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.
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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!