A New Blog!!!

Well, I've done it. I've just created a new blog, which will become the place for my rants. Surgeonsblog, if it ever revives, will revert to what it once was -- a place for insights and information about surgery and surgeons. My new blog is where I'll froth and foam.

It's called "Cutting Through The Crap." You can find it here. There (and on this post), readers can comment if they so choose. I hope people will find their way to the new place; and I hope there'll eventually be reasons to return here as well.

Public Option

I know a guy who was in a video...

Toons

In a comment on my previous post, a series of slides is recommended. I like the cartoon above even better. In simplicity there can be great truths.

Retort

Sooner or later, in any discussion of health care reform (to the extent that screaming and fear-mongering can be gotten past and actual thoughts exchanged), the issue of tort reform is raised. On that subject I'm of two or more minds. Neither a student of the various proposals nor particularly well-versed on the veracity of claims and counter claims about tortophobia adding to costs of medical care, I can only speak based on personal experience. Which is why I'm multi-minded. I've seen good and bad. I don't think I altered my practice style to avoid malpractice suits, but I can see why people would.

The central issue is this: there's a difference between malpractice and adverse outcomes. Most certainly, the one leads to the other; but the other does not imply the one. Were that distinction properly made and encoded in the law, the rest of the issue would become moot. If malpractice suits were about bad care -- actual errors, poorly thought-out diagnoses or treatments, willful neglect of patient needs; that sort of stuff -- I'd have no problem with them.

I was raised among lawyers. I've lived in their dens, eaten their food, learned their language. I agree with their claim that malpractice suits have, over the years, led to improvement in care, institution of protective procedures. And I absolutely agree there are bad doctors out there; lazy, lacking in judgment, in it for the money. Drinkers, drug users. Representing an overwhelmingly small minority, they nevertheless give us all a bad name; they are the cause of and the justification for the worst views the public has of us.

But, unlike the guy struggling to fix my freezer as I sit and type this (peering occasionally at what he's doing: my home improvement skills have largely osmosed from such viewings), I dealt with soft stuff. Every freezer of this type is exactly the same; the wires, the machinery, the outcome if you plug x into y. Not so of us humanoids. (I'm not saying what he does is less important; we're having to get along without freezing tonic cubes for our G and T's [a trick I highly recommend to anyone so inclined]. Or, judging by his grunts and mutterings, any easier. Just more predictable.) If he makes the correct diagnosis and replaces the parts properly, the outcome is the same for the same problem, over and again, on every like freezer. I've had some sub-optimal outcomes, despite (take my word for it, okay?) doing everything right. Not often. Not, thankfully, catastrophic. But the possibility is always there.

I've been sued, and I've written about it. It's humiliating, frustrating, depressing, and anger-inducing. I'd say that's entirely because of my certainty that in no case was malpractice, as I understand the term, committed. On the other hand, had I ever done something (or failed to do something) in a way that fell into that category, the last thing I'd want to do would try to defend it on a witness stand, nor try to prevent the patient from being compensated. Patients need a mechanism by which they can be protected from errors, and their injuries redressed. What form that takes is a complicated subject. The current system, because it fails to separate bad outcome from errors in management, isn't the proper mechanism. It wasn't my intent, in writing this, to suggest solutions.

My point, at last, is that I don't think tort reform, per se, will have much impact on the total cost of health care. Reducing errors will. Addressing inefficiencies and variations in treatments among doctors will. To the extent that docs order tests to cover their legal asses, such behavior would be reduced, asses covered, if there were guidelines that indicated when such tests were medically necessary and when not. It's true that there were times, when deciding a course of action based on clinical judgment alone (diagnosing appendicitis without a CT scan or ultrasound is a perfect example; taking a patient with a rigid abdomen to the operating room without the delay of additional testing is another), that I felt a slight breeze on my backside. Many docs are unwilling to do it; partly out of fear, but partly, also, out of being trained in the era of judgment coming in pixels. I guess you can't legislate judgment, but guidelines would help.

And yet it seems there's no discussing it without raising the specter of rationing and death panels. When President Obama suggests that investigating what works would save lots of money and improve care, he's exactly right. That's where the big bucks are spent, and wasted. Addressing it would solve much, including the need for tort reform.

The political party who has argued for reducing Medicare since it began, whose most recent candidate ran on cutting it, has now, for pale political reasons, resorted to demagoging attempts to do just that, as fascist terror. Without diminishing service at all, huge amounts of money could be saved by doing exactly what Obama proposes. Surely there are a couple of Republican senators and representatives who know this. But, clearly, the resistance is not about effective reform. It's about politics, and defeating the party in power.

The public be damned.

Grand Old Times

Nice Grand Rounds up over at the resurrected Dr Charles. His balloon is on the rise again, even as the hot air leaks soundlessly out of mine. Dr Charles has always been one of the most lyrical of medical bloggers, and it's nice that he's rediscovered his muse.

Stupid

Uuggggghhhhh.

Sorry.

I feel dirty, I need a shower, I may have to kill myself. Where are the death panels when you need them?

So Jon Stewart interviewed Betsy McCaughey last night, on The Daily Show. She's the one credited with raising alarms about the dastardly implications in the health care bill regarding end of life counseling. "Death panels," evidently, wasn't her exact term. "Disgusting," is what she said she wrote in the margins when reading it.

There was a point to which she kept returning (in between quite amazing dramatic gestures to the audience -- the kind when a stand-up comedian goes, "Am I right? Am I right? Huh? Huh?"). Medicare reimbursement is increasingly tied to performance standards, and it's an issue about which I've written a bit, and which, in its execution, is potentially problematic for all doctors. Nevertheless, her interpretation regarding end of life counseling was utterly, idiotically, cosmically ass backwards. Can you get it that wrong by mistake? Or must you be a willful liar? The lady, after all, was Lieutenant Governor of New York for a moment, which likely puts her in the upper four-fifths of the population in intelligence.

Doctors, she said, will be reimbursed, in part, based on the percentage of their patients who are given end of life counseling. Okay. And, she said, it will also depend on the percentage of cases in which the wishes were carried out. It's at that point that she went off the rails so grandly that, had I not been paralyzed with disbelief, I'd have reached for the remote. And shoved it up my nose. Aiming for my brain.

Her interpretation -- this former politico and self-styled patient advocate -- is that doctors get dinged if their patients change their minds. Really. That's what she said and, apparently, believes. (Okay, she may not believe it: she is, after all, a Republican hack trying to derail health care reform.) You sign an advance directive, that's it. No changes. Any doctor who allows changes gets penalized by THE GOVERNMENT. The lady is an idiot. And, sadly, Jon Stewart didn't call her on it.

Here's the thing: advance directives are for the time when you can no longer make your own decisions. By definition, that means as long as you have the ability, you can change your mind any time you want. In the hospital. In the ICU. Anywhere, anytime. Advance directives are not in effect until you are no longer able to express your wishes. What the bill is doing is making sure doctors follow the patients' expressed wishes when they're no longer able to express them. If a patient has said they want everything done, the doctors must do so. If they've said they don't want to be put on breathing machines, the doctors must honor that request.

