouble; flipping it over as you do it, so you see both sides. Trying not to let it slip out of your hands and lose your place. The colon, being either tethered to the periphery of the abdominal cavity, or draped in fat, or both, is harder to "run." You can't, really, so you need to look really carefully, and cut it loose to look behind if there's reason to worry. Likewise, the duodenum is fixed in place and held behind the transverse colon and into the retroperitoneum. Missed duodenal injury can be disastrous (they all can!); it's more likely in blunt trauma, wherein there's no knife or bullet hole to lead you in. You can read about my experience with that, in my book. (I -- and my patient -- lucked out.)

One of the cardinal rules of trauma surgery (particularly for penetrating injury) is, unless time prevents it, to get an image of the kidneys before you dig in; an image with dye that shows function -- not to mention confirmation that there are two of them. Among the apocryphal tales of trauma surgery is the story of removing a damaged kidney, to find out later that it was the only one, or the only working one. I assume it must have happened somewhere, some time. Happily, nowhere near me.

Monday, July 16, 2007

Traumarama


I miss the "Knife and Gun Club." (That's what we called the ER on a Saturday night -- and what ERs around the world are called at that time.) Or, to put it another way, I hate blunt trauma, at least the kind with lots of force involved. Give me a nice penetrating injury: I can handle it myself (with the necessary cast of partners in crime.) Bring in someone hit by a car, a jumper, or -- as seemed to happen in San Francisco with more regularity than one would predict -- someone run over by a city bus, and the scene devolves into a circus with many more than three rings, everyone (except us general surgeons) wearing blinders while deliberately focusing on as tiny a part of the squashed victim as possible. It's messy in every way. And, in private practice, it's much more common than those pleasant little knifings and shootings of the trauma center.

In big city ERs, it's an oft-heard aphorism: "Trauma happens to people who are asking for it." There are exceptions, of course; often, heart-breaking ones. If there weren't, the corollary age-old adage wouldn't exist: "Survival of trauma is inversely related to the victim's value to society." But in the typical trauma, the initial experience is heavily influenced by the nature of the victim: often belligerent, drunk, drug-addled, interfering with those trying to help. In that spirit, I offer a blip from my book, a favorite story from back then...

"...Yet compassion itself can become a victim after getting spit at, sworn at, lunged at by the people we were trying to help. I watched in admiration as a bearded (and therefore compassionate) family practice intern struggled to hold still the head of a gunshot victim who was thrashing and swearing, resisting despite his severe wound. The man managed to twist his head around and bite the thumb of the intern, whose immediate response was to shout, “YOU BIT ME!” and pull his hand back into a fist, ready to strike. But showing amazing control and taking a deep breath, he stepped away and walked into the hall, where I saw him pace up and down, talking to himself. Finally, after a minute or two of deep reflection and meditative self-analysis, he strode back to the head of the stretcher and looked down at the guy, thoughtful and calm. And popped him one in the nose."

With the air around them fouled by the stink of vomit, unsubtly seasoned with alcohol and rotting potato chips, drunk drivers are hard for me. Blubbering some times, producing an effluent of insults at the next, they remind me how dangerous they are to us all, and I have a hard time generating sympathy. May as well have snipers shooting at us from every overpass: that's how I see the fact that I share the road with these people. But I do what I need to do. I've always wondered if video-recording the scene and gifting the victim with a copy would help with their drinking problems. See yourself naked and struggling, blood in your hair, snot all over your face, vomit in your pubes, someone shoving a tube into your nose, your dick, while you snork incomprehensibly, flopping like a fish on a dock. Given all that, the simpler the trauma problem, the better I like it.

Trauma is digital: mostly yes-no decisions, needing to be made rapidly. The downside is its disruptiveness of my schedule or my sleep; the upside is that once I'm there in the ER, it's about running through a pretty-well-ingrained decision tree, and getting the hell to the OR. Penetrating trauma, anyway. Victims of blunt trauma may end up in the ICU, with or without some other specialist having pinned this or trephanated that, with me -- scalpel still sheathed -- getting calls from the unit all night and into the next days. (There's a seemingly unalterable dictum: multiple trauma is the charge of the general surgeon, whether or not there's an operable condition for her or him. I get it. I don't always like it.)

If a person hates drama, hates adrenalin, s/he shouldn't be a surgeon; especially a trauma surgeon. Drama surgeon. Having trained in a trauma center, I not uncommonly was part of getting a victim to the OR within ten minutes of arrival in the ER, tubed, IVd, catheterized. When it was serious enough, I'd step into gown and gloves wearing whatever I'd been wearing, no wash, no shave of the patient. Splashed around a little iodine, thrown on some drapes, and got to cutting, while a couple of people squeezed in blood and the anesthesiologist administered only oxygen and paralyzing agent, until we were caught up; if we ever got there.

