Saturday, September 20, 2008

Alternate Universe


Careful readers of this blog, those attuned to subtlety, may have sensed an occasional tendency to dip a toe, if ever so carefully, into political waters. My opinions, shrouded as they have been in gentle deference, may not have even been recognizable as such. Generally shy, and of the belief that I have no right to impose my thoughts on others, it will surely be agreed that I've never said anything unkind or provocative about politicians with whom I disagree.

I may have to speak up.

I begin with a question, a simple request for factual input: WHAT PLANET IS JOHN MCCAIN LIVING ON? HOW MUCH EFFLUVIUM OF BULLSHIT CAN ONE MAN SPEW BEFORE CHOKING ON IT? DOES HE REALLY THINK EVERYONE IS STUPID, OR IS IT JUST HIM???

Long have I admired politicians across the political spectrum for their ability to say one thing and do another, evidently free of embarrassment. It matters only which party is in power: complain about the other party's tactics until the power is reversed, then do exactly what it is you've been decrying. Without shame, without a second thought, without the need even to mumble something like, well, I realize I used to say "A" and now I'm saying "Z," but...

A pox on both parties. I'm partisan, but not above realizing that at the national level they're all a bunch of bullshitters. Still. It seems there must be some sort of line beyond which people couldn't cross without a grain of self-awareness pulling them back. Y'know: a point where it's so obvious they'd be unable to keep going, throat constricting involuntarily, words so ridiculous they'd be unutterable. Not so, evidently, with John McPOW.

So we have the spectacle, this week, of the economic meltdown. (Let's ignore the previously most obvious fact that everything he's been saying about Sarah Bush-in-Lipstick Palin has been proven false while he and she continue to say them). In response to the crisis, Barack Obama got together with several real heavyweight people -- past chairman of the Fed, previous Treasury Secretary, most successful investor on the planet, several others -- and calmly (okay not entirely without a political jab or two) presented a summary of reasons behind the crisis, and an approach to dealing with it. Called for bipartisan cooperation. John McNuts, on the other hand, got up and.... blamed the whole thing on Obama!!! He -- mister point man of the Keating Five -- claimed it was Obama who somehow represented everything that was wrong in Congress. His entire response was political attack, and at that, one entirely ungrounded in fact. Repeating, umpteenth, that Harold Raines is Obama's main economic advisor, among other demonstrably false notions. Disproven. No matter. John McCain, who's been in Congress since before the Constitution was written, whose actual economic advisor personally dismantled the regulations that were there to prevent such things as have happened, whose most visible (until a couple of days ago) surrogate on the economy was the CEO of HP who was fired after killing its market value but who nevertheless got a thirty million dollar severance package -- this guy actually stood up and said everything that has happened is entirely the fault of Barack Obama.

I mean, come ON!!!!

He didn't, of course, stop there. While choosing, rather than proposing anything serious, to spend the entire time blaming Obama, his campaign denounced Obama for "politicizing" the crisis. Complained about fundraising emails while sending out fundraising emails.

I know some conservatives. Even like some of them. Many are educated and thoughtful people: honest, generous (up to a point). So I'm quite sure that when the lights are off, bathed only in the holy light from their shrine to Ronald Reagan, some of them are cringing. He's lost it, they must think (in fact, before he was nominated, most of them thought he never had it.) Politicians distort, obfuscate, ignore facts. But really. McBush and Palin have crossed that line by so much that they're entirely untethered to Earth. Don't they even care? Evidently not. Nor, it seems, do their supporters, waving lipsticks in the air like lighters at a Dead concert.

I read a couple of articles recently that have helped me to understand. Here's one. It's touching. The other, if it's repeatable and accurate, really gets to the nub of the matter. Read it, and decide for yourself.

Sunday, September 14, 2008

The Bed In Which They Lie



Might there actually be justice? Could it be that McCain and his lipsticked liar have overplayed their hand to the point that even voters will notice? Is it possible that the dual deceivers have devolved in desperation, doubling down on duplicity? Might a campaign based on lies be rejected? Well, it's never happened, of course. But could it, finally? Would unsustainable deficits, lack of energy plans, an unfocused response to the threat of terrorism, health care failures, education devolution be enough to make a majority of voters think seriously enough to demand straight talk from their politicians? Not to mention their free press! Nope, nope. Probably not. But a guy can dream...

I've never bought the media-enabled persona of McCain as a man of integrity; but let's give him the benefit until now. Now. Finally, it's being asked: is there anything he and his campaign have been saying of late that's remotely true? Isn't it obvious that, whoever he might have been, he's happily and without any remorse lying about pretty much everything? Pigs, pork, sex-ed. Taxes. Travels, tallies.

And here's the thing: whereas it's clear that Sarah Palin and her fight against "earmarks" is a complete fabrication, even if it weren't, WTF??? I mean we're facing outrageous deficits and our debt is intolerable, with consequences so dire that practically no one is talking about them. (Want scary? Watch this.) So even if Slippery Sarah rides in on a white horse and eliminates all the earmarks that she ever asked for (lots), turns back all the money she kept from bridge to nowhere and other porcine programs (millions), and even if she wipes out all the acoustical aims of every other politician in Congress, it'd have virtually no effect on the budgetary problems we face. So it's a diversion, and a very cynical one at that. Talk all you want about Sarah Palin, says Juggling John. The more you do, the less time there'll be to look behind the curtain. 

What got me going this time? This. McCain's senior economic advisor, in a book to be released after the election, acknowledges that any president will have to raise taxes, that we simply can't sustain the current policies. And whereas McCain insists not only that he'll not raise taxes but lower them, and while he declaims against Obama for suggesting the need to raise them, the reality is that no one can or will speak about the fatuous folly. From the article, there's this:

"So why does tax-cutting mania persist among Republicans, I asked Holtz-Eakin, the McCain adviser--given...that, as Holtz-Eakin himself explain to me, taxes soon have to go up substantially in any event?
"It's the brand," he said, "and you don't dilute the brand." "

We are so screwed! I'm not so silly as to think that Obama and the Democrats will be lots better; but at least they're acknowledging the problem and saying unequivocally that the Bush tax cuts (which McCain has promised to make worse) can't be maintained. 

Patriotism. Love of country. Sacrifice. Country first. What empty words; how meaningless, as enunciated by John McCain and his apologists. In these dire times, what are called for are things no one wants to face: tighten our belts; use less oil; be willing to pay more taxes to save the country; address entitlements; stop useless military programs. Talk straight about oil, debt, terrorism. But that's the sort of straight talking that if McCain was ever for, he no longer is. Run on lies and innuendo and obfuscation; pick a veep willing to do the same, willing to say anything. Tabula rasa, like George was. Prestidigitation. It's obscene. At least they admit it:

“Every day not talking about the economy, the war and how to fix a broken system is a victory for McCain,” said John Weaver, a former top strategist to the nominee who left the campaign last year. “They’re going to ride it as long as they can and as long as the mainstream media puts up every ridiculous charge.”

The only way politicians would actually stand up on their hind legs and say and do what needs saying and doing, is if the electorate were to demand it; if they'd make it clear that the kind of sleaze, distractions, and phoniness that we're now seeing, mainly coming from the McCain side, will no longer cut it. Not now. Enough. Not in these times!

Might such a rejection actually happen? Well, so far it doesn't look like it. Fed a line of b.s. for the last eight years, told not to worry, everything's fine (well, not exactly not to worry: not to worry about anything but terrorism), voters expect not to be asked to think, nor to make demands. Prefer it, no doubt. So whereas it seems our pathetic media are finally waking up and seeing McCain and his campaign for the lies and sleaze that they are, I'm far from convinced -- the opposite, really -- that it'll make much difference. We're not about solutions in this country. We're about ignoring the facts, wishful thinking, scapegoating, and referring to anyone who points it out as part of the "hate America first crowd." Until that changes, nothing else will. And if it doesn't change in this election cycle, it'll be moot. The future will have slipped away irretrievably. Party on, dudes. Why not? They're playing the tune, and we're dancing. Party like there's no tomorrow.