It's about following the patients' request. It's about protecting the wishes of patients. I repeat myself. But the lady blew my mind. She couldn't understand her way out of a paper bag.

So this is where we are. This is the level of debate. In a matter as important as this, it's really appalling and disheartening to watch. It's not as if the issues aren't worth discussing. Tying reimbursement to adherence to certain standards is a tricky issue. But if we're going to have the discussion, let's have it with at least a toe still attached to the fundaments. Same with advance directives.

As long as people like that lady get air time without proper rebuttal (in fact, as long as idiocy that deep gets air time at all), we'll never have the kinds of discussions that we need. And deserve.

Bureaucrats

Among the many themes of dissent which have gained traction in the health care debate is the canard that we don't wont some government bureaucrat between us and our doctors. Funny thing about that: the only payer entity with which I never had a problem getting authorization for care was Medicare. Here's the sort betweenness I routinely encountered from private insurers:

In the fine print of nearly every private plan are exclusions for "pre-existing conditions." Okay. You had breast cancer, now you can't get any insurance to cover issues related to it. Fair enough, right? Guy's gotta make a buck, right? I mean, it wasn't their fault you got it, right?

But how about this: more than a couple of times I had patients with colon cancer who were denied coverage because of a previous history of.... hemorrhoids!! Yes. Hemorrhoids. Similarly, people who'd had, say, a rubber band placed for hemorrhoids -- a two minute, hundred buck outpatient procedure -- could not get future insurance that would cover ANY disease of the intestinal tract. Band on your butt, screw your stomach. Exit your esophagus. Not, I suppose, that a private insurer has to have any reason for something like that: their goal, after all, is to NOT spend your premiums on your care. Message: if you have hemorrhoids, live with them, baby.

There's more. Many patients of mine whose gallbladders I removed were informed by their insurers that they'd no longer be covered for any disease of their internal organs. A lot of territory excluded, that.

And, as everyone knows, if you lose your insurance because you lost your job, and if you've had any sort of serious illness, you are simply SOL finding new coverage. Imagine the frustration, as a physician trying to help, of dealing with insurance companies as they apply their exclusionary rules. Their rationing. Their death panels.

Yet there they are, those sign wavers, insisting that it's Hitleresque to demand changes in all this. For his attempts, Obama gets branded a Nazi. While the right wing screams, the left wing caves. Advance directives? Gone. Public option? Fuggeddaboutdit. Studies to find out which kinds care work and which don't? Nuh uh. Too... too... I don't know... logical?

I repeat: Medicare, which is in my mind the best paradigm for a public plan, NEVER refused coverage for cancer (or any) care. Not even for grandma. Those government bureaucrats? Not a problem. It was, as anyone might predict, the "market forces" guys who stood between me and my patients.

There is, of course, this little paradox: those people who hate government intervention generally are quite happy with Medicare. Those who point out it's running out of money are those most likely to recoil at suggestions that we ought to find ways of saving money in the program. The ones who think Medicare is shameful socialism would holler "they're trying to raise your taxes!!!" if anyone suggested premiums be scaled to one's financial status.

Is there a more clear example of why we're failing as a country than the debate over health care reform, and the arguments over Medicare in particular?

Death Panels

Surprise! It's a Republican idea.
.

One Small Step

If anyone here reads Andrew Sullivan's blog, runs across this post, and finds anything familiar in the writing, there could be a reason... Anonymity doesn't do much for blog traffic, but any way to spread the word...

The word, of course, is the extent to which health care reform is aimed at doing things that will be helpful. Even -- especially! -- for those very people who yell and weep and carry guns to meetings, spouting verbatim the insane ravings of Glenn Beck and Sarah Palin while having not the slightest idea what they're really talking about. "Keep government out of Medicare," they say. "Socialism."

The "socialism" trope may be the most laughable (were it actually funny): all of the proposals on the table fall over themselves to maintain the death-grip insurance companies have on us. (Talk about "death panels!" What is it when insurers deny coverage?) None talks about nationalizing the health care delivery system. Not even Medicare is socialism. Single payer -- which in my mind is the only option that makes sense, and which, like Medicare is NOT socialism -- is, clearly, off the table.

There's no possible health care reform package that will satisfy everyone; nor, given the way Congress works, one that will be free of pork-fat, undue complexity, or unexpected consequences that will need to be addressed. Still, what the various iterations seem to have in common are regulations to prevent rescission, to create portability, to remove limits on lifetime coverage, to banish denial for pre-existing conditions. Is it really possible that any of the screamers are against those reforms?

Cost is most certainly an issue, and there is a multitude of ways to address it. Starting, from the doctors' part, with the sort of thing mentioned in that Andrew Sullivan post. Only the surface has been scratched there. And, long after I'm dead, assuming the country still exists, I predict single payer will have come to pass, and people will be glad for it. Even the gun-totin' America lovers.

Signs at the meetings -- ignoring the ones showing Obama as Hitler, a completely ludicrous meme hatched and promoted at Fox "News" (sic) and ingested without chewing by its self-pitying listeners -- point out that Medicare is "bankrupt." While not yet true, it's a point worth considering. To the extent that it hasn't enough money, it's not the fault of Medicare, which spends far less on non-medical expenses than any private insurer. It's because of funding. It's because of the holdover idea from the Reaganomics that you can have what you want without paying taxes.

So, what if everyone were covered by a Medicare-like program, and no one paid premiums; or if there were the sorts of premiums and co-pays associated with Medicare? Currently I pay $14K/year in premiums for me and my wife. Would I be happy to have taxes raised in another area, even, say, by $10K/year? Who wouldn't take that trade? By getting rid of the 30% skim by insurers, that math works right away. And by taking seriously -- instead of demagoging as "death panels" -- the idea of finding cost savings in more efficient care, much more than that will be saved.

And yet, they rave and froth. Getting crazier and scarier. Arguing, in effect, for maintaining a system in which their premiums have likely more than doubled in the last ten years, which covers them sparingly, cutting them off when they need it most: sick, out of work. And they are ready to draw weapons over a plan to pay for help writing the very instructions that will keep them in charge of their care when they're unable to make decisions for themselves.

Who'd have thought people so in need of health care reform could be whipped into a froth by people who lie so freely and make easily refutable claims? I remain unable to understand. And bereft of hope.

Local News

Using local anesthesia, I always took care to do it gently, slowly, and thoroughly, and had reason to be proud of the results. Almost routinely, patients expressed their happiness and relief that the process was so... not unpleasant. I've written a bit about it before.

So when I couldn't seem to make someone numb, it hurt. As it were. In addition to having a dissatisfied patient, it made me feel like a failure. It has always been my belief that there are some people who, for some unknown biological reason, process the drugs differently; that it's more than just a few 'fraidy cats or me having a bad day. Now, it seems, there's substantiation. It's those darn redheads.

