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.]