Monday, September 08, 2008

Nation; Tubes; Down


Eight years ago, we elected as president the short-term governor of an oil state, unschooled and uninterested in foreign policy; a denier of evolution; a doubter of man's role in global warming; a believer that homosexuals are sinners who deserve unequal rights; a person who needed others to tell him what to think and do; a scoffer at opponents, a fomenter of cultural wars, a hater of freedom of the press, a stone-waller of investigations. That person misled us into and mismanaged a war, changed an economy of balanced budget and enormous job-creation into one of crushing debt and crashing markets. Eight years later, John McCain put lipstick on him and made him his vice-president.

Neither convention was a paragon. Bloviation abounded aplenty. But from only one did you hear a steady stream of mockery, derision, and hatred. Only one party paraded to the podium a panel of promulgators of profound and protracted putrefaction. Into the old pocket of political hypocrisy they reached, drawing out a hand dripping with the usual tropes of "elitism," media-bashing, demonizing of the other party. 

And it's working. 

The nation, evidently, is gaga over a person with absolutely no excuse to be President other than a story. And a phony one at that: no rejector of earmarks, she; no turner-away from vindictiveness, no believer in library books. But it doesn't matter. She's perfect, because... because.... why, exactly? 

John McCain is a war hero. Funny thing about war heroes. The ones I know don't talk about it. They don't say they don't talk about it while talking about it. In fact, most don't consider themselves heroes, even the ones that behaved heroically, by risking their lives to save others. Some that are called heroes did no more than survive, sometimes saying and doing things they now regret, in order to survive. Maybe some of those feel so bad about it they need to show themselves how really tough they are, for the rest of their lives. Guess what? They don't need to. Any of us would have done the same, if we'd made it through. 

Says John McCain's campaign manager: this election isn't about issues. Isn't about issues. When we are drowning in debt, might soon be drowning in sea water. When we need to find an alternative to fossil fuels; when we are fighting at least two wars and fomenting a return of the Cold War. As terrorism flames around the world, and our plan is to pour gas on the fire. When our nation is falling behind the rest of the world in education, invention, resolve. Isn't about issues. It is, he says, about stories. The war hero, the hockey mom. 

And it's working.

Political candidates who think deeply and broadly about complex issues are taunted for their "elitism." The ones that reduce problems to mindless black and white win the day. We simply can't accept that tough problems need cooperation, and careful thought. Too hard. Too demanding. Let's go shopping.

And it's working.

Nation, meet tubes. From the bottom, looking up. 


We're

Thursday, June 26, 2008

Milestone or Finish Line?


Well, staggering, flagging, and hyperventilating, I've made it (coupla' days short, but why wait?) to the two-year mark, bioarcheoblogically. Probably that's within a standard deviation or two of the average blogspan, and I'm not sure I have any more in me. My original intent -- to inform and to entertain, focusing on what it's like to be a surgeon, and to enlighten about some surgical diseases and situations -- seems generally to have been fulfilled and to have run its course.

I'm satisfied with most of the stuff I've written, embarrassed by a few items here and there (one of my posts on anesthesia was so poorly realized and understandably misconstrued as to have engendered some really hateful responses; I didn't take it down, but added an apology at the end. It still bothers me, because in the main my relationship with the givers of the gas was always excellent and one of mutual admiration. Such are the results of hasty writing.) Some of my informational posts, particularly my series on gallbladder issues, still get a steady stream of comments and questions to which I happily respond. Others, of which I'm more proud, creatively, (such as the series on deconstructing an operation, and those describing the exhilaration and honor and responsibility of doing surgery, of touching a person from the inside) are sort of mildly vibrating out there somewhere, nowhere in particular.

On a good day I feel justified in saying that in originally-intended areas, mine was, at least for a while, a useful and maybe even unique voice among the surgeon-bloggers. Now there are several more than when I started, and not only are they really good, they have the advantage of being still in active practice, which provides a steady stream of the new. In only looking back, my view gets increasingly hazy, repetitious. Less au courant.

Of late, many readers know, I've taken to ranting on most weekends. Heartfelt the words may be, but surely nothing unique. In my blithering I doubt I've said anything that hasn't been said many times, and better, elsewhere in cyberspace. Often over the top, I've begun to feel like a bit of a scold. I enjoy the repartee, even when it's pretty acidified (something about the air in emergency rooms?); still, I realize more and more that it's just noise, as opposed to what I was doing for the first one-point-seven-five years. Given the helplessness and frustration I feel in the political scene, ranting is some small measure of action; but it's of no real value except as a pressure-valve to me, and then only a little. The truth is I do find myself more and more frustrated and depressed by it all; yet the temptation to gesticulate and froth at the mouth isn't really doing anyone any good. Neither me, nor you.

So. As I've done a couple of previous times (this one feels different), I'll jack my "Sampler" post to the front of the line and sit back and see if I have anything more to say, sometime down the road a piece. At least one reader has suggested a sort of "Ask Dr. Sid" forum, a la "Ask Dr Rob," done well and humorously elsewhere. I guess I'd be different from Rob if I stick to things surgical and keep it straight. Otherwise, I think Surgeonsblog may have come to the end of its useful life. If I end up going back to work (not yet entirely sure), some good new stuff might be generated.

Meanwhile, "Sampler" is just that. The archive remains: there's lots more in there.

Wednesday, June 25, 2008

Food For Thought


Wedging a little update, for public interest, between my previous and tomorrow's (final?) post, I thought I'd mention a meeting I had recently. Some readers will recall I said I'm considering resuming, part-time, my surgical hospitalist gig. In discussing details, some interesting issues came up which go to themes about which I and other bloggers have written severally: namely, the changes going on in training programs and the products thereof.

I talked with two surgeons; one was of my era, the other much younger but having finished training just before the invasion of the eighty-hour work week. They have big concerns. Having just hired a couple of the recently minted, they are finding the need to establish a mentoring program, because the newbies seem neither to have the skills nor knowledge to manage completely on their own, despite looking great on paper. This, of course, is exactly what I've written about. In fact, I've suggested such a mentoring program will need and ought to be a formalized requirement of all new trainees, given their limited experience compared to those much decried days of yore (and myre.)

The ramifications are many. For me personally, and others like me, it might suggest a future premium: who better to mentor the fresh faces than the old and grizzled and recently retired? And for me personally, and for you, let's hope we never need surgery. At least until the full effects of the recent changes are realized and dealt with. Which would be, oh, another couple of decades. So good luck with that.

The warnings are out there, in this blog and comments thereon, and in many others, as well as in a trickle of papers on the subject. I've been saying there's trouble ahead; it may or may not be as bad as my worst fears. I'm certain there are highly-qualified people being cranked out. The questions are, how many, qualified for what, and willing to do how much? And how to separate the sheep from the goats.

Meanwhile, were I to finalize the job arrangements (not yet certain), there might be food for further thoughts down the road.

Tuesday, June 24, 2008

Old Time Doc


Clueless at the time, when I applied to medical school I sort of imagined myself one day making house calls, good ol' Doc Schwab, paid in chickens and pies, smiles and blackberry jam. There I'd be, delivering babies on kitchen tables, patchin' up Old Lady Jones's leg on the sofa, shaking out thermometers and feeling foreheads. One of my roommates in med school was the son of such a doctor, although instead of clopping around with a horse and buggy, he raced across the back roads of Kentucky in an Aston Martin DB4, before James Bond ever thought of it. State cops would look the other way: Aincha gonna stop 'im Jess? Do whut now?...hail no, that thar's Doc Munger, heading t' th' McCoy homestead, I reckin'...

I liked the whole idea of it.

More so in the early days of my practice, when I had a little extra time on my hands, but to some degree throughout my entire career, I actually made house calls. As time became more precious, I had to be realistic: not too far out of the way, people with a simple problem for whom a trip to my office was especially difficult. Or, once in a while, a friend. But as a youngster there were a few times when I went quite out of the way, and spent a lot of time.

For example: I've always had mixed feelings about "the phone call." A woman is awaiting the news of a breast biopsy; I call her and note the stoppage of breath at the other end of the conversation. To defer by saying she should come in is to let her know but provide no support. To give the news over the phone is in some way heartless. So I'd split the difference by breaking the news as gently as I could, and inviting her in for an immediate consultation. But sometimes, early on, I reversed the equation and said, "How about if I come over and we can talk about it?"

