Surgeonsblog

Sampler

2009-10-07T10:40:00.000-07:00

Moving this post once again to the head of the list, I present a recently expanded sampling of what this blog has been about. Occasional rant aside, it's been my goal to let people into the operating room, and into the life and thoughts of a surgeon; to share my take on some surgical conditions, and sometimes just to get a laugh.

Memorable Patients: I've told stories about people who made a big impression

here, (the most stool I've ever seen in a belly)
here, (when my partner got sick)
here, (she killed her caregiver, and almost killed herself)
here, (thirteen years old, and I couldn't save her)
here, (until the end, she kept bringing me food)
here, (kidney cancer in his pancreas, and he kept on truckin')
here, (bleeding so fast, I could hear it)
here, (no stomach, kept eating steak)
here, (breast-heart connection?)
here, (an extreme test of faith)
and here. (a screw-up in a great guy)

Series On Diseases, Organs, And Conditions:

Breast Cancer
one, two, three, four, five , six,
and this
oh yeah: and this one about outpatient mastectomy

Appendicitis
one, two, three, four

Hernia
one, two, three, four

The Pancreas
one, two, three

The Gallbladder
one, two, three, four, five

The Spleen
one, two

Trauma
one, two

The Back Side
one, two

Diverticulitis
this

Death
one, two, three

A Peek Into The Operating Room:

Deconstructing An Operation (wherein I tried to convey, in detail, what it's like to do an operation. Some of it is pretty good!)
one, two, three, four, five, six, seven, eight, nine, ten

What The Liver Feels Like:
touch it here

The Beauty Of Bowel:
here

When Food Leaks Out:
yuck

You Are So Beautiful:
a look inside

What Makes A Fast Surgeon:
it's not fast hands.

What Cancer Looks Like:
ugly as hell

The Mind Of A Surgeon: (no, it's not an oxymoron)

Playing God
amen

Taking Trust:
maybe my most controversial post (except for one on prayer. You'll have to search for that one.)

Liking the Horrible:
the paradox that is surgery

When It Scared Me to Death:
a sick baby

When Things Get Tough:
the need to concentrate

On Burnout (wordy, but heartfelt):
one, two, three

On Surgical Complications:
one, two, three.

On Palliative Surgery:
difficult decisions.
Think Slow:

shoot from the head.

Some Recent Good Stuff

Brittle Beauty (this one got mentioned in the New York Times):
here

About Surgical Names and Anatomic Places:
here

Ever Have A Maneuver Named After You?
he did

Surgical Clips, And A Good Story:

blip, blip

"Alternative" Medicine And Why We Love It:

we're nuts

Strange Things In Strange Places:
takes all kinds

Old Folks:
They take it in stride.

Hospital Politics, And A Memo:

one, two, three, four

My Malpractice Series: (lawyers hated it. Because of the title, it still gets hits on strange searches...)

one, two, three

Thoughts On Health Care Issues:

Insurance Companies

Doctor Ripoffs?

The BFH

Rationing

Solutions

A New Blog!!!

2009-10-06T13:03:00.000-07:00

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

2009-10-05T10:43:00.000-07:00

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

Toons

2009-08-27T04:38:00.000-07:00

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

2009-08-26T08:32:00.000-07:00

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

2009-08-25T08:12:00.000-07:00

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

2009-08-21T09:46:00.000-07:00

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

2009-08-18T10:01:00.000-07:00

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

2009-08-13T21:37:00.000-07:00

Surprise! It's a Republican idea.
.

One Small Step

2009-08-12T10:08:00.000-07:00

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

2009-08-11T15:01:00.001-07:00

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

2009-08-10T10:57:00.000-07:00

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

2009-08-07T20:25:00.000-07:00

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.

Certifiable

2009-08-05T12:06:00.000-07:00

Think Slow

2009-08-04T02:04:00.000-07:00

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 I guess 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

2009-07-29T01:51:00.000-07:00

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.

2009-07-27T01:03:00.000-07:00

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

2009-07-23T18:54:00.000-07:00

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"

2009-07-18T08:25:00.000-07:00

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

2009-07-11T08:52:00.000-07:00

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

2009-07-08T16:45:00.000-07:00

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

2009-07-02T11:48:00.000-07:00

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

2009-07-01T11:26:00.000-07:00

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

2009-06-30T09:26:00.000-07:00

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

2009-06-29T01:19:00.000-07:00

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.

2009-06-26T08:41:00.000-07:00

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

2009-06-25T08:38:00.001-07:00

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

2009-06-24T01:03:00.000-07:00

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

2009-06-22T01:18:00.000-07:00

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

2009-06-17T12:23:00.000-07:00

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.

Reform School

2009-06-15T12:50:00.001-07:00

What if every American of a certain age knew they had medical coverage; what if all they had to do was register? What if, in this program, they could choose their doctors, who would be privately or self-employed, not government workers? What if the hospitals they went to were the very ones they go to now? What might you call such a program?

Medicare.

And what if this coverage were extended to all Americans? What might you call that?

Single-payer.

For those who have insurance, the only thing different would be the paperwork: it would become far less, or cease to exist. Neither the care nor the people and places providing it would change. From the point of view of the consumer, I simply see no advantage to having multitudes of companies standing between them and care, sucking money out of the system which goes into the pockets of executives, investors, and into the paychecks of tens of thousands of workers filling out forms at both ends of the transactions. No one -- NO ONE -- is talking about a national health service, ie, a plan whereby everyone goes to government-run hospital, staffed by government employees. (Well, that's not entirely true: several in Congress are comparing the so-called "public option" to the Department of Motor Vehicles. But that's completely disingenuous. The comparison, as I've said, is to Medicare.)

I'm not saying there are no arguments to be made against that "public option," or to a single payer system that enrolls everyone. Many doctors worry about losing control over reimbursement, having to accept ever-decreasing payment for service; they fear the monolithic. It's not without reason, or precedent. Funny thing is, as I've said, Medicare is already pretty much calling the shots: insurers largely take their reimbursement cues from them. Moreover, I've seen several situations in which an insurance company plays docs against one another: fearing losing their patients who are covered by a particular company, they cave to the demands to accept lower fees. It works particularly well in towns that have several competing physician groups.