It never occurred to me to check. I wish I could play back the scenes in my head, in full color. Were the unhappy ones all rubro-capited? There's much I know now that I wish I'd known a few decades ago (and not all of it is surgery-related.) And there've been a few notable redheads in my life. Until now, I've had nothing but happy memories.

Advance Directive

On those few occasions when a patient had an advance directive, it was terrifically helpful. To me as their surgeon, to other caregivers, to the family, and, of course, to the patient. Which is why the outrage over a plan to assist people in making them (and cover the cost of counseling) is as cynical as it is ill-founded. Cynical, because people are turning it into "they're coming to kill grandma." Unfounded, because it actually puts people in control, not caregivers or government.

My parents serve as two examples.

Like most people (or so I assume), my dad had always said he'd never want to be kept alive by machines, and had a directive that put it in writing. Yet when he entered the hospital for what turned out to be the final time, after months of physical decline that had made his life only about the rudiments of existence, when the chips were down he opted for the ventilator. Which is an important point: nothing in his directive prevented him from changing his mind, as long as he could express it. At the time, his world had shrunk entirely, barely extending beyond his skin, having formerly been a man of superior intellect, a voracious reader, adviser to governors and senators, a mayor himself, a judge. Leading up to his death, he'd become unable to get in and out of bed on his own, needed help in all forms of personal care, had not the strength nor will to talk about anything but his own decline. He was miserable. And yet he opted for entry into the critical care unit, where he remained, kept alive, for two futile weeks, until he died. Even having had an advanced directive to the contrary, his wishes at the time were honored, as they should have been. (It did, however, make it easier for everyone, when the futility was evident, to take the steps to discontinue aggressive care. An important point.)

My mom, likely past the midway point in her descent through Alzheimer's disease, also has an advance directive. Composed with the help of her very caring doctor, who gently and carefully went through all the options, it directs that all reasonable measures be taken to prolong her life. Now well past the capacity to consider or reconsider, she gets wonderful care. With her strong heart and good genes, her body will likely live long after her mind is gone entirely.

Whatever else they might mean, these two cases illustrate, at the very least, that making advance directives available is hardly a step down the road to euthanasia.

They also illustrate something else: directives are not for people who retain their ability to make their own decisions. The intent is to carry out people's wishes when they're unable to express them. It's the opposite of euthanasia: it's giving PEOPLE -- not governments or others of evil intent -- legal control over their own fate!! THEIR OWN FATE!!!

The misinformation, willfully disseminated to the vulnerable by those who stand to profit from keeping things as they are, and by those whose only goal is to regain political power no matter the damage to people who need better care, is appalling. But effective. People are scared. They're becoming distrustful of the very thing that allows them to call their own shots beyond the time they otherwise can.

It's the perfect example of how people are being tricked into agitating against the very things they need. That, and the anti-reform protester who was injured at a town meeting, who's now asking for donations. To cover the health care he lost when he lost his job! Simply amazing.

Scam Alert

For months I've been getting spam comments linking to a website called "Findrxonline." I finally took the time to look at it, and find that it requires a monthly subscription which supposedly pays them to find you low-price meds from other websites. As if you couldn't do it yourself.

What a joke. I assume none of my readers is so dumb as to fall for it, but I thought I'd mention it anyway. An outfit that thinks leaving spam on blogs is a good business plan is surely one to avoid. There was another, recently, that responded to my complaint by apologizing. This one not only doesn't do that, but at least one of its email addresses bounces back.

Sigh. For all the beauty of the internet, there must be, it seems, a little ugly too.

Head-Scratcher

I simply don't get it.

Quite aside from the fact that the plan to disrupt health-care town-meetings is overtly to stifle honest debate on a very difficult subject, and despite the fact that there isn't even a bill yet (only a House version and several Senate versions that need reconciling), and even imagining that the anger is real and not ginned up by the distortions and outright lies of the right wing media or fomented by interest groups with a long history of ripping off the health care system for legal profit -- not to mention being fined one point seven billion dollars for fraud -- overlooking all of that: what the hell are these people so mad about?

As far as I can tell, the proposals out there -- the ones that are actually in writing as opposed to the absolutely insane claims of the Rush O'Beckly axis of a$$holery -- are fairly weak-kneed attempts at maintaining the status of most of the quo. Are people really that upset about a bill which aims to prevent their care from being disallowed? Is making insurance portable, and preventing the companies from pulling the plug on coverage when you get sick really that infuriating? In what way is any of it socialism? Do any of the protesters even understand the word?

Yes, there are plenty of problems -- huge problems -- with reforming health care. Which is exactly why the stifling of discussion is so tragic. But can it really be that those screamers and yellers and shouters like things the way they are? Premiums doubling every few years? Losing coverage when they lose a job? Defacto rationing by insurers bent on keeping as much of their money as possible, not spending it on actual health care? Is that what they want? Do they really hate Medicare?

What's so entirely dispiriting is the extent to which these mobs have been whipped up to argue -- once again -- against their own interests. In the most cynical of ways, for the most ignoble of reasons -- ratings, on the one hand, vis a vis the insanity that is Fox News; and pocketbook, on the other hand, vis a vis the insurers who are making billions off the dollars intended to provide medical care -- people have been spun into outrage based on a series of outright lies. Socialism. Coming to kill Grandma. It's unbelievable.

Except that it isn't. Headlong and happily, we're heading off the cliff, cheered on by the very people for whom the system is working fine: making them rich indeed while millions suffer. It shouldn't be possible, it shouldn't be that easy to decieve, but most clearly, it is.

The only thing I can't figure out is this: where do those guys plan to go when this country, at their urging and entirely of their making, is fully down the tubes?

Certifiable

Think Slow

Not too long after setting up shop in this town, I shared a tough case with one of my favorite intensivists. (By way of diversion, I'll add there were only two of them at the time, and they were both my favorites. Practical and canny, surgical-patient-wise, they were a pleasure to work with. Over the years we developed great mutual respect and affection; to the extent that caring for critically ill and deeply challenging patients can be fun, it was.

It's unique to private practice, I think, that such relationships can be so positive and mutually supportive and satisfying. I know I have said that in the academic centers, there's too much turf war and defensiveness. Was, back in the day, anyway. The discovery of such collegiality was one of the pleasures of my entry into private practice.)

To make a long and dimming story short and bright, the patient was an older woman, admitted in extremis to the intensive care unit. Dying, evidently, of infection of indeterminate source. Clearly, she had severe pneumonia. Was there anything else? I was consulted early on, charged with ruling in or out a surgical and operable cause of her illness.

Without going into details (mostly because I can't remember them), I became convinced that the lady's decline was not due to any kind of "surgical" condition. I continued to follow her three or four times daily, during which time the intensivist in charge kept working me over: she's dying; at least have a look inside to see if there's anything fixable. For those unremembered reasons, I continued to resist. At some point it became moot. If I'd been wrong and she indeed had a surgically treatable condition, she'd ultimately descended beyond her ability to recover from whatever I might do.