One time, in my pre-gray-hair days, after I'd spent at least an hour at their home, my patient and her husband gushed at how much they appreciated the visit and my care to that point, but they'd be going to Seattle to be treated. Probably thought I looked too young. And hungry. Pissed me off.

Most of the time, my house calls were to a post-op patient, usually older, having a hard time getting around: quick check of a wound, a little debridement, change a bandage, remove or unclog a drain. I'd load up with a few tools, some tape and gauze and ointments; sometimes I stuffed them into my black doctor bag, for my own nostalgia more than anything else. Walking to the door, wondering what the neighbors thought, figuring they'd be jealous, their neighbor had a heck of a doctor there. Always the visit was greatly appreciated, and generally met with amazement. Sometimes it was my own: finding out how my patients lived, in a trailer, in an unkempt crumbling home, in a fancy joint with all the options. And I'd learn about how they were able, or unable, to carry out the instructions I'd given them. Which led to a much more practical and pragmatic approach to what I'd tell people about after-care at home. Dispensing with certain residua of academe.

Once I got a call from a feisty old lady for whom I'd recently done a mastectomy: she was worried about her wound, or a drain, or something. To her obvious delight I'd said, "Well heck, I'm almost done here, how 'bout I swing by your place on the way home and have a look?" She answered the door buck naked from the waist up, her unoperated side of the enormous variety; responding to my undisguised surprise she said, "Hell, I figured you'd want to see it anyway, so why get dressed?" Her home was right on a main street. No screeching tires, far as I recall.

Making those decreasingly frequent but career-continuous house calls always made me feel good. The benefits were invariably mutual. Part of my medical school curriculum was the matching of every first-year student with a family in which the wife was pregnant. We followed her through pregnancy and delivery and were involved in the care of the baby. At least one home visit was a requirement, and we met in groups afterward to discuss what we'd found. Among others, the import was in learning that patients' illnesses are part of an entire life and not just the little slice of the day during which we see them.

All doctors -- and most especially surgeons, who typically send people home very significantly altered (if only, hopefully, for a short while) -- would be amazed by and learn from seeing their patients in their homes. It is, of course, completely impractical and nearly wholly impossible nowadays, which are very good reasons why it rarely if ever happens. Not to mention the occasional fright of seeing an old lady naked at her front door.

Monday, June 23, 2008

ER, Uh...


(Here's post I wrote but didn't publish, a long while ago -- well before a subsequent kerfuffle, or any of my recent rants and the comments thereon... So no, I'm certainly not talking about you. Or you.)

[And the preceding was written longer ago still. I'd figured I'd not publish it at all, because it might be seen in light of some comment-conversations I've had with a particular ER doc. Such is not the case. It was WAY long ago that I wrote it. I suppose the post makes me a hypocrite; except I only rant on weekends, and describe it as such; whereas many ER blogs are suffused with extremities all the time. Plus, I'm about to hang it up, so WTF. Since, increasingly, I can't think of anything new and good, I may as well put the old and bad out there. At one point so long ago, I took the time to write it. So here it is:]


It could be said that the blogs of ER docs are the most colorful of the medblogs (and, by golly, I just did!) With no exceptions that I know of, their proprietors are excellent writers and humorous, plus they have lots of great stories, working as they do with nearly perfect substrate. And it's a pretty good job: never boring, clear and specific (one might say "surgical") tasks, predictable hours, decent pay, no calls when not at work. So why are those guys so pissed off all the time?

Training in one of the nation's premier trauma centers, I think I've seen it all. Inundated every day with countless dispossessed and deprived people whose only source of medical care was the emergency room, we also saw all the trauma and emergency surgical cases transported by every aid car in the city. As an intern just starting out, at first I tried to attach every drunk and druggie to a social worker, the crazies to a shrink, to arrange rehab, make appropriate followup appointments. It didn't take long to realize that in spending that extra time, I was depriving others of needed care. I went from bleeding heart to speeding chart, and got a lot more care to a lot more people. I saw cops and criminals, drunks and dregs, do-gooders, junkies by the bagfull. I've been lied to, spit at, cursed up, dressed down, swung on by people I was trying to help. Some came back and back, promises busted like my nice suture-work. I have no illusions. I understand, and I participated. Dark humor, darker view of humanity: they come with the territory. It's self-preservation, if nothing else. Schadenfreude was I. Joker at expense. Still, I think I managed...

Spending day after day in emergency care takes a heavy toll, I know. I love the stories, I value the work. And yet. Reading some ER blogs -- not all, and by no means all the time -- I find the vitriol off-putting. The derision. And the take-no-prisoners attitude -- the downright hatred, so it often seems -- toward "liberals," suffused throughout. (Not to mention a similar attitude, quite often, toward their own clientele). I love political give-and-take; most of my work-colleagues politicked far to my right, yet we had enlightening and stimulating, good-hearted arguments. But reading some ER blogs, unlike any other category in the healthosphere, is like listening to Rush Limbaugh or Ann Coulter. It's a polemicist's playground. I've had my moments of moral muttering, liberally laced with haughty holiness. I consider George Bush the worst president we've ever had (and no, Mr. Bush, history will not vindicate you). But I've never called him "a bucket of spit." Nor do I kiss off all conservatives as some sort of existential threat. (Some, of course. But not the whole group.) Physicians are, in general, a conservative bunch. But they're also educated; enough, you'd think, to have left their minds at least slightly ajar.

Maybe it's an inevitable corollary: working in an ER turns people. Another possibility: people who lean loudest to the right are the ones who choose the job in the first place. Or perhaps (with a couple of exceptions) it's just that the rightward ER docs blog, and the leftward ones go home and tie-dye.

Saturday, June 21, 2008

Delete "Elite," Tout de Suite



[Another weekend rant. But be of good cheer: it'll be my last. Also, I wrote it a while ago, so it's a little out of date. I'm emptying my drawers. As it were.]


Here is an opinion column that pretty much says what I've been thinking ever since Hillary Clinton's and John McCain's dismissal of the universal condemnation by economists of their gas tax holiday proposal. "Elitists," they called them. Them there 'lekshuals. Well, I've been thinking about it since she (unexpectedly), the wife of a president and daughter of the Seven Sisters, and McCain (expectedly), the son of admirals and duacentamillionaire by marriage, began trying to paint Barack Obama as an elitist. Naturally, the talking heads have taken up the cry. Just as it's assumed without scrutiny that John McCain is a wizard at foreign policy, pols promote the Obama/elitist meme as neogospel. The writer of the opinion piece said it well enough, but here's how I'd have put it:

FER GAWDS SAKE, PEOPLE!!! THE WORLD IS COMING APART AT THE SEAMS. WE'RE RUNNING OUT OF OIL, WE'RE MELTING, AND BEFORE WE'RE SWAMPED IN SEAWATER WE'LL MOST LIKELY DROWN IN DEBT. WAKE THE FUCK UP!! WE'VE TRIED IT WITH DUMB PEOPLE. ISN'T IT ABOUT TIME WE GAVE ANOTHER SHOT AT HAVING A SMART PERSON AS PRESIDENT??? NOW, WHEN OUR LIVES DEPEND ON IT??? SHOULDN'T IT BE A GOOD THING TO HAVE LEADERS WHO ARE WELL-EDUCATED AND CAPABLE OF A COMPLEX THOUGHT??? DON'T THE TIMES DEMAND AN A-STUDENT, FERCHRISSAKES? ISN'T THINKING BEYOND BUMPER-STICKER PHRASES EXACTLY WHAT WE NEED? WOULDN'T YOU LIKE OUR PRESIDENT TO BE THE SMARTEST PERSON IN THE ROOM, THE ELITE OF THE ELITE? ONE WHO LISTENS TO OTHER REALLY SMART PEOPLE, WHO ARE EXPERTS!!!??? WHAT THE HELL IS YOUR PROBLEM??? ARE YOU REALLY GONNA BUY THE CRAP THOSE IDIOTS ARE TRYING TO SELL YOU??? #%$$#@@%&?&RS!!!