It's also been a repeated theme of mine that endlessly cutting reimbursement to "providers" is a policy doomed to failure. We're about as low as it can go, if there's an expectation that smart and dedicated people will take up the caduceus. Rather -- and President Obama at least speaks the words -- the real savings will be in identifying those treatments that are the most cost-effective; and, even more importantly, finding those docs that provide the best care at the lowest cost and spreading the word.

The concept is ripe for demagogurery. "Do you want the government to get between you and your doctors?" they ask. As opposed to, what, a high-school grad in an insurers cubicle, telling the docs what they can and can't do? Like it is now? (In the linked article, it would also appear some want to prevent -- by law!! -- research into what treatments work best. To me, that's pretty hard to explain. How awful could it be to be told you can't have one operation that has been shown to be inferior to another?) (Okay, I recognize the potential problems. But if an idea is a good one, surely there's a way to implement it with safeguards.)

Reforming health care, it seems to me, is a perfect metaphor for everything that's wrong with our political system. While faintly acknowledging that for tens of millions it's not working, some in Congress nevertheless want only to maintain the status quo. Their efforts, unashamedly, are mainly limited to coming up with loaded (and disingenuous) phrases calculated to obfuscate. Given the complexities, it would be daunting even for legislators committed to comprehensive and effective reform. Would that we had some.

I'd bet very few people feel loyal to their insurers, per se. They may be loyal to their "providers" and to their preferred hospital. (Sort of. I read a study a few years ago that put the price of loyalty at, as I recall, about twenty bucks: ie, if switching docs meant saving more than that per month, it was hasta la vista, dockie.) What is the argument, from the consumers' point of view, of having insurance companies in the middle of the system? Where, specifically, is the value-added?

I fault the whole gang: Republicans, Democrats, and those in the White House. I can think of no reason why single-payer isn't on the table, except for the fact that it has so little support in Congress. But why? Whose goose is being greased? (If that's the term...) If a plan were to provide the same care we're now getting (or, hopefully, better), using the current infrastructure of doctors, nurses, clinics, and hospitals, while costing less by keeping more money in the system, why would that be bad? Because some call it.... SOCIALISM? Might not the result be more important than the name?

Some who've traveled these parts before will know I've made some suggestions. Funny thing: President Obama seems to have read them and bought everything but the single-payer part. He talks about identifying best practices; he talks about a larger role for the Medical Payment Advisory Commission. The latter, of course, is a double-sided axe; how acceptable it might be to physicians and hospitals would depend on its makeup and its responsiveness to reality. But it's the idea that is a good step. Cautiously endorsed.

[Acknowledgment: I know I said recently I didn't want my return to this blog be by way of the politics of health care. But I find myself unable to cast it out. I think I may have to get a little rubble off the desktop before I can find my way back into the mind of a surgeon.]

I Dream

2009-06-15T10:18:00.000-07:00

I dream of surgery. It's in my mind, if not always on it. The fact is, I miss it. A lot. The good parts, anyway. The doing.

Even though the dreams aren't always pleasant, it's frequently disappointing to awaken to the realization that I'm no longer a surgeon. Last night, I was showing some sort of student how to repair a hernia, showing the anatomy (not exactly accurately rendered), explaining why I was doing what I was doing. The fact that it turned complicated, and that the student seemed annoyed that I was asking him to participate didn't diminish the sense of pleasure. (I think it's possible to sort of meta-dream: when I'm a dream-surgeon I feel like I contemporaneously know it's just a dream but also take pleasure in the pleasure of it. Like watching a movie, I'm simultaneously enjoying the story, the unreality, and the art of the making of it.)

There are many possible directions from the above: a plea to my fellow surgeon-bloggers not to do what I did, to find ways to prevent early burnout, so you might keep your craft active longer than I did; a discourse on the difficulties of leaving behind such an all-consuming profession; the wonderment at having achieved a measure of competence in such a thing; the extent to which leaving it behind confirms something I always said -- that surgeons in particular, and doctors in general, aren't really special. We're just people who learned some stuff. And now I'm back to that unspecial tabula, heading toward rasa.

I does convince me of one thing. I do want to resume this blog, if only to retain or regain a connection to that former self. Consider this another step, after the previous post. A stretching before the ride, a calesthenic. I'll see if I don't pull a muscle, flabby from disuse.

By the way and for the record, it's hard as hell to remain silent about the insanity of the real world. Surgery blogging is a weak set of arms, paddling toward the surface, trying not to drown in the sea of stupid which laps ever more insistently at our shores. Pretend I didn't say that.

Rumbling

2009-06-11T15:49:00.000-07:00

I feel a disturbance in the force, a stirring. Desire precedes delivery; but just this side of the edge of possibility I see resumption of Surgeonsblog, if only for a while.

There's no doubt I've always wanted to; it's been a combination of running low on ideas, and the taking over of my mind by the disignorable realities of politics, of our nation, our world. And it was easy: every day there are outrages aplenty, no end of blogfodder, as the evidence of devolution of our politics is everywhere. I suppose I got a few things out, decongested my hepatobiliary system. But really, it was the ever-truth that nothing I said on my other blog mattered. I always knew it. I don't know what led to the final recogniton that there was no point. Partly, I think, it was re-reading some posts over here, and the comments they engendered. It's not cold fusion, but I think it was useful, once in a while adding something to the common good, if only a tiny blip.

Here's the problem, though: now fully retired, I have only my diminishing memories on which to draw. My estimable surgical colleagues in the blogosphere are out there every day, doing good things and storing them up for good writing. I might have to steal ideas from them. I may have to repeat myself on a topic or two; spiff it up, add to it, make it better.

And I'd happily receive suggestions from any reader any time; comments here, or later. Barge in anytime. Meanwhile, I need a little more fermentation. But I think it's brewing.
.

Alternate Universe

2008-09-20T09:13:00.000-07:00

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

I may have to speak up.

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

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

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

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

I mean, come ON!!!!

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

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

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

The Bed In Which They Lie

2008-09-14T10:50:00.000-07:00

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

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

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

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

"So why does tax-cutting mania persist among Republicans, I asked Holtz-Eakin, the McCain adviser--given...that, as Holtz-Eakin himself explain to me, taxes soon have to go up substantially in any event?

"It's the brand," he said, "and you don't dilute the brand." "

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

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

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

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

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

Nation; Tubes; Down

2008-09-08T07:27:00.000-07:00

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

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

And it's working.

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

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

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

And it's working.

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

And it's working.

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

We're

Milestone or Finish Line?

2008-06-26T05:00:00.000-07:00

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.