"We're comin' in code three, two minutes out." The red phone would give us enough warning to head to the trauma room, open the instrument packs, bleed the IV fluid down to the end of the tubing, assign tasks. You: N/G tube. You: ankle cut-down if we need one. You: foley. Swinging doors, like a saloon but without the clinky piano and the dancing girls, burst open to reveal a gurney attended by EMTs and cops. (If there were music, it'd stop at that point; heads would turn.) OK, no one's doing CPR. That's a good sign. Look for movement as the scene comes into focus. Thrashing, whatever else it may be, is a sign of life. Already intubated (tube in airway)? Well, it's serious, but at least that part is out of the way.

"38 special, doc. Cops got 'im before he got them. One shot, that's it. Started crapping out on the ride in." Sweet. We can handle it. Or give it a hell of a try...

Saturday, July 14, 2007

Bless the Child?


Warning: here follows a rant that some will find offensive, but which is medically-related, so I'm doing it. Turn back now, if you have religious sensitivities.


The Seattle Times has been running a generally heartbreaking series about a young girl with terminal cancer. The latest installment has put me over the edge. I can understand -- even support -- the decision, after giving everything over to conventional treatment and seeing it fail, to stop the drugs and turn in another direction. I'd not, however, have chosen prayer, at least not in the way it's being done. What I see in the recent article is, pure and simple, child abuse.

I've mentioned religion before, relating how, as a surgeon, I've seen faith, for some people, make facing deadly illness easier. (I've also indicated that I've seen it accomplish just the opposite.) Patients' faith clearly can make it easier for me, when giving bad news and when caring for the dying. But this. These prayer circles, this continuing belief that healing will happen if enough people pray -- and, implicitly, if the girl herself is godly enough -- is setting the poor child up for a death bathed in self-recrimination. Evidently, it's already happening. (For those that didn't read the article, its title is a quote from the girl: "You Know I've Been Down... Forgive Me.")

There is nothing -- NOTHING -- worse than the death of a child. I've attended to dying children and their families; and, as some have noticed in the sidebar of this blog, I've lived with it in my family. I have nothing but sympathy and sorrow for the family and for this little girl. But I think if I knew them well enough, I'd be saying this to them, off camera and away from the press: pray if you need to. Pray for comfort, for understanding, for strength. But get off this miracle healing thing. You're ruining what life your child has left. Keep up hope? Sure, as long as it's reasonable. But give her an out; give her a way to accept what's happening to her, if such a thing is possible, without blaming herself.

God help me, I can't stop. I should just shut up at this point, and let it be about the care of the poor child. But I can't. I must also say this: there's something perverse to the point of revulsion in the idea of a god that will heal the girl if enough people pray for her. What sort of god is that? To believe that, you must believe he deliberately made her ill, is putting her through enormous pain and suffering, with the express plan to make it all better only if enough people tell him how great he is; and to keep it up unto her death if they don't. If that sort of god is out there, we're in big, big, BIG trouble. If people survive an illness because of prayer, does that mean that god has rejected those that didn't pray? If you pray for cure and don't get it, and if you believe that praying can lead to cure, then mustn't you accept that God heard your prayers and said no? If so, are you going to hell? But if you say either outcome is God's will, then what's the value of the prayer in the first place? In this case, it seems, it's only to make the girl feel guilty and unworthy. How sad. Since the whole idea is so internally inconsistent, give the poor kid a break.

Does this family's god need reminders; does he have DADD? Or is he waiting for them to hit a magic number of people praying? A certain quantum of prayer-units that must be achieved? Does he give credit for getting close, maybe knock off a little pain when they hit 80%, or is it all or nothing? In praying to him -- and if, as the article says, people around the child see God at work in all his glory -- shouldn't they be thanking him for their daughter's misery rather than asking for a change of plans? Shouldn't they be delighted with the whole thing? If He's perfect, how can you add to that by praying? Or expect a change? I simply don't get it.

And what of children who have no one to pray for them? If prayer works, what's going on with those kids? Does this prayer-tabulating yet perfect god not care about them? Or isn't he paying attention? Has he deliberately set them up in a situation where they're screwed?

If I were asked (and I surely won't be), here's what I'd say: If your child is sick like this one, and is old enough to comprehend what's going on, think it over carefully. If you need to pray, don't just pray for cure and lay it at her feet. It's virtually certain to be a losing proposition. Help her, hold her, care for her, do what you can to make her happy and to help her come to grips. But don't put the whole burden for survival on her. It's a horrible thing to do. She's asking God's forgiveness? Baloney. He should be asking for hers.

Friday, July 13, 2007

An Open Letter To My Referring Docs


Dr. Rob recently posted a very good letter to consultants. Here's my response, in the form of a letter I'd (never, even in my most erotic dreams) write to referring docs. And may I state that I love reading Dr. Rob: his humor and brilliance and insight are like a cool breeze (it's been really hot around here). If I actually worked with him, I'm certain he'd not be the recipient of such a letter (nor I of his!):

Dear Doc:

Hi, howya doin'? By the way, thanks for the note. It's one of my favorite wines. Glad you liked it.