Or something.

We seem to have come to a pass wherein people not only don't care about intelligence in our politicians but have elevated stupidity to some sort of golden ideal. C-student? Heck, we can do better than that! How about bottom of the class at a military academy? Voters, in numbers large enough to flip an election -- so it appears -- care more about "relating" to a candidate (whatever the heck that means!) than about what he or she says about the really difficult problems we face. Thus, the two-carbon-fragment test: who'd you rather have a beer shot with. I think it's a sort of a mind-melt, mentally checking out of the debate: it's just too damn hard to think about the important stuff, and too scary. Let's talk wives, flags, fist-bumps. Enter the stupid. Cling to it, one might say.

There's a paradox: we saw it in the reaction to Barack Obama's "bittergate." The very people whom Republicans want to characterize as insulted by Obama's remarks are those that they (Republican strategists) assume want the simplest answers in all spheres: the Bible is the inerrant and literal word of God. George Bush never made a mistake. Gay marriage is more important than energy policy. In decrying Obama's poorly phrased but easily contextualized words, they count on the very thing they pretend to dismiss. You gotta be pretty elitist to think like that! N'est-ce pas?

Wednesday, June 18, 2008

Ignore RSS

See, Blogger has a new feature where you can schedule a post to publish automatically on a future day. All you need to do is indicate the day, and hit the "publish" button. Cool. Except that I thought I'd entered a future date when I hadn't. So a post just published prematurely. Unlike some other premature happenings, there's a solution, which is to delete the blog and do it again. Readers who honor me with an RSS feed from here will have received that wayward post. Others will see it next week, as intended.

Sometimes I wonder why I don't walk into walls.

Empath


I received an email from a reader who plans on a career in surgery; she asked about empathy, or lack thereof, and how it affects a surgeon. It's an interesting question, and it plays in both directions. Other than situational intensity, I think it's the same for all docs.

Conventional wisdom has it that doctors must retain "professional distance" from their patients. To allow oneself to cross the line (where ever it might lie) and become too close (what ever that might mean) is to risk letting one's judgment become clouded when difficult decisions must be made. The argument is not without merit; to the extent that physicians must be dispassionate in their thought-process, I fully agree. But I think the calculations that are made necessarily include some knowledge of who the patient is. And, as I've said more than once, I think it's part of a doctor's job to instill confidence and trust in her/his patients, because I think it helps them to deal with their illness and recovery. In part, that requires the ability, at some level, to see inside their heads: empathy, in other words. Looked at that way, it's part of the job.

At minimum, I'd say, it ought to be possible even for the most aloof doctor to imagine how he or she would like his or her, say, parents to be treated by a phellow physician. For those who lack it naturally, empathy, one would think, ought to be acquirable, teachable, emphasized as a needed tool in a doctor's bag of tricks. Relating to patients from a place lower than a high horse; treating with respect and kindness; these are as necessary, in my view, as any other skill a doctor needs. It comes from empathy. If you don't have it, fake it.

The flip-side is the question of physicians' personal well-being: if you empathize with all your patients, do you risk bearing too much of a burden? Does it lead to burnout? Is that "professional distance" necessary for one's own survival -- forget about the patients.' As I see it, that is in fact the higher concern. Paradoxically, empathy needs pairing with the ability to compartmentalize, to relate one-on-one and leave it behind when you walk away. As if that's actually possible.

Somewhere above the middle on the list of factors in my own burnout is the sharing of pain with my patients. As my practice grew to include more and more patients with breast cancer, as one very large example, so did the proportion of patients that came to me with it every day. And as the years went by the average age seemed steadily to lower. More and more frequent it was that I found myself in my office, face to face with a young woman and her family, little kids, my words bouncing off that terrified mask, ineffectual, trying to balance hope and honesty. Each one was a little more painful than the one before; each time my chest felt tighter, my desire grew stronger to tell my nurse never to schedule another such patient. Worse, I had to fight harder and harder to resist the urge -- hollering from within my own burning brain -- to paint a rosier picture than the situation called for. Just to avoid the tears and the terror. (If empathy can be learned, I'm not sure it can be unlearned.) I think I never yielded. But the whispered temptation was among the voices telling me it was time...

It's easy to sympathize with doctors -- and stereotypically, anyway, it's more likely to be surgeons -- who purposefully remain above it, who relate to their patients in a perfectly matter-of-fact manner, or worse. And yet looking back on my career it's the times I've been thanked for kindness, have been told the time I took was appreciated, of which I'm most proud. Beyond telling myself I was good with the mechanics -- which I do, rightly or not -- it's the sense that I cared deeply that I think made me who I was as a surgeon. And without doubt, it's also a large part of what shortened my career. Had I cared less I might well still be at it.

So here's the answer I should have given the young woman: I haven't a clue!

Monday, June 16, 2008

To Sleep, Perchance...


Last night, as is occasionally the case, I watched "60 Minutes." (I love PIP. In my form of ADHD [figuratively] I rarely watch one thing at a time. I was watching the NBA finals, too.) Most of the show was devoted to sleep, and the lack thereof. It raised issues about which I've thought often over the years.

To anyone more than an occasional reader of this blog, it's well-known that I learned surgery in those bad old days before work-hour restrictions. Spending a couple of weeks straight (and in some cases a couple of months) in the hospital was the norm. Working through many nights, catching a couple hours' sleep here and there was how it was. And although I was frequently exhausted, and despite the fact that on my rare nights off I routinely fell asleep whenever I went to a friend's house, I would say then and I would now still insist that I never made a poor decision or improperly carried out an operation because of sleep deprivation. And I recognize that insisting such a thing does not make it so.

Youth has certain advantages. Back then, when I had a moment to sleep I made full use of it. Within moments of resting my head on pillow, I was out. If the phone rang, I was fully awake and firing on all cylinders instantly; heart pounding, brain sizzling. Whether I could handle the issue from the call room or whether I got up and did something somewhere, if and when I made it back to bed I was asleep again approximately immediately. Like the last canteen in the desert, I husbanded those moments of slumber with perfect efficiency. I'm pretty sure.

Past the middle of my career it was decidedly less so. A call at three a.m. (where have I heard that before?) often found me disoriented on waking. Whom are they talking about? Do I know this person? For that matter, who am I? After unscrambling my thoughts and pulling coherence together in a tug-of-war with my own brain, I'd produce some instructions and, after hanging up, lie there unable to regain unconsciousness. Unrarely, I'd think of something I should have asked, or said, and call back. Most often, sleep, like vapor, eluded me for the rest of the night.

And yet when it came to operating, no matter the time in the course of my career nor the amount of sleep or lack thereof, I say with the certainty which comes from knowing there's no way to prove it, that I always rose to the occasion in the operating room. The adrenaline, the focus, the intensity of the task at hand always cleared the mind and provided the needed clarity. Sometimes when it was over I'd feel entirely emptied of energy, trembling, nearly unable to write the orders, dictate the op note. But never, so I believe, in the act of operating.

Oh, there were times that I flagged during surgery, but it was never, I think, about sleep deprivation. When it happened (maybe twice, I'd guess) it was because the operation was so long, so difficult, so stressful that it took out of me nearly everything I had. I'd ask the circulating nurse to get me some orange juice and poke it behind my mask with a straw, a hard candy to suck on. I've considered taking a fifteen-minute break; I've wondered if I'd get to the point of asking for a replacement, but never did.

I don't doubt that sleep is an issue, even in youth, for physicians and most especially for surgeons. The medical staffs of which I've been a part allow doctors of a certain age to opt out of taking call; it makes sense, despite the resentments it sometimes engenders in the younger ones. Unlike those early days, as I aged I found that working all night made a wreck out of me the next day. Back then an hour or two seemed fully to recharge me for another eight or more. It didn't remain so for my all my active life. Still, I have a feeling -- unproven, unproveable -- that the sleep deprivation thing, especially during training, has been over dramatized. Between youth and necessity, one can rise to the occasion. So I think. In my case, anyway. So I think.