Food For Thought

2008-06-25T09:30:00.000-07:00

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.

Old Time Doc

2008-06-24T05:01:00.000-07:00

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.

ER, Uh...

2008-06-23T05:02:00.000-07:00

(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.

Delete "Elite," Tout de Suite

2008-06-21T05:00:00.000-07:00

[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?

Ignore RSS

2008-06-18T17:13:00.000-07:00

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

2008-06-18T06:00:00.000-07:00

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!

To Sleep, Perchance...

2008-06-16T06:00:00.000-07:00

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.

Love and Marriage

2008-06-15T06:00:00.000-07:00

[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.

Credit Where Credit Is Due

2008-06-12T06:00:00.000-07:00

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?

Arrrrrggggghhhhh!

2008-06-10T14:54:00.001-07:00

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.

Stem the Cell?

2008-06-02T05:00:00.000-07:00

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.]

The Question We Cannot Ask

2008-05-31T09:45:00.000-07:00

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

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

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

From innumerable McCain appearances:

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

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

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

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

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

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

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

Got Your Back

2008-05-30T05:15:00.000-07:00

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

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

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

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

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

Music of the Gods

2008-05-28T05:00:00.000-07:00

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

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

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

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

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

Looking In

2008-05-27T05:00:00.000-07:00

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

I digress.

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

Which reminds me of a story.

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

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

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

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

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

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

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

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

And, Of Course, There's This:

2008-05-26T13:36:00.000-07:00

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

Memorial Day

2008-05-26T09:00:00.001-07:00

Hillary the Horrible

2008-05-24T06:00:00.000-07:00

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

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

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

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

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

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

Especially in Zimbabwe.

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

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

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

Uh Oh...

2008-05-23T06:00:00.000-07:00

Another item from the American College of Surgeons:

COLLEGE OPPOSES RECOMMENDATION TO INCREASE PAYMENT TO PRIMARY CARE

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

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

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

Family Guy

2008-05-22T06:00:00.000-07:00

When I saw my brother-in-law dazedly slugging toward the house, blood streaming down his face in impressive rivulets, I sprang into action. Well, okay, not so much me as his wife, and my wife, and another of their sisters. But I did, eventually. Maybe not "sprang," exactly, but went over to have a look. And determined that on this Sunday morning, on an island, he'd need a few sutures. No problem. We had the whole cast of characters on hand.

It helps, on a Sunday on an island, to have the keys to the clinic. If the one holding the keys is the head nurse and clinic manager, sister-in-law to the subject, and weekend host, so much the better. What good is a surgeon, after all, with nothing to put in his hands?

So up we loaded D., pressuring appropriately the wound (rendered, it turns out, by a branch let loose by D. as he... well, I won't embarrass him...) and drove to the clinic. J. (not really a giveaway since the entire family of nine kids and two parents and, at one time, dog, thus initiate the spelling of their names) let us in and quickly gathered the needed utensils in a treatment room. With D's wife looking on admiringly, and ably assisted by J, I prepped the skin, infiltrated a little local (after calling for the stuff I'd need, all knowledgeable-like) and whipped in a few sutures, flashing my best instrument-tying technique in a blur of man and machine melding. We cleaned the place up and were out of there, the whole concerto from entry to exit having taken only fifteen minutes. Compare, if you will, to any day in any ER in any location. Helps to have friends in high places, especially on an island.

The image that remains in my memory is that of D's wife watching. D is a contractor and a builder and I've seen his work many times. Impressive stuff. And whereas throwing in a few scalp sutures isn't the acme of my work, it was the only way she could ever have seen me do what I do, and I liked that. Flipping the tip of the needle holder through a nicely proportioned loop of nylon; laying the sutures down in perfect intervals, bringing the skin together exactly, not too snug under a surgeon's knot, back flipping the next loop. Things I've done since I was a med student (less well, then), and hardly the equivalent of building a multi-million-dollar-home; but it was nice to let them, for a moment, into a corner of my world and how I live in it. Makes it real, after years of being the guy who was too busy to show up.

Says It All

2008-05-20T07:00:00.000-07:00

In the latest email bulletin from the American College of Surgeons:

....Practice Management Webcasts for 2008 and early 2009 include:

July 9, 2008 - Negotiating Better Third-Party Contracts
July 23, 2008 - Practice Valuations ... What's Your Practice Worth?
Aug. 6, 2008 - Compensation Formulas of Successful Practices
Aug. 20, 2008 - Effective Personnel Management
Sep. 10, 2008 - Dealing with Difficult People
Sep. 24, 2008 - Maximizing Patient Collections
Oct. 1, 2008 - Scheduling Techniques for Improved Productivity
Oct. 22, 2008 - ICD-9 Coding & ICD-9 Changes for 2009
Nov. 5, 2008 - E & M Coding ... Beyond the Basics
Nov. 19, 2008 - CPT Coding & 2009 Updates
Dec. 3, 2008 - Bottom-Line Budgeting for 2009
Dec. 17, 2008 - Billing Compliance: Avoiding Fraud and Abuse
Jan. 14, 2009 - Creating a 2008 Management Work Plan
Jan. 28, 2009 - Analyzing the Financial Health of Your Practice
Feb. 11, 2009 - Medicare Update for 2009
Feb. 25, 2009 - Advanced CPT Coding
Mar. 11, 2009 - E & M Coding ... From An Auditor's Perspective
Mar. 25, 2009 - ICD-9 Diagnosis Coding for Doctors & Staff
Apr. 8, 2009 - Appealing Third-Party Claims
Apr. 22, 2009 - Effective Governance and Management of Your Practice
May 6, 2009 - Benchmarking Practice Productivity and Profitability

Anyone wonder why I quit?

Yeah, I acknowledge that you can't avoid this stuff, and it's better to be smart about it. But trust me: this is but a teensy sampling of that with which we are regaled, pretty much daily. All I ever wanted to do was take care of patients. I had this silly idea that if I did a good job of it, the rest would take care of itself.

Faint Praise

2008-05-19T06:00:00.000-07:00

Syncope. Great word. SIN-co-pee. (I prefer SINK-oh-pee.)