I'm intruding on your valuable time with a couple of comments on our relationship, hoping they can improve care for our mutual patients. If you don't have time to read this now, maybe when you get home. And then if you want to talk to me about it, give me a page: I'll be at the hospital.

  • Surgeons aren't all assholes. I'm not an asshole. OK, I am, but NEVER to your patients. Ever had any complaints about how they were treated? Right. And you never will. By the way, sorry I yelled at you the other day.
  • I actually know stuff. In training, we used to say "a general surgeon is an internist who can operate." Whereas it might have been more true back then, when we considered it a personal failure (to put it more correctly: attendings considered it my personal failure) if we needed medical help, I still take it as a point of pride that I'm aware of and can manage most of my patients' peri-operative needs. It's more efficient that way, and cheaper for the patient. Plus, I'm there. You're not.
  • Rumors to the contrary, not every surgeon simply wants to cut no matter what. (How's Mr Jones, by the way? The one you sent for a chole who I discovered had gastritis?) Much as I like it when I don't have to think, I'm more than willing to do so. In fact, I'd be quite happy to be involved even before you send me a patient: working together, I bet we can get where we need to go and save a lot of the tests you'd otherwise have ordered. Give me a call. You may have noticed my nurse will get me right away when a doctor calls. (You may also have noticed that when I call you, I call you; I don't make you wait by having my nurse place the call.)
  • There's nothing wrong with early referrals; or failing that, early phone consults. Much as you hate it if I make a reference to the care you rendered before I see your patients (I bite my tongue; I really, really do), it's beyond frustrating to see a patient days, weeks, or months after a problem that you knew to be potentially surgical was handled, uh, suboptimally, alone. HMOs and gate-keepers notwithstanding, it doesn't save money in the long run.
  • In a related matter, how 'bout a call before ordering the interventional procedures recommended by radiologists on mammogram reports? If you think I'm trigger-happy... Seriously, lots of the things they see can safely either be followed, or are palpable and can be much more cheaply sampled by a fine-needle aspiration. I don't charge for phone consults, as you've noticed. I'll even have a look at the film if you'd like. Gratis.
  • Placing all sorts of restrictions on me up front is, y'know, sort of insulting. "Consult only. No tests authorized. You must discuss any intervention with me." We've worked together a long time, buddy o' mine. If you can't trust me, I guess you need to find another surgeon. Have I ever done unnecessary testing or operating on your patients? Ever failed to keep you in the loop? Right. And I never will. I really hate those referral forms. Maybe you do, too. I know we can't get rid of them, but hey, let's make it as infra-onerous as possible. You want my reports short and to the point? You're singing my song, baby.
  • I actually do think you're important. What you do isn't easy. If I liked sitting in an office all day, I'd have chosen to. Oh, and I have no idea what's fair compensation. I know you resent that I make more than you, but here's the thing: I get up every morning at 5 am to make rounds; on a good day I get home at 7:30 or 8 pm, assuming I'm not on call, which I am every third night and every third weekend. I take calls all night, whether I'm on call or not. I go back in, in the middle of the night, a few times a week. You? When I'm in deep doodoo in the OR, I can't take a break, or sleep on it, or have someone bail me out. I'm the bailer-outer. We both work hard; but doggone it, I work harder. And we both know our patients would be worse off if the garbage stopped being collected or the toilets backed up than if you or I shut down.
  • One last thing: please don't tell your patients what operation I'll be doing and how and when I'll be doing it before I've had a chance to see them. It's embarrassing to all three of us when I have to unexplain and disabuse. Sort of related: there are differences among acute cholecystitis, biliary colic, and common duct stone. Surgical approach, urgency, and timing: not the same.

Hey, man, it's been great. I tried calling but your nurse said it was your day off.

Sid

Wednesday, July 11, 2007

Lights, Camera, Inaction!


A hand surgeon I know told me about a lawsuit. He'd removed a ganglion from someone's wrist, and the incision had gotten infected. After pretty routine wound care, with not much hassle for the patient other than wearing a bandage for a couple of weeks, it healed with no after-effects. But the guy sued. Digging in his heels, since it was a routine and minor problem, the surgeon refused an offer to settle, and went to trial, during which the plaintiff's attorney brought in a giant-sized blow-up photo of the wound at its gooiest, set it on an easel in front of the jury, and left it there for the whole case. (Must have been a very quick decision, on the patient's part, to sue!) The jury found for the plaintiff. A reader mentions the idea of video-taping operations. I'm of two minds.