The case that led to the eighty-hour work week restrictions, so I'm told by reliable sources, was less about sleep deprivation than is generally believed. As is often the case when errors occur in training, it was (so I've heard, and can't confirm) actually about improper supervision. In no way am I disputing that sleep is an issue for physicians, in training or otherwise. Nearly all of us must work extended hours, through the night, into the next day; some more often and more routinely than others. I'm just saying that in my case I say with as much certainty as I can muster that I know of no case in which I identify lack of sleep as an issue in my operative conduct or critical thinking.

In the time leading up to my eventual retirement (if that's what it was), there was a related issue which may or may not be wrapped up in sleep as a factor. Finding myself working harder and harder, burning enthusiasm like the last briquettes in the bin, I began to worry if I'd try -- in the name of staying in bed one night, or of avoiding a difficult or depressing case -- to rationalize my way out of a situation improperly. I sensed the possibility. I had, figuratively, to slap myself in the face once in a while. And it concerned me. Was I on the edge of letting self-preservation override judgment? It figured in my decision to sheath my scalpel. Sleep, possibly, was a part of it. But it's more complicated than that.

Sunday, June 15, 2008

Love and Marriage


[Weekend rant. Homophobics and those uncomfortable with their own sexuality ought not read further.]
During training, in San Francisco, our landlords were Dan and Del, a couple who'd been together for several years, and who remained together for another twenty-five or more, until Del died. Loving, thoughtful, and kind, they were the best landlords ever; eventually we bought the house we'd been renting from them, and they gave us a great deal. Terrific guys. We visited them whenever we returned to SF. I talked to Dan recently, not long after Del had died, in his seventies I think.

Here are a few things that I consider inarguable.

First: By logic, and by mounting scientific evidence, sexual preference is largely determined by genetics or other biologic factors. (Logic = in a society that discriminates and harasses and to a large extent reviles, who'd choose to be gay?) I recognize there's a spectrum, and that people at all points on the spectrum are capable of experimentation. But for most -- and especially those committed enough to choose to marry -- it seems beyond obvious that homosexuality is not a matter of choice. Corollary: You can't catch gay. Additional corollary: if you think your god considers gays sinners, it seems he's the one making them, which says more about your god than about gays.

Second: For all of recorded history, in every culture, in every religion, in every country, there have been homosexuals. It's part of life. (And considering their contributions, a very positive part of it.)

Third: There is no argument against gay rights other than religious. In order to oppose gay rights, you have to believe one thing that's demonstrably wrong, and another that's unproveable; that is, you have to believe both that homosexuality is a choice, and that it is an abomination in the eyes of your particular version of the Person- or Persons-in-the-Sky. But on this planet there are lots of views of the sky-people and what they do and don't want. One is entitled to one's, but not to foist it on others.

"Defense of Marriage" is a bogus argument of the bumper sticker variety: I've seen no discussion, nor any attempt to have one, other than simple declaration, that explains why my heterosexual marriage of thirty-seven years is in any way threatened or diminished in value if gays are allowed to marry. None. What evidence there is on the subject is to the contrary: in Massachusetts there has been no decline in heterosexual marriage since gay marriage was approved. The same is true in countries that allow it. (The opposite, in fact, seems to be the case.) Which is, of course, exactly as expected: there simply is no line that can be drawn between allowing gays to marry and the decline of heterosexual marriage. Nor need it be said: heterosexual marriage has been on the decline for decades; gay marriage appears only recently.

Fourth: Lots of good-hearted people feel uncomfortable about and around homosexuals. Many religions, in fact, seem in very large measure predicated on dealing with sexual discomfort of all sorts. Hide women. Separate them from men. Marry a bunch of them and keep them silent. Sexual pleasure is sinful. Especially the personal kind. Religious mores, as they apply to sexuality, seem based on repression, which in turn is based on fear of one's own sexuality, displaced on others.

I don't like anything about brussels sprouts. I don't even like looking at them. Yet it doesn't threaten me that others do; nor do I feel the need for a law to keep others from eating them. From a secular point of view, there is no reason to oppose gay marriage. It has no impact on society, one way or the other. Objections are based on religion, or on personal discomfort, neither of which are the business of civil law. Unless it can be shown that gay marriage is in some way a threat to our country (it can't), there is no justification for passing laws to prevent it. (Asking questions about gay adoption is legitimate, I'd say; but it's a separate issue.

It's fair to ask if there's harm to kids living in a gay household. But the evidence is to the contrary. Which is also intuitive: growing up in a love-filled home ought to be good for any kid. (How many kids are in homes where they're not wanted?) And since sexual preference is biologic, it would be expected to have no impact on that of the child. Questions? Sure. Grow up more tolerant? The horror! Moreover, the logical extension of preventing it would be to forbid lesbian women from having babies. I'd think even religious conservatives would recoil from the state mandating who can bear children. Right? Right?...)

Among the oft-heard and stupid phrases one hears in the public square, at or near the top of the list is "the homosexual agenda." (Although, recently, "terrorist fist jab" has a special sort of transcendent lunacy that's hard to top.) It's freighted with hatred and fear, and implicit misunderstanding. Those who use the phrase, it seems to me, must be a little uncertain about their own sexuality: afraid they might be susceptible. After all, those who doth protest too much... That there is an "agenda" at all is pretty laughable, other than the desire to have the same civil rights as everyone else. Or is there something more sinister? Laws outlawing bad fashion? Outing closet thespians? Seems to me wanting an end to harassment and the right to marry hardly qualifies as an agenda. Unless breathing does, too.

Two adults love each other. They want to marry. Where's the harm? If a church doesn't approve of gay marriage, it shouldn't perform them. If you don't like gay marriage, don't do it.

Stick that on your bumper!

Oh. And happy Fathers' Day, GDad and GPop.

Thursday, June 12, 2008

Credit Where Credit Is Due


Here's a couple of websites commenting on the fact that the state of Minnesota, the liberal bastion, has just passed a law designating practitioners of naturopathy as "doctors." I share their concerns. According to at least one interpretation, they'll be able to admit patients to regular hospitals and manage their care. To the extent that it's even imaginable, I find it frightening. On the other hand, in my state of Washington it's been the case for years that, by law, health insurance must cover such crapola as chiropractic, accupuncture, aroma therapy, massage therapy (yes, to the extent that it's the same as physical therapy, I have no problem, but there's all that other therapeutic touch nonsense...), and, of course, naturopathy. Far as I know, homeopathy, too, which is at the very bottom of the barrel, unproven-bullshit-wise. But that's not my point. My point is to give credit when it's due.

Seattle is home to Bastyr University, the mecca of "natural medicine." They claim the mantle of scientific research. And, contrary to what I'd have expected, it seems they actually do it. In the Seattle Times a couple of days ago were the results of a study they announced, on the efficacy of St. John's Wort for treatment of ADHD. It appears to have been an actual double-blind prospective study, and darned if it didn't show exactly what you'd expect real science to show: bupkis. So I congratulate them on being willing actually to subject their stock in trade to the science it requires.

I applaud Bastyr for doing the study and for publishing the results. I assume they'll continue doing so, even though I'd guess someone there must be worried they'll science themselves out of business eventually. We'll see. Meanwhile, it sets a standard for advocates of homeopathy, chiropractic,* Reiki,* accupuncture,* aroma therapy, etc etc ad nauseum to show the same kind of character and honesty and subject their modalities to the same rigorous and reproducible study. Good job, Bastyr.


*What I'd love to see done for those manipulative therapies is a randomized prospective study where the manipulations were divided into "approved" (or whatever you'd call it) and bogus, with neither patient nor provider knowing which was being foisted... er, sorry: provided. It would be tough to do. If you had actual "practitioners" giving the, uh, therapies rightly or wrongly, they could easily have different behaviors with the patients. So you'd need to have neutral people shown what to do for a given diagnosis and then do it not knowing whether they were shown the "real" stuff or deliberately wrong stuff. And although practitioners would object that only by years of training can they learn their craft, I'd think a single intervention for a single agreed-upon diagnosis could be taught. Stick a needle here, or there. Wave your hands there, or here. Crank on this, or that. Be fun to know, wouldn't it?

Tuesday, June 10, 2008

Arrrrrggggghhhhh!