Summertime, during college, I worked on a construction crew. One job was in the woods, following behind a D-9 CAT as it pushed down trees, clearing a path for a sewer line (the job I then had building manholes killed the guy that took over for me when I returned to college. That's another story). I'd saw 'em up with a chainsaw, buck 'em up with an axe. Filling the wait time, I kept that double-bladed axe sharp as a scalpel, honing it with a broad file, the metallic hrrizzzzzz, hrrizzzzzz and the sway of my hardening shoulders convincing me I was Paul Bunyan. In one of my moments of brain-body disconnect (I also nearly produced a sagittal section of my head with the chainsaw, cutting a log lying across a gully, above me), I tried whittling with that axe, whizzing it past the fist that held my would-be chunk of wood sculpture. Gee, I thought. I could really hurt myself; and with that, I did it again, this time slicing into me just beyond the sino-thumbic M-P joint. It bled quite a lot.

After a few comical moments, wherein I grabbed my thumb and flagged down the CAT driver, who hopped off with a first aid kit and tried dabbing an iodine ampulet into the considerable flow, I found myself in the office of a nearby doc. "Lucky you didn't get the tendon," he said. And then, "Oh, it looks like you did..." As he readied his suturing materials, he suggested I lie down. "Naw, " I blustered. "I'm gonna go to med school. I've dissected frogs. This stuff doesn't bother me." So I watched as he injected some local and began sewing. It wasn't the blood, or the hurt. It was the sensation of feeling some sort of tug as the needle passed: I thought I could hear it or something. An awl through leather. Weird. About the time he looked at me and suggested again that I lie down, I said I thought I might go ahead and lie down...

I've seen a lot of people faint over the years. Since an episode during internship when a friend of a patient who'd insisted on watching as I sewed him up fell like a log, straight and unfettered, to a concrete head-lacerating floor, I've anticipated it. Still, it happens. Nearly always, on arousal, the fainter is embarrassed. Don't be, I'd tell them. It's natural. There are some situations when it's best to lie down, and when we fail to recognize them, or act, our brains are wired to see to it that we do. I always liked that explanation. I think it might even be true.

It's interesting. For some threats to our well-being, our adrenals squeeze like a fist and out comes the "fight or flight" response. Pumped up, ready to go. (Or is that "fired up...") For other situations, the better choice is "sit down and shut up." When you think about it, it makes sense. For a threat before which you remain more or less intact, a racing heart and fleet feet seem right. If, however, things take a turn such that your pipes are open with fluids leaking out, it might be wise to shut things down. So I think fainting is nature's way of telling you to cool it. If you're too dumb to get your brain at or below heart level, your head will make the move for you. And turn down the pump at no extra charge.

Well, nothing's perfect. Why we should keel over when someone else is in trouble escapes ready explanation, at least by me. Maybe it's slop-over, an individually exaggerated form of communally-needed empathy. You know you should help, you want to help, but shit-oh-dear: gotta take a pass! Of course, it might ensure that you'll have a second chance when you both wake up.

JB

2008-05-18T08:28:00.000-07:00

It can't have escaped notice that of late my blogging has wandered from the prime directive to inform and entertain about surgery and surgeons. So this post splits the difference. It's about friendship, and it's about a surgeon. I've mentioned him already.

Not entirely by intent, in recent years I've become more of a recluse than is my nature. Time was, I had lots of friends. In college, we were a group of four guys who ate nearly every meal together, went on dates together, did funny bits up and down the Northeast Coast; and there were a few others, my freshman roommate included, that were close and with whom I've stayed in occasional touch. Med school included new pals; with one or two I have rare contact. During surgery training, my wife and I had several couples who were much more than typical friends; not all of them were medical, and the friendships intersected in all possible combinations. I knew we were lucky, and I loved it. Once I started in practice, things narrowed into mostly professional acquaintances. Sitting in the doctors' lounge when there was a moment, shooting the breeze. Non-medical friends were fewer, and mostly consisted of people with whom we shouldered solidly on sidelines of our sons' sports sagas. Those were good friendships, too; but time, and our son, have moved on.

In the last few years of my practice I was so busy and so exhausted I really had time for little of life outside work. Since retiring, I've finally gotten close to my wife's large and noisy and wonderful family. They, entirely, are my friends now. Which ain't' half bad, except that they're all over an hour away. But as of a couple of weeks ago, I'm reminded of what I've been missing: JB and his wife were here for a few days, and now their absence feels like a hole.

On paper, there should have been problems: he's conservative, I'm liberal. He's religious, I'm not. I'm old, he's older. Where we both trained, ten years apart, he cut a wide swath; I came and went without fanfare. But here he was, after corresponding for about a year, and a brief meeting for only a couple of hours in San Francisco a few weeks ago. With his wife, whom I'd not met, he flew up from his place near Yosemite to spend four days with me and my wife, whom he'd not met. We've been married about the same amount of time (longer than many of my readers are old); our wives got along great. JB and his wife, Jeannie, met in Vietnam: he a surgeon, she a surgical nurse. Clearly, it was a central event in their lives. That, and the entry into it of their much-loved son. If our wives were unsure, JB and I knew with some instinctual certainty that it'd work. And it did. Despite certain philosophical differences, we have much in common. I'd even go so far as to say that we have our differences in common, although I'm not sure I know what I mean.

Going through surgical residency and war, which are not in all ways dissimilar, leaves a person with experiences that can't be fully imagined by others, and which bind people who have, no matter their other differences. JB and I did both: the former pretty much exactly alike, the latter less so in that he was a fully-trained surgeon and I just a general medical officer. But it translates well. His video from then (warning: parts are very graphic for people not used to trauma surgery -- and there's some of his writing here), though much more intense than one I could ever make, has overlap with my experience; some of it quite exactly. At the least, we both know war as much more than an abstraction or a slogan, and have seen its futility and horror at its worst (me, a little less than he!), and its fellowship at its best. And having had many of the same surgery teachers, we have stories to tell. Tell them, we did.

Amazing to me, we also have in common the abandonment of busy and successful surgical practices in our fifties, and for the same reason: it wasn't as much fun as it had been. A sense of it literally killing us (in his case, the signs were unmistakable). To do that, I'd say, requires a certain sensibility; maybe more than anything else, that decision alone tells me we're of similar cloth. It wasn't easy; nor free of worry, or of deep ambivalence. Whether on the basis of these things or not, there was an instant feeling of commonality and of trust. And that led -- preconditions set out in a couple of emails to the contrary -- to the ability to talk about politics, and religion, and life, without worrying that differences would break us down.