"Can we get a camera in here? I want a picture of this." I've done that a few times, for various situations. I like showing pictures to patients, assuming they want to see them. And nothing beats the real thing: I've shown some pretty ugly appendices to people when they've asked; everyone enjoys seeing their gallstones. Some of it, I suppose, is the drama: surgeon demonstrating his brilliance and his ownership of the situation with visual aids. For sure, it's also about communication and understanding. It's the back-end of the time I always took before surgery to draw diagrams or show pictures of what I planned to do. So yeah, in theory, if a patient asked me to videotape an operation, part of me would want to comply.

Early in the history of laparoscopic surgery, which is visualized indirectly on a TV screen, it was nearly routine -- at least for many surgeons -- to videotape the proceedings (it only requires having a recorder in the system; no special cameras or intrusions, since the whole thing is done with cameras in the first place) and give a copy to the patient. Now, far as I know, it's a pretty-much universal recommendation of malpractice defense attorneys, and insurers, that surgeons NOT record operations. Why? Simple: in the same way that that barf-inducing, gargantuan photo swung a jury, so have videos, even -- hard as it might be to believe -- when nothing was all that significant. Hands shake instruments around. Bleeding occurs; it's cauterized in an effluvium of smoke that can fill the screen. Things are picked up and dropped; bile and stones run out of gallbladders. It happens. But, in the context of a patient having some unspecified post-operative problems, much can be made of these images when they're on a big screen in living color.

I'm a ham. I like having students and other medical people watching when I operate, and I love telling them what I'm doing. I've even set up mirrors so patients could watch me repair their inguinal hernias, holding things up and showing them their own anatomy (mirrors because if they were sitting up, I couldn't expose the area properly.) If bleeding occurs, I'm perfectly comfortable saying something like, "Oh lookie there, better get that guy..." With my attitude, I can control the situation. And, although I never did, I could take down the mirror. I've welcomed husbands/others into my office surgery when I've done breast biopsies under local anesthesia when the woman has wanted it. But I always have them sit down, on the opposite side of where I'm working, holding hands but not able to see. It's less about not wanting an observer, and more about not wanting to worry about them passing out onto the floor. Once was enough.

But I've not agreed to have a family member actually observe an operation. Proud as I am of my surgical abilities, much as I like to hold forth during an operation, I'd feel extra pressure to be perfect; I'd worry that the person simply wouldn't understand the occasional left turns that an operation takes, the inadvertent "oops." And, as I said in my previous post, there's enough pressure already. Any way I can avoid extras, I want it; and so, I'd think, would the person lying there. Videotaping is the same thing, only more so, for the reasons I've already mentioned. If good surgery requires concentration -- and it does -- then any distraction is a bad thing; some more than others. A present family member, or worry over a recording device is a distraction. Human nature, even in a surgeon.

The one exception to the no-visitor-in-the-OR mantra -- which isn't by any means a CIA-level "slam dunk" -- is parents accompanying a small child into the OR. I've not had a problem allowing it during the induction of anesthesia, as a means of dealing with the kids' fears. But I leave it to the anesthetist: some are OK with it, some aren't. I've watched kids snuggle in their mothers' arms while the mask is held to their face, to be whisked onto the OR table as they drift off, at which point Mom is escorted out. On the other hand, there are ways around it: drugged lollipops, for example, that gently hammer the child before leaving the pre-op area.

I've been known to ask for particular anesthesiologists for some kids, when I thought that sort of TLC was indispensable. In the same way, if a patient really wants a recording of an operation, I'd say she or he has a right to look around for a surgeon who feels comfortable doing it. But they should be understanding of those that don't; and that includes, I'd say, most. Which leaves a small pool (ought I add: of questionable judgment?) from which to choose. And, of course, along with the rest of us, they can blame it on the attorneys.

Tuesday, July 10, 2007

Surgeon General

[image from saraphonic.com]


OK, this is going to be a little political, but it's related to surgery, and to me personally, if vaguely.

A recent Surgeon General of the US, David Satcher, was a classmate of mine in medical school. And the most recent one is a surgeon like me. In fact, he trained where I trained. Them's my bona fides.

I find the following outrageous, and as far as I'm concerned everyone but the most blindly partisan ought to share the feeling:

"Anything that doesn't fit into the political appointees' ideological, theological or political agenda is ignored, marginalized or simply buried," Dr. Richard Carmona, who served as the nation's top doctor from 2002 until 2006, told a House of Representatives committee.

"The problem with this approach is that in public health, as in a democracy, there is nothing worse than ignoring science, or marginalizing the voice of science for reasons driven by changing political winds. The job of surgeon general is to be the doctor of the nation, not the doctor of a political party," Carmona added.

Carmona said Bush administration political appointees censored his speeches and kept him from talking out publicly about certain issues, including the science on embryonic stem cell research, contraceptives and his misgivings about the administration's embrace of "abstinence-only" sex education.