Below are three pages from the latest ACS (American College of Surgeons) Bulletin. I apologize for the quality, but it was a pdf file and I couldn't copy it directly; these are screen shots. For any readers who are surgeons, I also apologize for picking at a scab.





Assuming it's not really readable, let me explain. It's three pages of codes and explanations for how to bill for lymph node biopsy (SLN: sentinal lymph node biopsy) in various scenarios with or without various breast procedures. Let me also add: improper coding, as far as Medicare is concerned, is a felony. Fraud. Punishable by very heavy fines, and imprisonment. For nearly any other operation, there are similar rules, exceptions, combinations, suggestions, complications.

Now consider this: unless over-ridden by Congress, there are scheduled payment decreases in the pipeline for Medicare reimbursement, to the tune of about 16% in the next year. That's, of course, after lowering payments by about two-thirds since I first went into practice, and making it illegal (felonious, of course) to charge for the difference between one's "fees" (as if one's personal setting of a fee has any meaning) and Medicare payments.

Despite the inevitable comments that doctors are overpaid, ego-driven, profit-taking purulent pustules of putrefaction, isn't it logical to think that we're heading for trouble? Is it reasonable to think there's a point, for even the most selfless of people in any walk of life, at which the graphs of increasing hassles and of decreasing rewards (monetary and otherwise!) cross, and drive current workers out and turn away future ones?

Stir in and mix thoroughly: the projected shortfalls in the future number of surgeons required to fill the needs of the US.

Trouble. And that starts with T and that rhymes with R and stands for retirement.

Monday, June 02, 2008

Stem the Cell?


Until recently my main problem with cellphones was that they turn drivers into idiots. My wife and I have both had close calls with distracted drivers, obliviously pulling into traffic, making turns, whatever, without even an indication of seeing us. Nor, when the tires squeal and the horns honk (and, unwisely in these times, a finger rises), a recognition of error. When I was working, no one knew my cellphone number. I wore a pager, and when it went off in the car, I pulled over to call back.

That, of course, hasn't changed; and in terms of killing us off I'd guess it'll always be in the driving mode that they are most dangerous. But there's something rising above background noise: do cellphones cause brain cancer, or do they not? Ted Kennedy, among other things a crusader in the fight against cancer, now has it, in his left parietal lobe, which is where a right-hander holds his phone. A senator, I'd assume, is on his cell a lot. Of course, it's not just him; but I'd guess the question will rise on the news.

From what little I know, it's still an open question. But a very recent report was just the latest among others that raise alarms. Not everyone agrees. In medical populism, I'm a skeptic by nature: I (along with pretty much all respected and respectable researchers) reject the vaccine/autism link, for example. The world is full to overflowing with pseudo-medical charlatans and credulous victims. But I've begun to think it calls for continued serious scrutiny. The question of increasing incidence of brain tumors has been out there for many years. In general, the consensus has been one of no link to cellphones. I'm in no position to render a meaningful opinion on where the science is, but I do know that retrospective comparative studies are less useful than prospective ones. And it's hard to imagine the construction of a definitive forward-looking study that would satisfactorily address the question, short of strapping cellphones to the heads of monkeys for the next ten years. (Given the low incidence, you'd have to enlist enormous numbers of people into a prospective study; how could you find matching groups of people who differ only in their willingness to live with or without a cellphone for ten years?) Off the top of my head (near where the phone resides) I'd say it must be that if there is a connection, it's complex: perhaps a trigger of some sort in those otherwise prone for reasons not yet known. Because even if the incidence is rising, it remains very low compared to the number of people using the devices.

Meanwhile, it seems prudent to be prudent. I'm not giving up my cellphone: it sits in the glovebox of my car most of the time. Neither I nor my wife is the kind who live with a phone attached to the ear all day. But I'll use mine as little as possible; maybe switch sides regularly. It'd be nice to know if using earpieces makes a difference; and if so, whether wireless ones are just as bad (assuming they are bad) as the cellphones themselves. Maybe the smart thing, until more is known, is to use a remote but wired earpiece. And to keep paying attention.

[Update, 7/08: Here's a recent article of interest.]

Saturday, May 31, 2008

The Question We Cannot Ask


[Some might call this another rant. I call it a serious question we ALL should be asking.]


From an article about John McCain's entry into politics, in the New York Times:

"After five and a half years of listening to senators’ antiwar speeches over prison camp loudspeakers, Mr. McCain came home in 1973 contemptuous of America’s elected officials, convinced Congress had betrayed the country’s fighting men by hamstringing the war effort."

From innumerable McCain appearances:

I'll never surrender in Iraq... Obama wants to surrender... Democrats want to wave the white flag of surrender... If we leave, the terrorists win...

So let me ask a question that no one wants to ask: might five years of torture in a prison camp be expected to have an effect on one's (or some's) thinking about war? About challenging a war policy? Is it possible that one subjected to awful and inhuman and nearly unbearable conditions (for many, they were unbearable) could develop certain visceral reactions to the idea of war, positive or negative? To those who raise questions about a war? Might they affect the ability to distinguish between negotiating and collaborating? Could arguments be filtered through that personal horror in a way that makes one's reasoning different from one who never suffered in such a way? Faulty, even? Just theoretically: isn't it possible?

My experience in Vietnam compares to John McCain's as a bee-sting compares to a shark attack, but I have some memories, and things that trigger them. I hate the sound of a helicopter, of a fighter-jet taking off. (I live near an airport, and I hear both.) Sirens of a certain kind raise my pulse; distant explosions, as on the Forth of July, remind me of nights spent diving for cover. And no one beat me when these things happened; no one broke my arms. (Oh, I got a little broken in one rocket attack, but I healed fine.) I got up every morning and took a shower, ate a nice meal, went to the clinic and set up shop. In my room was a hotplate and a stereo. My wife sent me the fixings for chocolate pudding. Still, there are little things, and little reactions.

When John McCain equates talk of leaving Iraq to "surrender;" when he says those who question whether the war has done more harm than good are waving a white flag -- is it possible his judgment is clouded? Are those things that he survived (which many of us, myself included, probably wouldn't have had the grit to do) in any way affecting the thought process that connects skepticism to surrender? I'm just asking.

Given the stakes, and given the unprecedented situation of a presidential candidate who was a tortured prisoner for five years, in a war that split our nation asunder and which, in retrospect, accomplished nothing, isn't it an issue that ought to be considered? I don't have an answer. But I'd think, based on the fact that I'm a human and therefore have at least some knowledge of how humans behave, it is at least possible that this man's approach to war has been made, in part, irrational by what he went through. His is a voice to be listened to, a point of view worth knowing; but is it the one that ought to have the final say?

Believe it or not, this isn't the partisan me speaking; not the usual weekend ranter. It actually worries me, separate from my political opinions and views on the war. In these most cataclysmic of times, in the aftermath of questions not asked, I think this issue of which we dare not speak needs raising. Plenty of people believe, and are saying, that the time Barack Obama spent, as a young child, going to a Muslim-run but multi-denominational non-religious-based school makes him untrustworthy. What about being tortured for years, seething in a cell while anti-war propaganda played, and then being tortured again?

[The New York Times Magazine, in an article on McCain from May 18, quotes some fellow Vietnam Vet Senators from both sides of the aisle, all of whom have less jingoistic (and generally quite negative) views of the Iraq war: Kerry, Cleland, Hagel, Webb. Their take (and these are all guys who consider him a real friend) is slightly different from the question I raise. They imply that since he spent his time as a prisoner, he never faced the ambivalence of war that's seen by those on the ground, in combat, shooting and being shot at; they came to see it in shades of grey, as do most (I'd say) who've been in combat. McCain, they suggest, remained in a situation where right and wrong were entirely black and white. An interesting, and less dire, point of view compared to the question I raise. Either way, it takes a willingness not to give John McCain an automatic pass, just because of the horror of what he went through.]

Friday, May 30, 2008

Got Your Back


Where I trained, it was a very top-down place. At all levels, you were expected to inform the person next up the ladder before embarking on nearly anything. Which, as far as I'm concerned, is how it should be. Learn your limits: nothing is more important in being a safe surgeon. Ask for help, get advice, know the need. There were no mistakes as unforgivable as those of not following the chain of command.