Young, and not much established in the community, I didn't find it at all easy. The phrase lobbed to me more than a few times was, "It's time to fish or cut bait." I was well aware that if I was wrong it could be awful: for the patient, of course, but very likely for me, too.

Not a good enough reason. It's not unreasonable sometimes, when all else fails, to "have a look." Before the ready availability of quite accurate non-operative testing, such an undertaking (as it were) was not entirely rare. In this case, certain as I was, I simply didn't want to do it. Not absent from my thinking was the realization that if I did operate against my better judgment, and found nothing to fix, I would have become, in a very real sense, her executioner.

If anyone has the answer to such dilemmas -- which, I might say, we still face despite our imaging capabilities -- I'd be happy to hear it. Meanwhile, in the case at hand, the unfortunate lady died.

With more than a little dread, I awaited the autopsy findings, and came to have a look when it happened. (There's another subject: autopsies are done increasingly rarely nowadays. This case is an excellent example of why they are still needed.) I'm happy (if that's the right word) to report that it confirmed my conclusion that she did not have any pathological process going on in her belly.

There's really no lesson to the story, other than sort of confirming my belief that more mistakes are made in operating too hastily than in giving things time to sort out -- assuming there IS time. But the real point is that for the next twenty years of an extraordinarily productive and rewarding relationship between myself and the intensivist, the phrase fish or cut bait was used uncountable times. With varying meanings, depending on who said it, where, and why.

Kung Fu Surgeon

Somewhere in my home is a letter I received from a Shaolin priest, one of five (so I was told) grand masters of the martial art of kung fu on the planet. The letter is embossed with the gold seal of the temple of which he was the head honcho. With its beautiful calligraphy and that timeless seal, I've thought of having it framed.

The temple is in another country. The master came to me, that I -- and only I -- might operate upon him. (To put it a little more dramatically than circumstances might warrant.) According to the man who sent him, he taught only a select few, and demonstrated his skills only in private. The referring person, who had been a student of kung fu (but not of the master), described to me the man's ability to toss a group of attackers like fish, and other unearthly wonders. The priest was in his seventies.

I'm not sure what I expected. An aura? Rays of light? Surely, were I to give satisfactory care, I'd be granted some sort of special status, maybe presented with a holy relic, invited to the temple for a secret ceremony, rooted in ages past. I admit I let myself imagine special things.

He arrived in my office dressed like a Florida retiree. Looking age-appropriately fit, but neither athletic nor powerful, he was of no more than medium stature. Less surprised than embarrassed for my silliness, I immediately discarded my dream and proceeded into my usual doctor/patient partnership, treated him like everyone else, operated in due course, saw to his recovery, and he returned to his homeland.

The letter, which compared my art and skill favorably to his, arrived with a package. Really, the elegance of the letter was more than enough. Once again, I entertained a brief fantasy of what might be in the box.



It was a Mont Blanc fountain pen.

I'm not sure I'd heard of them before that. Very expensive, for a pen. A nice gesture, no doubt, but of not much use to me. A little too showy, it was also impossible to use for writing orders at the hospital, because you need to push hard enough for several copies. Nor was I interested in lugging around a bottle of ink on rounds. I confess to being disappointed. It seemed so impractical, so materialistic, so... unlike a Shaolin priest. Not that I had any information other than a TV show.

In its elegant box, the pen sat on my bedside table for a decade or so, along with its exotic ink bottle. Then I wrote a book, got it published, gave a few readings, did some book signings. Wow, it eventually occurred to me. It's karma, or whatever Shaolin priest kung fu masters believe in. He forsaw it, it was perfect, meaning revealed. I took it to the next signing. With its elegant gold nib, its meaty heft, its characteristic emblem, the soft lines of ink it imparted to the page, perfect for a signature and a few well-chosen words. The mark of a writer of distinction.

After reading from and commenting on the book (I will humbly say my readings were always a hit: I'm enough of a ham to enjoy it and get plenty of laughs -- the first time I did one, it was at a fairly fancy book fair in Portland, called "Wordstock." My reading, in a small room, was at the same time as Gore Vidal's, in a much larger one. "This is my first reading of my first book," I told the audience. "So I'm really looking forward to hearing what I have to say.") I sat at a table and proceeded to sign books for people, bringing out the newly-glorious pen, studiously acting as if it were as normal as breathing.

It leaked all over my hands, and wildly smudged the first book I signed.

Rationing. There. I Said It.

Thirty percent of Medicare money, it's said, is spent in the last month (or is it six months?) of recipients' life. It shouldn't be surprising: people who die are generally sick. Sick people -- especially ones that die -- require more care than healthy people, or people who survive an illness. But it gets to the most thorny of issues when tackling health care costs. And it's a perfect example of why real reform is next to impossible: our politicians are too venal and stupid, special interests are too powerful, media are too superficial, the issue it too freighted with grayness, and the public is too easily distracted for there to be a meaningful discussion.

Notwithstanding the truths just enunciated, I have a few things to say. A proposal, too.

Absent having all the money in the world to spend on health care, I think it's fair to say that everyone is in favor of rationing. If all we had was a million bucks, would anyone choose to spend it on ten demented ninety year olds with advanced cancer and a 5% chance of recovery, instead of ten ten year olds with leukemia, with an 80% chance of recovery? So, like the old joke, we're not really arguing about rationing; we're haggling over details. Not to mention the fact that rationing, so loudly decried by the Foxoid among us as possible under "Obamacare" (whatever that is) is already happening with private insurance: of the dozens of plans offered by each of the twelve hundred insurers, how many cover all things for all people with all conditions under all circumstances? How many people get dropped after an illness, or refused in the first place? Wouldn't it be better to have such decisions made in a system open to public and medical input? (Along those lines, here's a pretty good, and humorous, commentary on the reality we currently face, still defended most arduously by the nay-sayers of the right-wing persuasion.)

End of life care presents us with some of the most difficult decisions we make, as families, as patients, as physicians. Likewise the related situation of "futile care." In neither case are there clear criteria to guide us. The exact same operation -- say, bowel resection for perforation -- would certainly be futile in that ninety year old (let's add some heart and kidney disease to make it easier), and entirely reasonable in a thirty year old, even if that person presented in septic shock. In the latter case I wouldn't hesitate for a second. In the former, I would try (and have, many times) to present for consideration the option of providing comfort care only. I won't psychoanalyze myself, but I hated doing operations wherein I felt there was virtually no hope of survival. (Need I mention that I made more money when I did operate than when I didn't? Yet I tried like hell not to, by presenting as candidly and openly as possible what I thought the situation was.) Not every surgeon would have done so.