We ferried to Lopez Island and spent the day with my sister- and brother-in-law, talking incessantly on the way up, and back. I perfectly grilled some halibut, taking (of course) full credit for the entire meal made over the previous couple of days by Judy. Making up part of the smallest crowd ever (literally: the smallest ever!) at Safeco Field, we went to a Mariners' game, and afterwards to a luscious chocolate shop and talked till midnight. It's been a while since I've done that, unconscious of the time.

In this post, I thought I'd be describing JB in more detail and better than I had in a previous one (he was highly amused by the "wiry" moniker.) But I'd risk embarrassing myself (as if I haven't done that before!) or having it come off as hero-worship. So I'll just say this: JB is about as real as they get. No artifice. Honest. Knows who he is, and why, and what that means for him. Hell of a story-teller. A little paranoid about us liberal types.

I like him. I like his wife. We all got along, and well. For the first time in a long time, I felt I was spending time with a friend, it felt good, and I miss it.

[Update, 10/10: How things change. I guess it's the oldest friends that are the best ones, after all. Preferring to believe Barack Obama is a closet Muslim, JB finally had enough of me pointing out that he wasn't. Concluding I was an America-hating, terrorist-loving Jew, he kicked me to the curb like the remnant of a retread. I missed him for a while, even then. And I still miss the person I thought he was.]

Dougie

2008-05-15T07:25:00.000-07:00

"Ready...." A long pause, milking it for all it was worth.

"Aim...." Blindfolded, I squirmed. I figured it was what he wanted.

"FIRE!!...." Then ...nothing. Not a surprise. This was, after all, payback. "C'mon," I said, making it sound like begging (which it was, partly.) "Just shoot me." Tick, tick.

Pkkfftack. Buried right next to my spine, deep and painful. Fair enough. Otherwise, he'd have told my mom.

Like many kids, it was by indifferent luck that Dougie and I survived childhood, and each other. On this particular occasion, we'd been shooting one another with a BB gun he'd borrowed from a neighbor. Unlike our Daisys, this one had some oomph; you could pump it more than once. Because we weren't totally clueless, we'd been using protection: the shootee wore a diving mask and a raincoat, and was dashing between trees across the street from Dougie's house. The shooter, from a window in Dougie's bedroom, took shots at the victim as he zigged the space between the trees. Given the distance, and the precautions, it was fairly harmless, although it's hard to say where all the pellets ended up. After Dougie had had his turn as prey, he peeled off the mask and coat and ran toward the house. Who could blame me, really? It was such a clear shot. I fired one more time.

Being one year the younger, he was used to abuse by me. But this time he was really pissed, and I was scared of what I'd done. He'd screamed, "MY EYE!!!," and slapped his hand over his face, stopped dead for a moment, then run into the house and upstairs, hand still in place. (No one else, of course, was home.) I was cold-fingered and, I'm sure, white-faced as he removed his hand. The welt was within the hairs of his eyebrow, sparing his eyeball for no particular reason. He was, among other things, threatening to tell my mom. The firing squad was our negotiated settlement, a way to retribution for him, and a promise to remain silent, for me. It's my recollection that he had to dig the pellet out of my back. Impressed with its power, we fired the gun again, at some sort of metal pan, and it went right through. Or dented it pretty good. Don't remember which.

I hog-tied Dougie once, playing cowpersons and Native Americans. Accidentally dropped him on his chin, causing enough bleeding that he thought it was coming out of his eyes. Another time my brother was showing us how to swing a golf club. I was looking over his right shoulder, Dougie over his left. My brother is right-handed. Enough said. Sounded like a coconut.

The time when actual death was among the possibilities (although I guess the golf club came close) involved bows and arrows. The real kind, with metal tips, albeit not the hunting variety. We'd been at a field at Reed College, where there were straw-stuffed archery targets. Shooting at those static circles got boring in about five minutes, so we did the natural thing: started aiming straight up into the air and seeing how close we could get ourselves to where the arrows came down. Pretty close, as it turns out. Ssshhppt. Couple inches from the shoe. Well, maybe a foot or two. Until one went up so high we lost sight of it. Quickly computing the consequences, we sprinted in opposite directions. Dougie ended up scronched several yards away, having pulled his jacket up over his head. As if guided by the judgment of fate, the arrow returned to earth by way of Dougie's jacket and the space between his elbow and his left side. As I learned in anatomy class many years later (for this is a surgical blog), there were any number of comparatively vital structures within a shaft-breadth or two. No negotiations were required to keep us both silent about that one.

It wasn't all bad. We got hold of a couple of Army-surplus intercoms and strung wires between our houses, which were on the same block, around the corner from each other. Securing permission from every intervening neighbor, we ran the wires along fences and property lines. Battery powered, the boxes weren't very potent with that much wire between them, and there was no call buzzer. You had to lean pretty close to hear anything. Sometimes we could alert the other of a call by scraping something across the metal face of the box; usually, though, we'd call on the phone, and then hang up and carry on using the intercom. Charmed by electricity, I did once try to electrocute Dougie, in the guise of a "lie detector" which a brainy friend and I put together. In actuality it was a battery and a capacitor to which we hooked a couple of wires and then talked Dougie into affixing them to his fingers. Asked him a question, and then zapped him. We were too young, I'd say, to be called assholes. Idiots, more properly.

Amazingly enough, Dougie and I maintain the friendship that started nearly sixty years ago. Exuding enthusiasm from every orifice, he teaches astronomy and cosmology, and the actor in him has made his planetarium show the talk of greater Portland. He played his guitar at my wedding. We call each other on birthdays (his was last week) and see each other on rarer occasions. Always it's easy and comfortable, and for the past many years, pretty much risk-free.

Jock

2008-05-13T21:00:00.000-07:00

On first meeting over the years, many patients have asked me if I played football. I'm sort of a big guy and, during some cycles of my life, have actually looked in reasonable shape. The answer would be in the affirmative, with the qualifier that in general I was comparatively lousy at it. Slow. Not particularly agile; hypo-endowed with the killer instinct. (I was captain of the high school team, and was honorable mention all-city, on a team that finished dead last and never won a game. At halftime of my final game an assistant coach finally got to me: the Knute Rockne rah-rah never worked, but this guy managed to shame me. You coulda been a leader, you dogged it, etc etc, such that I got a little steamed had a noteworthy second half, made a few tackles, a sack or two, blocked a punt; so the opposing coach gave me a nod at voting time.)