In "Cutting Remarks," I told the story of a fellow resident who performed an emergency tracheostomy in the Emergency Room. That it turned out to have been unnecessary was not what got him in trouble. It was that when the nurse asked if she should call the Trauma Team, he said no, he could handle it, which he did, in terms of technique. But for his failure to communicate, he was called into the Chief's office and told this: "A cat has nine lives. A surgery resident has two. You've just used one. Now get out of my office."

That Chief was F. William Blaisdell, or, as we referred to him, the Blazer. A leader in the formalizing of trauma care, Blazer ran the Department of Surgery at San Francisco General Hospital while I was there, and he was one of my two most influential teachers. Some of his demands were a little annoying: no facial hair, no scrub clothes out of the operating room, wear a necktie at all times. But it was about respect. Respect for our patients, most of whom were derelicts and drunks and down on their luck. No matter. We handed every one of them a personal business card that Blazer had seen to for us, including the number of the surgery department and of the paging system.

What Blazer expected of his Chief Residents, of which, eventually, I became one, was not that we be right all the time. His expectation was that every decision we made was well thought-out, that it took full account of the situation, of all the possibilities, that the proper data had been collected and evaluated. Short-cuts, sloppiness were indefensible offenses. When I called him in the middle of the night to describe a patient and tell him of my plan, he might or might not choose to come in to assist. (I appreciated his confidence in me when he stayed away, but I always liked having him there. It'd be soon enough, I figured, that I'd be on my own. Now was the time to pick as many pearls of wisdom as I could.) And here's the thing: if he felt you'd properly reasoned he'd never second-guess or fail to support your decision, even if it didn't work out. He'd talk it over, dissect it; teach back from the problems. But he'd stand up for you. Unlike some of the other staff.

Like most training programs, we had a weekly conference in which every imperfect outcome was discussed. "M and M" is the most common designation, for Morbidity and Mortality; ours was "D and C," for Death and Complications. The conference took up several hours of every Saturday morning, delaying the beginning of the infrequent weekend off, if such it was. But it was the best conference we had, probably the source of the most learning outside the OR. Chief Residents of each service presented the cases, but the grilling might be directed at anyone, even the loftiest of professors. When I was on Blazer's service, the one thing I could count on, though, was that he'd be there for me. If there was a bad outcome, as long as he believed I'd done the right thing at every step of the way, he'd defend me against whatever onslaught, from whatever lofty source. Some of his junior professors were not so solid. "I told him he shouldn't do that," they'd lie. One guy in particular, whom I won't name. A tough case with a great result, he was there to take the credit, as if he'd done it and not me. But if something was imperfect, he sidled away like a crab catching the tide, wagging his tiniest claw behind him: not me, not me, not me.

Wednesday, May 28, 2008

Music of the Gods


This article is so dense with intriguing stuff that I hardly know where to start. Let's begin by ignoring the guy's extraordinary brilliance, with PhDs in stem cell biology and in music, before getting his MD. Ignore it, because it puts him so much in a class by himself that it must make the rest of us feel like tiny-brained sub-species. If he's superhuman, we'd be kidding ourselves to apply it to ourselves. So let's just consider the mind-music-medicine-surgery implications, starting with this:

“If I don’t play [the piano, if you didn't bother to read the article!] for a couple of days ... I cannot feel things as well in surgery. My hands are not as tender with the tissue. They are not as sensitive to the feedback that the tissue gives you.”

Fascinating. Is that an effect that translates to the rest of us? Or is it related to his special brain-wiring for music? If the latter, does music raise him above the level of other surgeons, or is it that it's necessary to keep him from falling below ours? Is it, in other words, a gift or a handicap? In my book, and here, as well as other places in this blog, I've likened surgery to music, and to ballet. At its best, it's apt: when the process of operating comes together in all its parts, with surgeon, assistant, scrub nurse, anesthesia in a kind of flow of understanding and anticipation, the result is symphonic and thrilling. Allowed to do so, freed from distractions and stops and starts arising from unfamiliar team-members, I can get into a rhythm of operating that seems to play like music, both carried along by it, and carrying it along. Does Dr. Conrad exemplify the phenomenon at its highest? Do musicians make better surgeons, do surgeons make better musicians? Without doubt (to my observation, anyway) there are some surgeons much more gifted in the art, in the technical process of surgery, in anticipating how a given situation will unfold. Do we have "musical wiring" (by which I mean something in common with musicians, as opposed to being necessarily gifted in music)? (And, yeah, I said "we," and I know it's braggadocio.)

The article also addresses the physiological responses to music, both in terms of its potential soothing and healing effects, as well as an implication that it might raise the performance of surgeons in the OR. I've written about music in the OR: contrary to the belief on which I was raised that it's a distraction, it's generally been found to be of psychological benefit, and I like it, mostly (sometimes, when fans became fecal, I'd ask that it be turned off while I concentrated intently). That some music might raise levels of growth hormone is quite amazing. The possible specificity of Mozart, even more so! Dr. Conrad's point about Mozart intentionally or subconsciously writing to ease his own maladies is provocative. I love the idea that he's trying to flesh it out: music vs no music; types of music compared to each other. (Maybe athletes can get their growth hormone through headphones. Headline: "Baseball Bans Beethoven!")

To me, music is among the highest of human endeavors: that we can create it, that it moves us. (My theory: there's a survival advantage from being able to distinguish among and to reproduce sounds of other animals.) Those that are truly gifted with it are sublimely lucky. For some, like my aunt, it's part of their metabolism. For the rest of us, most of us, there are pleasures to receive from those so gifted. And now, it seems, the benefit may be beyond the merely esoteric.

Tuesday, May 27, 2008

Looking In



After my recent "Family Guy" post, and a comment by the estimable bongi, I've been thinking about sharing. In the new-age sense of the term: letting people in on what you think or do or feel or other nerve-grating uses of the word. Y'know: "Thanks for sharing..."

I digress.

What I mean is that the esoteric world of surgery, so dramatic, and intimately knowable only to a small and generally comprehending audience, is quite isolated from those with whom we might most like to share it: family, close friends. I always wanted my son to see me do an operation (my wife did, once, when I was in training. But it was a small deal, and I wished she could have seen something more complicated). As much a part of my life as it has been, and as much as it took me away from his, I'd have loved to have had him watch it, just once. Demonstrate; explain. Perform, impress. Yet it's nearly impossible for a surgeon really to let people from the outside in on what it is that he or she does. I suppose it's not unique, but I think in most other fields it's more possible, easier to gain access. As thoroughly as it envelops us, as proud as we might be of what we've accomplished in learning it, what we do in the operating room must remain hidden from those we love. The fascination, the beauty, the talent (if that it be!): forced, by its nature, into secrecy. How many are the times I've wished it were otherwise. One of my proudest days was when my father-in-law, an anesthesiologist, came to town and spent the day in the OR with me. But he had business there. He's the only one.

Which reminds me of a story.

After years as a trial lawyer, my dad was appointed to the bench (meaning, to be a judge). As his days in front of the bench were winding down, I -- a freshman in high school, as I recall -- mentioned to him that I was sorry I'd never seen him in action, in court. Okay, he said, how about we have you come? Great!! Don't get your hopes up, he warned. It's pretty boring stuff, not like Perry Mason. As it turns out, he was entirely wrong. Other than the fact that the case was about a taxi and traffic, it was exactly like Perry Mason.

Dad was defending the taxi driver. There'd been some sort of accident in which the passenger was (not very seriously) hurt. It had been determined that the taxi was not speeding, but in Oregon there's this thing called the "basic rule:" when conditions warrant it, speed limits don't apply. If it's snowing, driving at the posted speed limit of, say, 35 mph, might be too fast. Common sense. So the plaintiff was on the stand, being interviewed by her attorney, and at some point claimed it had been raining. I saw the taxi driver lean over and whisper something to my dad. In turn, my dad leaned over and whispered to his Della Street, (actually, her name was Frances) who got up and left the courtroom.