I was always scrupulous about cost in my practice, from the little things to the big ones. Saving a few bucks on every case by not demanding different suture for every step when it made no difference: it adds up. So does thinking twice before heading down the road to futility. But it's neither universal, nor easy to know the signposts. Ought there to be some guidelines at the end of life, or should it be up to serendipity? I don't want to take judgment out of the equation; but not everyone has the same capacity for it. Which is part of the problem.

I can't back this up with any data, but when their grandma was dying, it seemed to be those who'd been with her the most who were the most able to let go. It was the out-of-town shirt-tail relative who blew in at the last minute who seemed to demand that "everything" be done. In those circumstances when it was insisted I go for the one/million shot, I've wondered if the same decision would be made were the family responsible for the cost.

So here's my proposal, in the context of the brouhaha over the idea of studying what works, and not paying for what doesn't: let's lay the money on the table. If a family wants to go ahead with an operation or other intervention, for which the odds of success are very long, or which is judged ineffective based on research (let's not get into details for now), here's the deal: if it works, Medicare (or is it Obamacare?) pays. If it fails, the family pays. Cash (credit card?) up front. Takers?

I see this health care "debate" as the quintessential test of our democracy. The need for reform is clear; the trajectory is, without doubt, toward disaster if changes aren't made. And yet, here we are, bogged down in disingenuous rhetoric, in overt efforts to stop it for purely political reasons. Trading amendments and concessions to various profiteers like bubble gum cards. Watering down the most serious proposals like potted plants. Media covering it lazily (all of them), sensationally (most of them), or entirely falsely and politically (you know who.) Advertisements and talking points designed to frighten, inflame, misinform. Citizens unwilling to think about it carefully. Faced with a crying need and a failed future that is not seriously in doubt, we seem unable to have serious debate, to argue on the merits, to legislate the sorts of changes that are needed. How can other countries have done it, and not us? And what does it say about our political system?

Can a nation of half-educated people, unable or unwilling critically to evaluate data; a media industry degenerated into selling soap over meaningful reporting -- and, worse, owned, operated, and scripted by people with overt political agendas; legislators elected for their dogmatism above all, the less serious the better; political parties more interested in power games than doing right -- can such a political system meet real and serious and undeniably needed challenges, or not? We'll know pretty soon. In fact, I'd say we already do.

Campfire Blues

As I once understood it, it's the pampiniform plexus, the veins around the testis, the prolonged congestion of which during unrequited (as it were) sexual stimulation, that is responsible for an unpleasant pain syndrome particularly prominent in adolescent males. This is a medical blog. Blogs are, by definition, personal. So, here's a post about something vaguely medical, and highly personal. Suffering from topic deficit, I've sunk to this. But it's a good story. In short, I may be the only person known to have passed out from a case of, well, you know...

It was at summer camp, a co-ed religious camp, which makes it even better. A high school freshman, by any standards, even in those innocent times, I was inexperienced. And there was a girl, a California girl, wiser than me by light years. One cool night found us together, in the woods, for quite a while. I will say no more; but you can easily infer how it didn't end.

Despite being what might be called distracted, we heard the call to the evening campfire. As we made our way back, I became aware of discomfort. Increasing discomfort. Significant, unfamiliar, impedimentizing discomfort. Double discomfort, throbbing, heated, encompassingly discomfiting uncomfortable discomfort.

The evening ritual involved encircling the fire, all the campers and counselors crossing arms and holding hands, some nice words to end the day, and singing. Henay matovu manayim... a mantra, hypnotizing, over and over, the words guttural, shevet achim gam yachad, soothing, repetitious, chocolaty, warm, pulsing, rising heeNAY... achim... yachad... The ch not like "chop" but kha, no English sound, a throaty sound, the letter X in Russian. Lozengy, physical. Percussive, drummy. Pounding.

Swaying back and forth, all together, the warm night, the song in minor key, repeating, the swaying the throbbing the singing, taking over, obliterating, the pain, rising, the throbbing, spreading to torso, to head, the forehead the cold forehead the singing pounding thrumming pain melding manayim throbbing matovu pounding drumming pain swaying swaying buckling swaying... the vague sense of someone falling, who?, people murmuring.

Looking up at faces looking down. Was it only concern, or was there knowing amusement? I'm okay, I insisted, wondering if there was... evidence. I'm fine, just got dizzy from the heat of the fire, or some other excuse. I didn't -- and don't -- think there was any way for them to have known. Somehow, I managed to convince them I didn't need to go to the infirmary.Walking slowly, I made it back to the bunk. Under observation, even if I knew the cure, there was no opportunity.

The pain was gone in the morning. Wonder if that was the beginning of my journey away from religion...

Note To "Andrew"

You, sir, are the scummiest of the scum that is blog spammers I've ever seen. You discredit yourself and the "business" you "represent."

Meanwhile, to anyone who might be thinking of satellite TV: I'd strongly advise against an outfit that calls itself "directstarTV." If its advertising methods mean anything, it's a total scam.

[Update, 7/22: I emailed the business, and today I received a reply which included the following:

Thank you for informing us of this issue. We’d like to offer our apologies for these incessant and unnecessary blog posts you received from a former affiliate of our company. Please know that DirectStarTV does not support such marketing tactics. As of July 22, 2009, this affiliate has been terminated and ordered to cease and desist immediately.

So I feel a little better about them.]

Truthteller

If I can't write, there's no reason not to post things that write themselves.

The interviewee is Wendell Potter, former head of corporate communication for CIGNA, one of the largest health insurers. He left after twenty years, in order to work for health care reform.

False Start

I've tried, but I don't seem to have it. Much as I'd like to return to the sort of writing I was doing earlier in Surgeonsblog, it's not happening. It's as if I'm in a darkened house with many rooms, but all the doors are locked. In a deja vu sort of way, I know there is stuff behind the doors, but it's inaccessible. Familiar, yet out of reach.

Re-reading old posts, I feel envious of the person who was able to write them, and of the good I feel it did, not to mention the wider world it created for me. But now I'm an interloper in my own life. It feels unnatural. Or, at least, unavailable.

So we'll see. I'm rummaging around in my brain, but so far it's like showing up for an Easter Egg Hunt. A day late.

To anyone who may have wandered here for the first time, I invite you to check out the "Sampler" post, for a sense of direction. Meanwhile, I'll keep trying.
.

Oldies But Goodies

An article in today's NY Times got me reminiscing about operating on old folks. While it's true there is inherently increased surgical risk in their care, my list of favorite patients is heavily populated with the elderly.

Like the ninety-six year old who lived with a very cumbersome hernia because he'd been told repairing it would be too risky. He had some friends over for a truss-burning party after I fixed it under local anesthesia. Or the WWII vet, rejected by other surgeons for his age and (only slightly) less than perfect heart, who told me I'd replaced Douglas MacArthur as his hero after I cured his debilitating reflux esophagitis. The many many older women who took their breast cancer in stride; the sturdy lady who fought tooth and nail, literally walked out on me, when I first told her she needed a colostomy but who finally acceded and insisted on seeing me bi-annually forever afterwards, bringing treats from her garden every time.