Probably it was my first game that did me in. I knew literally nothing about football before high school. My dad, unrealistically wanting bragging rights, convinced me to turn out for the freshman team, and to sign on as a fullback. I didn't know that position from the missionary position, which I also didn't know. Within a day or so, after observing me trying to execute a cutback, the coach said, uh, I think you need to be a lineman. We practiced, I learned, vaguely, what I was supposed to do, and we had a game. Before play began, the guy across from me said "I'm gonna kill you, mutherfukker" after which, when the ball was snapped, he popped me one in the face, resulting in a bloody nose and a revelation. Returning to the huddle as the quarterback called the next play I said, "Hey, I have a bloody nose..." He continued the play-calling. "Excuse me, I have a bloody nose. I need to lie down." With derisive disbelief, the quarterback looked and said, "You BABY!" It was then that I realized in football, you play hurt. Your mommy doesn't give you a cold wash rag and say nice things while gently squeezing your nose.

I kept playing for the next four years, mostly screwing around with my buddies, not too worried about the score. We shared an attitude.

In college, at the end of freshman year, during which I mostly rode the bench, I discovered rugby and never played football again. Our team was actually good; we were East Coast champions, beating much larger schools, Ivy League heavyweights, and I got inspired enough actually to get in shape, run a few miles a day, pump a little iron. Despite the fact that the team was run by a rival fraternity I made my way to the A team by dint of making myself better than the favorite (and frat-brother) of the leadership.

In five years of football and four of rugby, I was never seriously hurt until I returned to my college during the first year of med school. My former team was playing a traditional rival in rugby, and that team was a man short; I was pressed into action, playing for the enemy against my old mates. In a desperation tackle I lunged at a halfback, caught his collar and hung on, somehow managing to detach the tendon of the flexor digitorum profunda of my right ring finger. The required surgery was just before a pathology final. Operating my old-fashion microscope, with its clunky machinery, right hand in an above-elbow cast, was a challenge. And the professor was unamused when I hollered out half-way through the practicum, "Would someone like to come over here and twist my knobs?" It did, however, lead to a romance with a classmate that lasted a couple of years...

[I have realized I've told part of this before. Which means it's confirmed: I've officially run out of things to say. Sorry.]

Moomump

2008-04-30T08:00:00.000-07:00

Since I was a tyke too tiny to say her name, Mildred was "Moomump" to me, and the appellation stuck for the whole family thenceforward. At every stage in my life, she was the perfect aunt. When my age was in single digits, I could cajole her into giving me the presents my parents refused. I called her a few times at that age when I felt picked on by my parents, and she'd come over, subtly mending fences. In my teen years, it was Moomump who first let me drive; in her big Chrysler 300 we'd blast our way to the Oregon coast, me a fourteen-year-old, being prodded to get it over eighty. "Don't drive like an old lady," she'd say, offering me a cigarette. In my young adulthood and later, I realized how brilliant she was, and what a great source of good advice and amazing stories. Of her famous friends: artists and actors and musicians and politicians.

She and my dad -- he the older by a couple of years -- grew up at the poor end of lower middle class. During the depression, their father, so they told me, would hide in the closet when the doorbell rang, lest it was a bill collector. One of them would answer and say they were alone. But they were both superior students and musicians; her piano gifts were greater than my dad's on the violin. As a young woman she was offered an opportunity to study in New York under one of the great pianists of the time, but turned it down for the need to care for her diabetic mother. (Until I looked him up just now, I thought the potential mentor was Emil Gilels, but clearly it couldn't have been. Rather, I think it was he that she considered the best ever; someone else must have offered the position.) Unable to afford it, neither she nor my dad went to college. Both eventually enrolled in a night law school; she was one of Oregon's first female attorneys, and also went to a business school. (My dad ended up on the Oregon Supreme Court and was Chief Judge of the Court of Appeals. So they did okay, legally speaking, thin resumés notwithstanding.)

I'm not sure of the order of events, and there's no one left to tell me. There was her law practice, and there was her time working for Ariel Rubstein, a concert pianist and impresario, who brought classical musicians to Portland. Which one led to which, I can't say; but at some point Moomump did legal work for Arthur Rubinstein, having been told by him how he -- along with many other musicians -- was being screwed by RCA, the only record label that handled such classicists. Sketchy are the details, but sales numbers as related to royalties were tightly held by RCA. Never enough, they claimed, to pay their artists very much. When the phone rang from some girl lawyer in Portland Oregon (chain smoking made her voice anything but girlish), the bigwigs in NYC telephonically patted her on the head and told her to buzz off. When they got a pre-arranged call within minutes, from the largest accounting firm in the country announcing intention to audit the books per fine print in the contract, it wasn't long before they relented, leading to recompense for Rubinstein. And, not long after, for many other artists who heard about Moomump and came to her. My brother the attorney says the contracts she forged remain templates for artist/recording agreements today. RCA, presumably to get her off their backs, offered her a job in their New York legal office, but she demurred.

Moomump and Arthur Rubinstein became friends. She was dining at his home one night when he announced, at around age sixty, that he was to be a father again. "When," she asked, surprised. "Nine months from tonight," he smiled. (Genius musicians don't leer, I assume.) And nine months later, she got a telegram (I've seen it) saying only, "And his name is John." There were friendships with other great pianists, too. In one of my favorite pictures of her (which I can't seem to find at the moment), she is arm in arm with the sweet Vladimir Horowitz. Nor did her acquaintances end with musicians. Paul Newman, Michael Jordan, Hal Holbrook, Robert Joffrey, Yul Brynner. She knew them more than in passing, and had stories. But her friendship with Van Cliburn surpassed them all.

They were polarities: he, much younger, slender and upright, proper and handsome; she, stocky, untidy, and rough. She was quick with a bawdy laugh, he with a gentle smile. Sometimes when he performed on the West Coast, he'd send a plane for her, and she'd fly down, to San Diego or wherever. For his mother's ninetieth birthday, he brought her to his Fort Worth home for a two or three day party. On one occasion, when Van was playing in Portland, I -- a high-schooler -- picked him up at his hotel, stuffed my pockets, at his request, with oranges from his room, and drove him to the concert hall where I unloaded the produce, and him. Leaving an impression that lasts, strong, to this day, Moomump arranged for Van and his mother to have dinner at my in-laws' home in Bellingham, Washington one evening, just them, where he dutifully listened to their pen-youngest play the piano, and rummaged some more food in their pantry after they'd already fed him a couple of steaks.