When it was Dad's turn to cross-examine, after taking plenty of time, he got around to asking the witness about the rain: You're certain it was raining? Oh, yes. Do you recall seeing puddles in the street? I sure do. Splashes. Were the taxi's windshield wipers on? Yes, they were. People on the streets, using umbrellas? Absolutely. Umbrellas up the ass.

While he was doing this, Dad paced around the courtroom doing his tongue-of-death maneuver. It's hard to describe. When he was angry, my dad stuck his tongue part way out, flexing it (if that's the word) so that it became as thick as a Porterhouse steak, and clamped down like he'd bite it off if it weren't so impressively muscled. To us kids, it was a sign to head for the hills. One can only wonder what the hell the jury thought.

The doors at the back of the courtroom banged open, some heads turned that way. Papers in hand, the barest hint of a smile on her face, in trundled Della Street. Excuse me, Your Honor, my dad asked. May I have a moment? A nod of the judge's head, a back-flick of his hand. After Dad and Della conferred, Dad looked over the papers, and handed them to the judge. May I have these entered into the record, marked as an exhibit? So ordered.

Tongue active but unbloodied, Dad gave the papers to the witness, and asked her to read the title. They were, she read, from the Weather Bureau. The date? The day of the accident. And what is this column here? Precipitation. Can you find the heading for rainfall? Yes, here. And what does it say? Zero. Do you see the place for hail? Yes. Is any listed? No. Was there any snow that day? No. Was there any precipitation at all, precipitation of any kind? I guess not. Thank you. No more questions.

Well, yeah, okay. No sobbing confession on the stand, no close-up of those buggy eyes. There was no da dah, da DAH. But otherwise, it followed the script pretty well. I was impressed.

Later, I mentioned the tongue thing to Dad. Did he know he was doing it? Sure, just to impress the jury. That I didn't believe, not for a minute. Too creepy for that. Way too creepy.

Monday, May 26, 2008

And, Of Course, There's This:



The words are by Mark Twain, a tone-poem, if you will, that he wrote but was not published, at the urging of his family, until after his death.

Memorial Day

Saturday, May 24, 2008

Hillary the Horrible


[Until now, I thought I was done with my weekend rants. But once again, I find myself needing to vent. So turn away, all ye who want it not.]


In my state we have a female governor and two female senators. I voted for every one of them, happily, and will again. I married a woman, and thus into a family of nine of them; my mom was one, too. I like women. I have no problem whatsoever with the idea of a woman as President of the United States. In fact, I'd love it. I even heard Hillary speak in Seattle a couple of years ago, and was impressed as hell. She'd be a great president, I thought. That was then.

The campaign Hillary has run in the past couple of months has filled me with disgust. The demure dredge-it-up/deny-it-down racial stuff. The gas tax pander; Bosnia fantasy. That was minutiae, background noise. They all do that (although what was the Bosnia thing? Hallucination or lying? Either way...) But the Florida/Michigan maneuvering is pushing it. I agree the rules are stupid, caucuses are crazy, the DNC made itself a fine mess. But she, along with everyone else, agreed to the rules, and is now acting as if breaking the rules is the only way to follow the rules. Now, she says, on the twenty-yard line, they must be ignored. But she went further, invoking Florida 2000 and Zimbabwe 2008. Yep, Zimbabwe. She's saying, basically, that abiding by the rules, the election becomes fraudulent. And her arithmetic isn't all that good, either.

At some point, her supporters need to wise up. It's not about misogyny; it's not guys taking it away from girls. It's this one. This woman. She ran a lousy campaign for the first several months, and a dishonest one later. Time and again she has shown there is no level below which she won't stoop, and it's unbecoming. It's the feminist thing to do, to say THIS woman is wrong. She's a woman, and she's wrong, and the two have nothing to do with each other. It's not about her ovaries. It's about her outages. Has there been sexism? Sure there has. Just as there's been racism. For each of them, in both directions, for and against. Not a pollster, I, but I'd guess it approximates cancellation.

Now, finally, the last straw has been laid on the back of this camel. In responding to why she shouldn't drop out in June, she points to the Robert Kennedy assassination in June 1968. To the immediate wave of disgust, she disclaimed by saying, well, the Kennedys have been on my mind lately, as if to say it was sort of a slip of the head, like Bosnia maybe. Except that she said the same damnable thing two months ago.

Hillary Clinton is perfectly happy to de-legitimize the whole process in the name of her own personal gain. She's fine with setting up a situation wherein if she loses, her supporters will have been made to see it as a personal slap in the face to all women; by her definition, any outcome that doesn't give her the nomination was, prima facie, unfair to her, to women, and therefore to support "her opponent" (as she likes to refer to him) is betrayal of women everywhere.

Especially in Zimbabwe.

Hillary Clinton is the opposite of change in how politics is done. She's the epitome of saying anything, doing anything, excusing anything as long as it promotes one's own narrow political interest. Barack Obama, while hardly perfect and maybe not even able to succeed in his message of change, is miles higher than her in tone and tactics.

I dislike her for making me dislike her. Were she the nominee (which, thankfully, seems all but impossible) I'd have a moral dilemma. I will not vote for John McCain. In many ways, I respect him. I admire his bravery in Vietnam, and doubt I'd have been as strong. He's been known to take tough political positions. But I think his "straight talk" has been seriously compromised, and he's happily distorted his own record when it suits him. Mainly, his policies on the war and the economy are too much a continuation of the Bush disasters: he even goes further than Bush on tax cuts, increasing the curse on the next generations. His foreign policy "expertise" is anything but; his military judgment shown false. But really: I consider myself a person of principles. As such, despite how much I'd hate to see a McCain presidency with its pre-failed economic policies, crazed right-wing judges, discredited foreign policy bluster, and phony anti-lobbying posture masquerading as ethics, to vote for Hillary would be to legitimize her tactics. And that I couldn't do. I'd have to withhold a vote, and that pisses me off.

Note to Senator Obama: Please don't yield to those who think she should be on the ticket. Then I'd really have a moral dilemma.

Friday, May 23, 2008

Uh Oh...



Another item from the American College of Surgeons:

COLLEGE OPPOSES RECOMMENDATION TO INCREASE PAYMENT TO PRIMARY CARE

On Friday, May 16, the American College of Surgeons and 13 surgical specialty societies sent a letter expressing strong opposition to a Medicare Payment Advisory Commission (MedPAC) recommendation, which calls for increasing payments to primary care physicians, while cutting reimbursement for all other physician services. The payment reductions for other physician services, including major surgical procedures, would occur because the pay hike for primary care must be budget-neutral. Only two of the 17 MedPAC Commissioners....opposed the recommendation. In their correspondence to MedPAC Chair Glenn Hackbarth, JD, the College and the other surgical societies noted that primary care is not the only specialty experiencing significant challenges in today’s health care environment. The letter cites several difficulties facing surgery, including decreased reimbursement, surgical workforce shortages, and increased practice expenses, especially for professional liability. Copies were sent to leading congressional committees with jurisdiction over Medicare policy. The letter concludes by noting that “[if] this recommendation is acted upon, the ones who stand to lose the most are not America’s surgeons but rather the patients who rely on the life-saving care that only surgeons can provide.”
[Interesting side note: the Chair of the P.A.C. is a JD, ie, a lawyer!]

I've been known to say, when my clinic and the non-clinic docs in town were even more acrimoniously at war than they now seem to be, that the insurance companies must love it: set us upon ourselves, grabbing at whatever is offered lest the other side make an even less-favorable but exclusive deal. This sort of thing will get worse before it gets better. If it gets better. Which it won't.

It's amazing, isn't it? In our lifetimes -- who'da thunk it? -- we're actually going to see cataclysm: events are moving so fast, we're living in the time of the passing of the tipping point on oil, on the federal budget crisis, and we'll bear witness to the collapse of health care in the US. And there's a good chance that in my dying breath, as we rise up as a nation and begin killing one another, I'll be able to say, recalling the pivotal 2008 election which turned on race and religion and spouses and fear of the dark instead of on energy and budgets (and infrastructure, and health care, and environment....), "I TOLD YOU SOOOOOOO00000oooooooooooooooooo......."