I don't know Carmona personally, but from what I do know, I doubt he's some liberal. Yes, I realize that he's appointed by the president, and, as we've heard ad nauseum, serves "at his pleasure." But dammit, there are some areas in which reality -- not to mention the common good -- ought to trump politics, ideology, and theology. People argue, and I don't disagree, that science isn't the same as policy; that scientists aren't the ones setting political agenda. Fair enough. But when science is simply ignored, redacted, or debased, then we are all the worse off. Our future is at stake in many areas. The facts ought to be on the table, unvarnished (I mean the facts, not the table. I don't care much about the table.) When decisions are being made only by a bunch of narrow-minded ideologues, we're in big trouble. They are. We are.



[Update: this is from the red states' favorite newspaper, the NYT:

"The administration, Dr. Carmona said, would not allow him to speak or issue reports about stem cells, emergency contraception, sex education, or prison, mental and global health issues. Top officials delayed for years and tried to “water down” a landmark report on secondhand smoke, he said. Released last year, the report concluded that even brief exposure to cigarette smoke could cause immediate harm.

Dr. Carmona said he was ordered to mention President Bush three times on every page of his speeches. He also said he was asked to make speeches to support Republican political candidates and to attend political briefings.

And administration officials even discouraged him from attending the Special Olympics because, he said, of that charitable organization’s longtime ties to a “prominent family” that he refused to name.

“I was specifically told by a senior person, ‘Why would you want to help those people?’ ” Dr. Carmona said.

The Special Olympics is one of the nation’s premier charitable organizations to benefit disabled people, and the Kennedys have long been deeply involved in it."

Monday, July 09, 2007

Blood Oath























Couple of good posts by ema, and Dino, about the obligation of doctors to provide standard care even if it conflicts with personal religious beliefs. For the record, I couldn't agree more: doctors who feel they can't do certain medically necessary procedures or prescribe certain drugs only for religious reasons ought not to be in the field with which they find themselves in conflict. From the other side of that coin, here's a related story:


When you get a call from a doc who, for various medico-political reasons never calls, you have to wonder what's up. Terrible case that he wouldn't want to dump on a buddy? No insurance? Three a.m.? Usually, yeah, one of those. This was a call to the ICU in the middle of the afternoon, which eliminated one explanation off the bat.

The smell of blood in stool is unmistakable. Metallo-putrid, it lets you know what you're in for several doors away from the room to which you're headed. You can even guess whether the bleeding is in the stomach, or the colon, because the former passes through the small intestine, where digestion affects the odor. Even more: the faster the bleeding, the less digestion. A good nose can tell you things before you enter. In this case, I was clued in from well down the hall.

Curled around and resting her chin on a stainless-steel pan splattered red, lying on absorbent blue pads stained with the maroon of partially digested blood at her backside was a woman in her forties, pale, looking frightened and miserable. Her husband was standing by the head of her bed, mutely and resolutely holding a cloth on her brow. The attending doctor, whom I knew vaguely but with whom I'd not worked professionally, looked up as I approached and head-waggled me to a halt in the hallway. "Thanks for coming," he said, hustling toward me and sticking out a sweaty hand. "Tough situation. Jehovah's Witness, bleeding like stink, refusing blood. She's got a duodenal ulcer, I saw it on a scope. Surgeons A, B, and C wouldn't come see her. I appreciate you being here." Maybe I was young and naive, or maybe I was right: I couldn't fathom those other docs refusing to engage. It dawned on me that if I were to operate and do something that caused more bleeding, and if she died for lack of the blood needed because of my error, things could take on an entirely different aura. Still, I didn't see how I could walk away and let her bleed to death. I went into the room.

Some ulcers bleed and stop on their own. If they start up again during the same hospitalization, the odds get serially less and less that it'll heal without surgery. This lady had bled and stopped, and was bleeding again, fast. At least one of the other surgeons had been called during the initial bleed, as he should have, and when she ought to have been operated. Given her refusal of blood, she was hovering very near to deadly danger, and the decision to operate was clear-cut in my mind, and urgent. I told them so. "Just to be clear," I said to the woman, including her husband in the sweep of my eyes, "You refuse blood under all circumstances, even if it means bleeding to death?" It's what we believe, they both indicated. "Blood products, plasma, everything?" "Yes." "OK," I said. "The odds are this will be pretty straight-forward. I ought to be able to get the bleeding to stop. But, you know, nothing is for sure. It could take much more than it seems right now. And surgery always causes some bleeding. No matter what, her recovery period is complicated by her very low blood count. As clearly as I can see it, the odds of getting through this are significantly better if we operate, but I have no crystal ball. She might stop without it, and heal. She could succumb either way. It's just that I think there's more control at this point if we operate. And if you really refuse to receive blood no matter what, I'm prepared to accept having her bleed to death in my hands." I wasn't sure I was, but that's what I said. Plus, I really didn't expect to have to face such a scenario. Surgery, after all, is good for you.