This unlikely pair talked frequently on the phone; he wanted her critique of every new album, every concert she attended. And she knew her music. When a little girl, she once told me, she'd lie in bed reading piano concerto sheet music before she went to sleep, and could play it fully, from memory, when she awoke. I heard her play only a couple of times -- she hardly ever did, except for herself, when I knew her. (She put on a concert or two, for charity, in her political life, but I wasn't around to hear them.)

Artists, dancers, actors, when they came to Portland, often partied (and sometimes performed spontaneously) at Moomump's house. I was there for some. As full as her social life was, she never married nor, as far as I knew, had any sort of romantic attachments. But was she known and loved! From her position on the Planning Commission, she was appointed by the Mayor of Portland to fill a vacancy on the City Council, to which she was re-elected by huge margins, three times. Both Police and Fire Commissioner, she was adored by those people in blue, and they campaigned hard for her. She'd show up at one fire station or another, usually at dinner time, encourage the captain to volunteer to walk her dog, and talk to the troops about what was going on. My four-year-old son and I partook with her of such an occasion, after which we went along on a fire-boat run on the Willamette River, the kid holding onto the water cannons as they sprayed. If the timing was right, Moomump would show up at fire scenes, having hitched a ride on an engine.

When the Portland Trailblazers played the Chicago Bulls in the NBA finals, we two were there, too, in her season seats -- she'd found another for herself; at half time, people came out of the stands to talk to Moomump as she walked at the edge of the court, her public ignoring Magic Johnson and other stellars who were broadcasting nearby. She introduced me, that time, to Michael Jordan's dad. Hardly an athlete, she loved sports, went to the Blazer games, and to the Timbers' soccer games, sometimes kicking out the ceremonial first ball. Maurice Lucas was a good friend; Clyde the Glide an acquaintance plus.

But it was of her time on the City Council, running a financially tight ship, that she was most proud. That, and her dogs. In her forties, or maybe fifties, she decided for the first time ever that she wanted a dog. There followed in succession several German Shepherds, first Hildy, then Ranger, then Blitz. She doted on them, had an oil painting made of Hildy, the best of them all. Often they came to work with her, sleeping under her desk unless someone came in and got a little heated; at which point it was nose to nose, two paws on the desk, with a clear inference to be drawn that more respectful dialog would be prudent. Among her most-told stories, punctuated as usual with her gleeful cackle, was when Blitz walked down the hall and shat upon the mayor's carpet. (A subsequent mayor, with whom her relationship was a bit prickly.)

No matter how many opponents, she won her elections with seventy or eighty percent of the vote. College kids, downtown business people, liberals and conservatives, all loved her, for her intelligence and straight talk (when the term actually meant "straight talk"), for her lack of artifice, her clunky clothes (she hated gussying up, as in that picture with Van) and her dogs. You showed up at a council meeting hypo-facted at your peril. Shoot off your mouth without engaging your head, she'd help you out on a limb and saw you off, whoever you were. And tell me about it later, ending the story with a sawing motion of her arm, and with that "heh-heh-heh-heh-heh-heh," staccato, like a tommy-gun, and just as lethal. Fiscally conservative, socially left of center, she answered only to herself when it came to staking a position.

When my wife, Judy, ran for our local school board, Moomump gave her plenty of advice, and pulled no punches when criticizing her first drafts of campaign literature. And as she had me, she loved our son. Every time I called her, or visited, she asked about him; would have given him anything he wanted if she could.

Toward the end of her life, she suffered congestive heart failure (ah! it IS a medical post!!) and sank, frustrated, into herself. Her home was dark when we visited, oppressively smoke-stenched. The parties that had filled the place with sound and color were nowhere to be sensed, the room downstairs where they'd been held now fungoid and cluttered. To the end, she smoked, driving her amazingly devoted cardiologist crazy (I met him when he drove her to Seattle, shortly before she died, to attend a Cliburn concert, at the intermission of which we went backstage -- she barely made it down the hall -- and talked with Van, whose assistant took a picture of Moomump, Van, Judy, and me, and promised to send a copy. Never did.) We went there more frequently as she became more homebound. Closed-down concentric as her world had become, she filled back up when we were there. On the rare occasions she'd agree to go out, people still came up to her, anywhere. And, sitting on her sagging sofa, she still rolled out the stories, with relish. Backstage at the Joffrey Ballet, schmoozing with Kitty Carlisle, at the racetrack with Paul Newman. And Van: always a story, with love, about Van. A little dirt on a politician or two, commentary on family (her appearing at family gatherings, no matter the import, was a rarity. She didn't much like the dynamics, but loved visits on her terms; which included, thankfully, me and my chunk of the family.)

They found her sitting at her kitchen table, ashtray filled with stubbed Tareyton 100s, a couple of days before we'd planned another of our regular trips down there to see her. Van Cliburn sent an armload of red roses; a mayor and a governor attended her memorial, and cops and firefighters, in their dress uniforms; engines with ladders raised were parked, sparkling in the sun, outside the temple. She'd have loved that above all, even if the venue might not have been to her liking. The picture (my favorite by far!) at the top of this post was on the front page of The Oregonian when she died. A nice article from another paper is here, in case you think I might have exaggerated anything. My brother and sister and I spoke at the ceremony, and my dad. Good stories by the former gov'. In my part, I revealed her name to those that never knew it. Moomump.

SurgeXperiences, Learingly

2008-04-27T07:40:00.000-07:00

So here it is, the TWENTIETH issue of SurgeXperiences. That this carnival of all things surgical has made it to this milestony moment is testimony to the perseverance of Jeffrey Loew, who birthed it quite alone and without benefit of breathing techniques. If this is how he addresses all his goals, he's sure to become the surgeon to which he aspires. It seems a significant passage. I'm honored (so I've convinced myself) that he chose (forced, cajoled, tricked, shamed) me to mark the occasion. So...

There follow the entries received,
In rhymes I have lately conceived.
I offer to you
The best I could do.
It's over, so I am relieved...

_______________________________________________________________

In general I'd say I'm inclinedta
Avoid making holes in vaginas.
The trend, though, is clear.
You can read of it here.
To explain, Rico's taken the timeta.

__________________________________________________________

That's not the first time it's been said.
It's possible you may have read
When Buckeye spoke out.
And I've had a shout.
Some surgeons have holes in their head.