The oldest I ever operated on was a Russian immigrant from a town in the Ural Mountains where they live half way to forever. He was 102, which was lower than his temperature, caused by a gallstone stuck in his bile duct. His family assured me he was sharp as saber and strong as slivovitz. Two weeks later, he was back working his garden.

It was always my impression that older people were more matter-of-fact about their illnesses, and I found it almost universally true that they were less troubled with post-operative pain. Maybe it was physiological; maybe because they were more sensitive to narcotics. But I always thought it was simply because they'd made it through the better part of a hard life and pain just wasn't that big of a deal any more.

For an older person, the default mode was trust (the "sturdy" lady excepted. Sort of.) They listened when I talked. "Do what you think is best, Doctor," they said, which was like flopping into a comfy chair, after a day of walking on nails. It's impossible to care for the gray-haired and not think of grandparents, not to relax a little, to feel respect.

Okay, in the intensive care unit, not so much. Called there to consult, finding an ancient-looking person, tubes in natural and unnatural orifices, knowing survival odds are in inverse relation to those tubes, one is faced with often impossible questions having unknowable answers. To do what is reasonable; certainly no less, but hopefully no more. And humane. But that's another matter, with not just immediate but global implications (health care costs!). I was talking about the sort of relationship that begins in the office, or maybe a regular hospital bed. Relaxed. Time to get to know each other.

The NYT article points out some ways in which the geriatric population differs from the younger. (It also makes the very good point that whereas all med students do time in pediatrics, obstetrics, etc, there's no requirement for geriatrics. Older folks aren't just wrinkly.) It's certainly true in terms of length of recovery time, healing issues, complications from accompanying disease.

I wish there were objective ways to measure risk, to predict outcomes. Absent that, I always found a couple of reliable -- if unscientific -- predictors: people do like they look. An eighty year old who looks fifty will recover like a fifty year old; a fifty year old who looks eighty will recover like eighty. And, no matter what age, anyone who walks a mile or two every day will do just fine.

Not Guilty

I haven't heard directly from Blogger yet, but I note the red-flag warning is removed from my dashboard. Guess the human reviewer was convinced this isn't a spam blog.

Ironically, I've just deleted a spam comment from the previous post: it's one I get sort of frequently which links to an online drug seller. Annoying. I've contacted them and they deny doing it. Now they don't return my emails.

Excessive links, indeed!

Insult

This morning in my email was the following message:

Hello,

Your blog at: http://surgeonsblog.blogspot.com/ has been identified as a potential spam blog. To correct this, please request a review by filling out the form at [link deleted by me.]

Your blog will be deleted in 20 days if it isn't reviewed, and your readers will see a warning page during this time. After we receive your request, we'll review your blog and unlock it within two business days. Once we have reviewed and determined your blog is not spam, the blog will be unlocked and the message in your Blogger dashboard will no longer be displayed. If this blog doesn't belong to you, you don't have to do anything, and any other blogs you may have won't be affected.

We find spam by using an automated classifier. Automatic spam detection is inherently fuzzy, and occasionally a blog like yours is flagged incorrectly. We sincerely apologize for this error. By using this kind of system, however, we can dedicate more storage, bandwidth, and engineering resources to bloggers like you instead of to spammers. For more information, please see Blogger Help: http://help.blogger.com/bin/answer.py?answer=42577

Thank you for your understanding and for your help with our spam-fighting efforts.

Sincerely,

The Blogger Team

P.S. Just one more reminder: Unless you request a review, your blog will be deleted in 20 days.

But the real insult was in following the link to explanations, finding this (emphasis mine):

As with many powerful tools, blogging services can be both used and abused. The ease of creating and updating webpages with Blogger has made it particularly prone to a form of behavior known as link spamming. Blogs engaged in this behavior are called spam blogs, and can be recognized by their irrelevant, repetitive, or nonsensical text, along with a large number of links, usually all pointing to a single site

So much for my assertions that this blog has been of value, or, at least, once was.

I should add that in order to perform any action in posting, I now have to do a word verification. The distortion of the letters is so extreme that I can barely read them. So you might not actually be seeing this. I await the judgment of the blogger overlords. Meanwhile, I'll have the words in my brain: irrelevant, repetitive, nonsensical. Alas, it is I.

Trauma Call

In response to a call for ideas, Mike asked about trauma. Specifically, he mentioned hearing that the most common cause of death in motor vehicle accidents (MVA) is injury to (and, presumably, exsanguination from) the femoral artery. He didn't hear it from me. (In fact, he admitted he heard it on an episode of "ER." That surprises me a little, because that show -- despite a completely inauthentic and distorted portrayal of emergency care -- didn't often give out-and-out false medical information. Or maybe they did. I stopped watching a few years ago.)

I'll admit I didn't look it up. But I can say that in several years working at one of the busiest trauma hospitals in the US, during training, and having cared for many MVA victims including fatalities then, and subsequently in my private practice, I don't recall seeing a femoral artery injury resulting from a car crash; certainly not a fatal one. By far the greatest number of deaths were from head and/or chest injuries, and I'd guess that is universally true.

During training, trauma care was the center of the world, the cauldron in which the steel of the surgeon was annealed. At every level of training, and especially as Chief Resident, my involvement in trauma care taught me more about surgery and surgical patients than any other time I spent in hospitals. I'm grateful and lucky to have put in several years, literally living there much of the time, at one of the (at the time, probably still) preëminent trauma centers in the country. Brilliant and tough, my teachers at SFGH (actually, when I was there, the emergency wing looked like this) gave me my sense of duty and commitment to my patients, the ability to make difficult decisions and to take responsibility for them, an understanding of the sort of "digital" thinking that a surgeon needs in the operating room. From them I learned a lot of technique, too; but the frosting on that cake I really owe to another, a decidedly non-trauma surgeon, Vic Richards, a legendary innovator, surgeon of singular intelligence (M.D. at age twenty, give or take), and a significant figure in my book.

But in real life, trauma was a pain in the ass. Unlike training, when we waited hungrily for the next case to roll in, in practice it was by definition a disruption. Destroying an operative schedule, crashing a full office, or robbing a night of sleep before a fully scheduled next day -- those were the least of the problems created by a call to the ER. It was the circus of managing a complicated and unexpected case in a hospital not primarily devoted to such things. It was dragging in a bunch of reluctant other surgeons (depending on the problem) -- orthopods, neurosurgeons. And the worst were the MVAs, for that very reason: multiple organs, multiple docs. If I had to come in to see a trauma case, give me a tidy gunshot or stab wound every time.

And I DID see a few injuries to femoral arteries from those causes. And to much bigger and bleedier vessels than that.