I motioned her husband to come with me into the hall. "I'm OK with this," I told him, "but I don't really like it much. And, just so you can think about it ahead of time, I want you to know that if we get into the soup in there, and if I think the only way to save her is to give her blood, I'm coming out into the waiting room and telling you and asking for a final time." He gave me a leaden and eye-contact-free nod, saying nothing. A nurse came up with a clipboard. "Shall I have them sign the blood-refusal form now, Doctor?" "I don't know, I don't care... uh, sure, have them sign it. Both of them. Not that it'll make any difference..."

When time is of the essence, you do everything you can to save minutes, from calling ahead to the OR and telling them it's urgent enough to "bump" a case out of the schedule, going there and helping set up the room, to wheeling the patient down there yourself. Let anesthesia know what's happening, help put in extra IVs, make it a quick prep, shortcut the scrub time. I've described techniques for rapid incision in previous posts; it takes only a minute or so to get in and get the stomach into your hands. These kinds of ulcers are usually within a centimeter or two of the pylorus, so you quickly elevate it by placing a couple of traction-sutures, and cut across it longitudinally. Sometimes the bleeding artery spurts in your face: a finger into the hole gains temporary control, while you place a strong suture on a big needle underneath, then lift it up. Now you have it. The typical arterial culprit runs vertically behind the pylorus, so two stitches, north and south, are what you need. Another stitch like the first, and the bleeding is over. When it is.

It's nearly magical: as soon as you get that bleeding stopped, faster than it takes to refill the tank with fluids, the rapid pulse of hemorrhage slows down, as if the body senses the sealing of the hole and relaxes, even before the lost volume is replaced. You can hear the decelerating beeps on the monitor, and it's like a musical exhalation. When it happens.

Before every operation, I get psyched up: for some, of course, more than others. Sometimes there's great anxiety, concern over what I might find, over whether the existing circumstances are such that I could encounter terrible problems. I bring to bear all the concentration I can muster, focus everything I have -- experience, knowledge, judgment, technique. Knowing that -- probably most patients really don't consider it -- you'd think anyone about to go under the knife would want to avoid like poison putting constraints on the surgeon, interfering with the process; eschew limiting the options, interfering with carrying out the procedure in the best way possible, making specific demands, tying -- of all things -- his/her hands. There have been times when I've responded to certain demands by saying I couldn't, on the basis of my best medical judgment, provide care for the patient given the demanded restrictions. Never, for reasons I can't explain, because of religious objection to blood. In fact, I was on the JW list of "bloodless surgeons."

When I ran my malpractice series (one, two, three) a while back, I got several comments from attorneys. I'd welcome them here. Correct me if I'm wrong: the law covering this stuff is all over the map. In general, doctors haven't been held liable for untoward outcomes deriving directly from blood refusal; but there have been unfavorable judgments when an operation caused bleeding that led to death or complications, even if those outcomes could have been easily avoided by transfusion. Anecdotally, I've heard of doctors being sued for not giving blood (when giving it was contrary to the patient's directive!) when the patient died. And, of course, for life-saving transfusion that led to recovery, but were against patients' wishes. It's grayer still with kids. Court orders have been sought, not sought, granted, refused.

There's a difference, in my mind, between my acceding to patients' religious convictions, and forcing mine on them. It's a question of who's got the power. I could have said no. In the reverse situation, a patient may not have alternatives. A doctor's highest obligation is to do what's medically right for the patient, regardless of that doctor's personal beliefs. Clearly, there's not always a perfectly clear border between medical judgment and personal beliefs. If my choice of a particular operation differs from that of another surgeon, how can I say certain "morality" issues haven't been at play? Quality of life. Predictable time remaining, chance of helping... Still -- recognizing that judgments are made of more than book-learnin' in medicine -- a doctor shouldn't be able to refuse either to provide or to arrange for the obtaining of recognized and standard treatments because of religious belief, any more than a firefighter ought to be allowed only to save those people in a burning building with whom his moral judgments are in conjunction.

I've operated on lots of Jehovah's Witnesses; I know surgeons who never would. Same with people with AIDS. I've been fine with patients using all manner of "alternative" and useless methods, as long as they were adjunctive to rather than supplanting what I thought was best. On at least one occasion, I've agreed to do a lumpectomy for a woman with breast cancer who told me in advance that she refused further conventional treatment and planned to take treatments that I knew to be bogus. Figuring she had at least some chance of cure with the tumor gone, I did what she wanted, while trying like hell to talk her out of her plan. I even encouraged her to keep seeing me so that when the nearly inevitable recurrence happened, we'd find it as soon as possible. (It did; we did; but it was still too late.) I've taken a perfectly normal appendix out of someone planning to climb Mt. Everest, and have removed an asymptomatic (but stone-containing) gallbladder from a person leaving for missionary work in a medically-deprived area.) I guess the common thread is the ability for give-and-take. When lines are drawn, on either side, based only on (most often) religious beliefs, allowing nothing across but a thrust-out chin, the whole relationship is chilled, and bad things can happen. Not that it'll ever change.

Friday, July 06, 2007

More Solutions, Long Post


Free health care isn't free. The money has to come from somewhere; the question is how to get it into a bucket, and then how most effectively to get it back out, to where it's needed. People frame it in all sorts of ways, depending on their political persuasions. Andrew Sullivan says that in arguing for government to pay, liberals would have us all be permanent supplicants. Brilliant. And it fits nicely onto a bumper sticker. But it's fatuous. If the ultimate virtue is the taking of money out of one's own pocket and paying directly for one's health premiums, then probably less than 10% of Americans are virtuous. (No comment.) Premiums are paid by employers, by governments, but by only a few individuals themselves (I'm among them.) We're already supplicants. (Well, not me.) If there were universal coverage, taxes would go up somewhere, but premium expenses would go down. The money that goes into the bucket, in other words, would be mostly a wash. Left hand or right hand, it comes and goes. My argument is, in part, that by eliminating the countless insurers and their enormous overhead (their profits, their executive pay and shareholder dividends -- not to mention countless redundant clerical no-sayers) you could fill the bucket to the same level and have lots left over. That would be good, by whatever method the money is taken from us, and by whichever agency it's given back in the form of health care. Package it with a name that makes you happy. Money comes from us one way or another, gets centralized somewhere, and returned in the form of plaster and penicillin. In what way does having insurers in the middle help that happen?

The always-thoughtful Eric worries: "The problem I have with single-payer systems is that I fear a serious erosion in innovation - what compels a single-payer to add coverage for a new-but-expensive lifesaving modality? If your choices are "take what you're given" or "pack sand and pay for it yourself", new technology won't be deployed to save people's lives nearly as quickly." He makes an important point, but, like my concern about monolithic control of reimbursement, it can be addressed (so says me, the non-politician, non-economist, non-systems-wonk) by having at the top panels of consumers and providers making reality-based (remember that bygone concept?) decisions. If such a structure were in place, given that we're now talking about a single entity instead of hundreds, it would be possible for providers and consumers actually to have control. This makes a strong argument for single-payor, as opposed to our current situation, wherein we're divided and conquered. How should such panels be constituted, by whom, with what feedback loop attached to the citizenry? I'm thinking, I'm thinking! But I'm guessing people much smarter than I could figure it out.

I haven't seen "Sicko" yet, but I've seen M. Moore's other movies, so I'm guessing that at its center, he has the problem right, and that in examples and solutions he's overplayed his hand with anecdotes and shot himself in the foot with hyperbole. Speaking of which, in a review of the film James Christopher of the London Times says, "What he hasn’t done is lie in a corridor all night at the Royal Free watching his severed toe disintegrate in a plastic cup of melted ice. I have." Interesting: in my opinion, universal health care has no business covering the re-implantation of toes. Fingers, yes (depending on which ones). Toes, unh-uh. If surgeons use big toes to replace thumbs, -- and they do, they do -- that they are otherwise dispensible, foot-wise, is spoken to. A thing to which it is spoken.

And that gets us to the nitty-gritty. The bucket isn't bottomless. We can decide how much it holds, but at some point we also have to decide for what kinds of care the contents will be doled out; unless we want to make it bottomless, which we could in theory, but won't and can't in fact. Keep the costs down, we all say, except (you know what's coming) when the care in question is for us or our loved ones. "Spend a little as possible on them, and as much as needed on me" is a plan, all right, but is hardly a workable one. (Less so in the minds of one political party than the other). But let me be clear (since I've given myself the soapbox): I'm OK with tiers in the system. Not tiers of joy, to be sure. But this is America; plus I've said in my previous post that I think payments to providers ought to reflect quality of work: if I'm asking for rewards for the quality of my work, I can't begrudge it elsewhere. It's not without moral unclarity (if health care is a right, it doesn't automatically follow that people should be barred from obtaining different levels thereof), but the idea that there might be a difference between basic coverage given to all, and that available to those willing and able to spend more is one I can accept. It's just the way it is: a system that is the same for everyone with no avenue for opting up won't fly, pragmatically, at this point in the US; but one that provided everything for everyone under all circumstances will bankrupt us, absolutely, eventually. Heck, we're heading there (bankruptcy) already, on more than one track.