Once I got over the frustration at having been called (I'm an orderly sort of guy), it was never hard to be swept into the torrent. There is unequaled immediacy to trauma care, a series of "yes-no" decisions, absent "maybes." Real time, instinctive, urgent in the extreme, it's invigorating. There's nothing like the intrusion of certain death, turned around and sent away by the coming together of everything you know, to give a sense of purpose. There's nothing like slashing into a dead man's chest, sticking a finger into his heart, and watching him awaken even as your hand is beyond the wrist into him.

And I can do without it just fine.

Gotcha. Not.

From a commenter:

I think as long as Obama admits that he wouldn't subject his own family to the limitations he proposes for everyone else, his plan will fail.

Regards,
A Better Angel

I assume he/she refers to comments by Obama during the recent ABC News "town hall" held at the White House, in which there was this exchange, edited selectively in many "news" sites:

"Q: If your wife or your daughter became seriously ill, and things were not going well, and the plan physicians told you they were doing everything that could be done, and you sought out opinions from some medical leaders in major centers and they said there's another option you should pursue, but it was not covered in the plan, would you potentially sacrifice the health of your family for the greater good of insuring millions or would you do everything you possibly could as a father and husband to get the best health care and outcome for your family?

OBAMA: [....] I think families all across America are going through decisions like that all the time, and you're absolutely right that if it's my family member, my wife, if it's my children, if it's my grandmother, I always want them to get the very best care.

Predictably, this has been jumped on by detractors and touted in pretty much the way the commenter did: Obama's plan is good for your family but not for his, says Obama. Since we all love our country and don't wish our President to fail, I'm sure it was just an honest misunderstanding. Like my snippet above, most of the criticism leaves out the President's next sentence:

...but here's the problem that we have in our current health care system. Is that there is a whole bunch of care that's being provided that every study, every bit of evidence that we have indicates may not be making us healthier.

Which, of course, is the most important thing he said.

First of all, the wording of the question was, well, questionable. It's a false premise. It implies there are "plan physicians." It implies that treatments recommended by "medical leaders in major centers" wouldn't be part of "the plan." There's simply no reason to think either is true. There isn't, as far as I know, a proposal to separate "plan physicians" from others. And there most certainly is NOT an implication that therapies that carry the weight of "leaders" in "major centers" would be off the list. The opposite is true.

And it's exactly the point Obama was making. But it's neither sound-bite worthy nor easily explained; and, as we've seen, it's very much selectivequotable and outofcontextable. (Incidentally, that he got tough questions like that sort of shows the right wing fury (ie, Fox News) over the "unprecedented access" ABC was granted was so much hot air...)

Among the many ways to control health care costs is to establish what works and what doesn't. As I've written, severally. Patients and families, as President Obama said, face such dilemmas all the time. "The very best care," he said. Exactly. Would that it were always as easy as the example that the questioner (a doctor) gave, in which there would be general agreement from the creme de la medical creme. (It'd have been better if Obama had pointed that out: again, showing the session was hardly planned and canned.) On the contrary. It's often a decision involving futile care: the operation with a one in a million chance of helping; prolonging life in the ICU; trying dangerous drugs with virtually no chance of helping. Or -- and one assumes this would not be covered, since it currently isn't -- heading to Mexico (or, like Farrah Fawcett, to Germany) for entirely bogus treatments.

These sorts of things are, in my opinion, way too difficult for our political system, as currently manifested, to handle. Rather, at best (if that's what to call it), we'll get a plan to pay for insurance for those who can't afford it, leaving the excess costs of insurance untouched and not tackling effectiveness in any meaningful way at all.

But, perhaps, we could at least do it or not, without deliberately taking out of context what the President said.

Yeah.

Right.

Why It Won't Happen

An eye-opening (for those with closed eyes) interview with a former executive in the health insurance industry.

As long as there is an enormous industry whose aim it is to make money from insurance premiums, and as long as that industry is able to influence politicians and credulous reporters, and as long as that industry remains between money spent and money received to deliver health care, we'll always have care that is too expensive and which fails to serve those who need it most.

Simple as that.

Progress

Kodak announces it will stop making Kodachrome, and I don't care. I'm down with digital. I mention this so as not to sound like a Luddite in the following paragraphs.

I don't know if we'll get health care reform or not; nor, if we do, whether it'll be in any way significant. Unlikely. Meanwhile, there are examples in surgery which illuminate one aspect of the problem of skyrocketing costs. Technology, in a word. Technology as selling point; technology as sexy; technology for its own sake. Unlike my digital camera, medical technology includes much about which it can be asked: "Huh?"

Previously I've expressed an opinion on "NOTES" surgery. More recently, I opined about robotics. I've also described the way I did gallbladder surgery through a single small incision, as an outpatient, with recovery times the same as laparoscopy, at significantly less cost. The latest hotness is single incision laparoscopy. The linked article describes a half-inch incision. Maybe. What they stick in is this baby, which, according to what I've read, requires a 3.5 cm incision, or about an inch and a half. In total, that's at least half again the total length of incisions made in standard laparoscopy, for removing the gallbladder, anyway. No less painful, one would assume; although the pain isn't that great, usually, in either case.

Now I must admit I've neither seen nor done it. As I've said about laparoscopy and robotics, it's fun to do, and I have no doubt this wrinkle is fun, too. So far the operative times are longer than "regular" laparoscopy, which equates to more expensive. In that article, the recovery is no different from standard stuff. Without knowing for certain, I'd say there are also issues with exposure and perspective, since the camera and tools are all coming in at the same angle. That, one might predict, adds up to higher risk. Time will tell.

The other day I read an article about a kid who had his spleen removed this way. Nice scar in the belly button. Humbly, the surgeon says it's not about fame, or being first. It's about preventing the trauma of a scar. The cynic in me says it's about referrals. But what do I know?

Here's my point, about which time might well prove me wrong. In my opinion, NOTES, robotics, and single-incision laparoscopy, so far, have one thing in common: dubious value compared to other options, more expense, and possibly more risk. For what? In the case of robotics, marketing. In the other two, marketing and cosmetics. These are examples, it seems to me, of therapies which, if effectiveness research becomes pervasive and meaningful, may well be taken off the list of covered procedures. And then what? Well, for one thing, the disconnect between reform and having it all will be illuminated. Maybe, rather than disallowed (which, realistically, is unlikely) the extra costs of these operations will need to be paid by the patient. Surgery which is purely cosmetic, after all, is never covered by any payers.

In any case, this is the sort of thing that doctors and patients alike will need to face if and when real cost control is effected. It won't be pretty, even if the data are there. Because when have data had anything to do with anything?

The Nubbin



One need think about the implications of this video only for a moment to understand the essential issue: a system that depends on private insurance is potentially no system at all. That insurers routinely deny coverage for any number of reasons means that, in addition to the forty-seven million who have no insurance, there are potentially millions more who only think they do, despite paying premiums.

Insurance companies do not provide medical care. They collect money, invest it, dole it out when they have no way not to. Even for the so-called "non-profits," it's a money-making business, the basis of which is taking money intended for health care, keeping as much of it as possible for as long as possible, returning to the system as little as possible. If it can also be said of physicians and hospitals that they profit from the ill health of others, at least those entities are providing actual care. If we're serious about real health care reform (and it's evident that the "we" is the populace, but not its elected officials), it ought to be the case that any citizen who gets sick can receive care, regardless of the timing of their illness or where it falls in the fine print. Period. And, of course, the same ought to apply to well-care (assuming we know what interventions actually add to health. As opposed to prophylactic spine manipulations, homeopathy, and other forms of woo.) The criterion for coverage: you exist. Other countries do it; why not us?

This is the central idea, the raison d'etre, of a single payer plan. Same rules for everyone. Guaranteed coverage. No wondering, no legions of people spending dollars intended for health care trying to find ways out of spending dollars intended for health care.

And, taking it all the way, what if this care were not only guaranteed but free (or nearly free) of premiums? So what if certain taxes were raised to pay for it? Wouldn't that be more than offset (or at least evenly offset) by freedom from those premiums? And by the fact that there'd no longer be an unnecessary and very expensive intermediary between people and the care they get?

To me it's obvious. Inevitable, even. Although watching Congress I conclude it won't happen for a few more decades, assuming we still exist by then; and only after a complete failure of the current system. The opposition continues to parade their hand-crafted talking points, designed to scare and distract. There simply are no salient arguments I've heard that make a case for maintaining the intermediary of hundreds of insurance companies, other than what amounts to "we need them because we have them." What good are they adding? What particular and essential need do they fill? For the billions and billions of dollars, intended for health care, that insurance companies make, take, and keep, what do consumers get that justifies their existence? The "public option," they tell us, "is just a way to get rid of insurance companies." And that would be bad, how?

Seriously. Somebody tell me. I can't think of a thing.

And yet, if you listen to our Congresscrowd -- practically all of 'em -- you'd think it's the insurance companies that are responsible for everything that's good about American health care. "The best health care the world has ever known," as one of them recently said, ignoring the price we're paying compared to the rest of the world, the millions with limited access to it, and the fact that we are at the bottom end of most measurable health criteria.

This might be a good time to insert a cartoon that Ellen sent me:

I think it is the essence of the contrary argument. Although, as I've said, were we to go all the way to provide universal coverage under a single payer, taxes would be offset. For those who love insurance companies, there ought to be a way to provide them the option.

Or, if they want the same result without all the paper work, whenever they get sick they could run into their bathrooms and do this.

Fee For Service

Not too many years ago, as the many-layered onion that is physiciandom brought tears more and more constantly to my eyes, I said, "What the hell, I give up. If this is all just a way to break us down and put us on salary, bring it on. Just tell me how much I'll get, and I'll decide if I want to keep doing it."

Paperwork propagating like potatoes; rules compounding themselves like viruses; payments receding like ice-caps. There's no doubt it affected my enjoyment of my work, steadily plunging the pleasure, the honor, the gift, and the psychic rewards of being a surgeon deeper into the bulb of the allium, harder to find without crying. And yet such thoughts find little if any resonance with the public. Fee for service, it's said, is the root of the economic evils of our health care system. I don't entirely disagree: what we have now is the worst of all possibilities.

There are many ways in which health care doesn't follow other capitalistic models. Attempts at controlling costs have included, for instance, both restricting and increasing the number of doctors produced in medical schools. Neither worked. To date, disguised and dressed in many pretty outfits, the main tool for cutting costs has been reducing payments to physicians and to hospitals. At best, results are mixed: forced to work harder and harder to maintain income, many doctors (speaking) have burned out and quit in their prime. Turned into bean-counters, those that stay have adopted methods that frustrate patients: cramming more visits into an hour, charging for phone calls, etc... Ancillary charges are outrageous: a friend recently wrote me about a $3,500 CAT scan, a charge of $850 for a simple automated blood test. (Not that anyone but the uninsured actually pays them: in some sort of dance macabre, insurers reimburse ten or twenty percent of those fees and the rest is smoke.)

(In a related note, I read that President Obama's doctor isn't happy with Obama's health reform proposals. In the article the good doctor says neurosurgeons get $20,000 for "cutting into the neck" of his patients. Now, I have no idea what goes on in Chicago, but I'd propose that, if twenty grand is an actual fee, like the $3,500 CAT scan, the reimbursement is a small fraction. In this post I don't want to get, yet again, into the frictions between surgeons and real doctors; but such a claim suggests a certain amount of hyperbole in the discussion. On the other hand, he implies he's for a single-payer plan; on that, we agree!)

Pay for doing stuff is the wrong incentive, so we are told. It leads to over-ordering of tests, over-doing of procedures. Can't entirely disagree. Read Atul Gawande in The New Yorker, or Buckeye Surgeon in Buckeye Surgeon. But if it's a problem, what is the solution? Salaries, says Atul. Better docs, says Buck. And me. With the right incentives.

I've said before -- to hoots and snark -- that I don't think many physicians are in it primarily for the money. But I do believe that, as in most other professional pursuits, people willing to work hard and who produce superior results have an expectation of some sort of recognition. Which includes income. And that's precisely why I said above that what we have now is the worst of all possibilities; fee for service with no incentives for quality, no differentiation among bad, mediocre, and excellent providers. For doing a colon resection in half the operative time (saving thousands in OR costs), sending a happy patient home two or three days (or more) sooner than average (saving thousands in hospital costs), with a lower rate of complications, I got exactly the same reimbursement -- from Medicare, from any insurance company -- as the surgeon who did none of those things. If, to a payor, a colon resection is a widget, the only criterion for payment for which is agreement to accept the latest slice in compensation, why bother to do those things? (Getting patients home quickly requires, among other things, making rounds two or three times a day, which most docs no longer do -- but which I always did. Faster operative times result from many things, among which are attention to detail, making sure in advance that what you need is in the room, keeping the team informed of what's coming next. Even helping move the patient and clean the room. Not seen frequently. Since I retired.)

A high percentage of doctors are human beings. That means they often respond like other people. Incentives and disincentives have an effect on behavior. Which is among the reasons "effectiveness research," or whatever the proper name for the effort (the blocking of which is desired by several legislators on the rive droit) to identify best treatments, makes nothing but sense.

I suppose it gets tiresome to read such treati. The bottom line is I think a system works best when there are incentives -- positive and negative -- to do the right thing. Some will, no matter what. (Of those, some have hung it up...) Salaries (at least those with no opportunity for adjustment based on performance) encourage laziness; capitation encourages the withholding of care. Fee for service which makes no allowance for differences in quality encourages abuse. And burnout.

Based on the snippets coming from the halls of Congress, I'm pretty well convinced that whatever so-called reform we get will fail substantively to address the real problems in our system: insurers, excessive or inappropriate "care," reasonable reimbursement across all fields of medicine, costs. And, for the life of me, I can't understand why.

Well, of course, I can.