It's either/or. Either we decide as a nation that we're happy spending whatever it takes on health care, or we address the issue of rationing (ok, let's call it "prioritizing.") Some countries do it openly: in England, on "the National" it was true at least at one time that, for example, a person of a certain age with a certain percentage of body burn got supportive care only: pain medication, comfort. Some do it de-facto and maybe even cynically: in Canada you have to wait a long time for certain procedures, which means some don't get them, even though it's not specifically proscribed. A few years back a British orthopedic surgeon responded to outcry over long waits for hip replacement by saying that the line wasn't as long as it looked, since some people die while waiting for the operation. Probably the hardest thing any health care worker does is deciding when further care is inappropriate. It goes on all the time; it's just not formalized. Somehow, sometime, on paper and in public, it needs to be. A comatose hundred-year-old in kidney failure doesn't get dialyzed. A ninety-five year old? Not him, either. Sixty? Sixty-five? OK, eighty-five? And if the idea is repulsive -- which it is -- and if it simply can't be addressed (certainly Congress never will), then let's just agree that the best we'll ever do is nibble at the edges. Which, to date, has pretty much meant nothing more than continually lowering reimbursement to doctors and hospitals. Turnip. Blood.

Outraged comments on posts such as this notwithstanding, people willing to work extremely hard under lots of stress to provide an excellent product have a natural inclination to expect some sort of commensurate reward. Certainly no doctor expects to get as much as a mid-level executive for Healthcom, or as much as a second-string second baseman. But something that reflects work and which doesn't continually drop would be nice. The price for the current approach has been, and will continue to be, burnout of the best, and the looking elsewhere than medicine by the sorts of people you'd like to see choosing it as a profession. The problem with us goddamn doctors is that we're also human beings. Tell me what you think a colon resection is worth, then stop lowering the amount every year. And if you won't let me charge more on my own because I do a better job (every other professional does), then show me a way you'll try to figure out if I'm better and slip me a little something. If not, don't expect everyone to keep striving. It doesn't work that way anywhere else; increasingly, it's not working that way in medicine, either. Which makes the next paragraph, probably, wishful thinking.

There's one thing to do before playing the rationing card. Doctors, as a group, have a hard time with it; but it's coming, and it needs to arrive. To the extent that it has arroven (yes, I know), so far it's pathetic. I refer to finding out what works, why some doctors get better results than others, why some can get the same results as others at half the cost. Determining, in other words, "best practices." Finding that out and putting in place methods to encourage the good and eliminate the bad. Care, that is. What we have so far, referred to by the much unloved acronym "P4P" -- which stands for "pay for performance" -- is, at best, silly; and at worst, counterproductive, because it's so stupid. An example of bureaucracy at its worst, the list of parameters seems to have been generated by a committee with little input from actual practitioners. Big surprise. I know medical quality is hard to quantify, to solidify into a checklist. But for surgeons, for example, the archetype is getting pre-op antibiotics into the patient no longer than an hour before surgery. Funny. In training, we were told to get it infused at least an hour ahead of time, so tissue levels could rise and equilibrate. Yeah, you can measure it and write it down. But what goes on much before that -- in terms of selecting and planning an operation -- and after that -- in terms of carrying it out and in providing post op care -- has volcanically more impact that the ticks of the antibiotic clock. Everyone knows that. Getting a handle on it is where the action is; but if it's possible at all, it'll take a hell of a lot of work. Thousands of records will need to be reviewed, outcomes compared, methods dissected. Necessarily, judgment will be called into question, egos will be threatened. Worse, errors in data collection and analysis will be made; conclusions may be wrong sometimes, or tainted. The various specialty societies and colleges will need to be at the helm, and it'll take time and will generate lots of heat (with good planning, maybe enough to reduce oil imports), but in my opinion it has to be done. All doctors and nurses know it: there are good ones, and better ones. And some bad ones. Crazy maybe, but I think most docs -- given the right incentives and handled in constructive ways -- will respond to information that allows them to do a better job, even if it means admitting that they may not have been in the past. Scream, yell, get pissed off, feel insulted. Then lie awake at night and think it over, look yourself in the mirror when you get up. And make some changes. Been there. Done that.

To the extent that people running for president are addressing health care at all, keeping the money-changers between consumers and providers seems to be a given, which strikes me as feckless and crazy. Why should a national health-plan include a layer which provides no care, is clearly dispensable, and which serves to suck huge amounts of money out of the system? It's like paying someone to put the key in your car before you start it.

So my thoughts distill to three things, needed in this order: a single-payor system that includes real and actual control at the top by providers and consumers; a no-holds-barred effort to find and encourage (enforce) best practices, which recognizes and rewards excellence; and, when all the money that's possible to save has been saved, the toughest of them all: prioritizing care; deciding which expenses make sense, and which don't -- rationing. (Alternative to number three: stop complaining about costs of health care.)

(I suppose it's not trivial that if the insurers were really to go away, there'd be lots of decent people without jobs. But that's hardly a reason to keep a useless system going. Maybe some of those displaced would be willing to do those jobs that, you know, Americans don't want to do. That way we could solve immigration, too.)