_________________________________________________________

A surgeon must do what is right.
But there is some trouble in sight.
The first thing to go
As plastic guys know
Is beauty, when money is tight.

_________________________________________________________

This frightening tale is from Bongi
Who tells us he's doctored a zombie.
I believe every word
'Cause I've never heard
A suggestion that he's ever wrongi.

_________________________________________________________

I'm not sure I know what I thought
When I read what technology wrought.
It might just be true
That no one will rue
The day when I'm dumped for a bot.

_________________________________________________________

Before Annie started her journey
Of sharing her words with attorneys,
She was a young nurse
Who avoided a hearse
In an OR once used by McBurney.

_________________________________________________________

Bob Bernstein has something to share,
Although the hirsute may not care.
He'd just like to reachya
About alopecia,
And move around some of your hair.

_________________________________________________________

We learn quite a lot from a guy
Who lets a doc laser his eye.
He gives us the facts;
If you're worried, relax:
He thinks you should give it a try.

_________________________________________________________

From David who writes on an isle,
A lesson in what sort of style
A doctor will need
If he's to succeed:
You listen and try not to smile.
_________________________________________________________________

Another from Dave is right on.
He's singing my favorite song:
For deep in its heart
Our work is an art.
Ignore that and you will go wrong.

_________________________________________________________

When tripping down memory lane,
Rob Oliver hopes to explain
What was going on when
He was two years and ten
In the field in which he's now playin'.

______________________________________________________

From the Philippines comes a post too serious to rhyme: as in boardrooms, jury rooms, employee and teachers' lounges, in the operating room there are sometimes words spoken and behavior manifested best left out of the public realm. But this clearly went way too far.

_____________________________________________________________________

Dave Gorski calls surgeons to task.
Before jumping in you should ask
If the new ways are best
Or might still need a test
Before you slip into your mask.

____________________________________________________________

This article sends out the love
To surgeons who don double gloves.
It's not that it's dumb
But my hands feel numb;
I say "no" 'less there's cameras above.
_____________________________________________________________

Ramona is one of a kind.
If ever you're caught in a bind,
The shirt off her back
You never would lack.
She'd give it and not even mind.

(The preceding has nothing to do with her post; it just happens to be true. In her essay she eyes, in fascinating detail, a little-discussed syndrome. )

__________________________________________________________________

Since the days of our heroes of old
Surgeons have thought themselves bold.
But sometimes it's best
If we give it a rest
And helpfully do what we're told.

(Especially if it helps prevent sterility in cancer patients.)

______________________________________________________________________

In thinking of losing her bits
She's come to the end of her wits.
Less parts in the nether?
She does wonder whether.
At least her new blog will get hits.

(Originally, the last line was "Of course she will still have her... sense of humor." But I decided against it.) And part two of her post is here.

__________________________________________________________

Another post from bongi. The subject seems unsuited to lighthearted verse. We make difficult decisions every day; the hardest are often when it's time to do nothing more.

______________________________________________________

A dentist requests that I act
On this informational tract.
It's less like a post
Than many or most,
But there's data for you to extract.

________________________________________________________________

Readers might say it's uncool
To hype oneself, but there's no rule
Preventing me from
Referring to some
Faves from my memory pool.

_________________________________________________________

Now Bongi once more raised his hand
From his home in a far away land.
Midst branches of nerves
I guess he deserves
To brag how he handled a gland.

_______________________________________________________________

Our carnival ends on this note:
I thank you for all that you wrote.
Were I more a poet
I'd happily show it.
On the other hand, it's admittedly a questionable way to showcase your work, forcing, as I did, a thumbnail into an unyielding format; and if anyone feels their essay got short shrift, I'm sorry.
And I hope that you know it.

The next issue of SurgeXperiences will be hosted at The Sterile Eye and will appear on May 11. I assume there'll be word of it at that site; and if past is prologue, posts ought to be submittable here.

There's No Hope. Seriously. None.

2008-04-26T08:31:00.000-07:00

[Yeah, it's another weekend rant. Don't know why I bother anymore.]

Maybe it's just me. Maybe things aren't as bad as I think they are. Perhaps a nine-trillion dollar debt isn't a threat to our country; maybe the rising cost and self-limited supply of oil doesn't bode ill. It could be that environmental degradation and global warming are just a bunch of hype; and, I suppose, our country is not facing the possibility of governmental gridlock and economic meltdown. Nor, it could be, is the war in Iraq leading us to self-destruction. I hope so. Because from where I sit, it's now or never.

I really thought people would get it. To me, it seemed tautological: eighty-plus percent of the people think the US is on the wrong track. Therefore, whatever direction they think it ought to take, the one thing everyone might agree on is that the politics of the last several decades isn't working. QED. If there's one kind of change behind which everyone could get, it's the way we elect people. Attack. Destroy. Make shit up. Focus on irrelevancies; distract from the important issues. Fear the impossible, ignore the actual. But no, it's clear I was wrong. Whomever we elect as our next president -- and likely the same is true for most of our congressional folk -- the decision will not turn on energy policy, the war, the unsustainability of our deficit spending. It will be about convincing the electorate (easily, it turns out) that one candidate is a closet terrorist; and/or that realigning our military priorities will amount to "waving the white flag" to al Queda, that someone wants to raise taxes (as opposed to what? Moneh from heaven?)

Barack Obama began his campaign by saying, among other important things, that he'd tell people what they need to hear, not what they want to hear. And, to a certain extent at least, he did. For a while. But he's finding out, big time, that that's not a winning strategy. People want to hear what they believe. Which, of course, fits perfectly with the fact that more than any other developed country, we are a nation of believers.

In comments on my rantings, people tell me to cool it. Why, they ask, do I get so upset about religion? Well, it seems pretty clear: the instinct for religious belief has slopped over into politics to the extent that it's made it impossible for us to face facts without magical thinking. Honestly, if people could keep their religious beliefs and their attendant make-believe separate from their ability to confront earthly truths, I'd have no problem with it. But to me, it's of a piece: magical thinking in the face of overwhelmingly difficult problems is the easy way out. It's the equivalent of the brain going into "tilt" mode. Fear of death, meaning of life? Sure. Do what it takes. Energy policy, economics, Iraq? Sorry. We need to look at them clear-eyed. If the magnitude of these problems isn't enough for people to stand up to the muck-meisters and say, NO, not now, not ever again, then it's over. Really. It's over. It's become apparent that the only way people might wise up and say it's time to elect people willing actually to confront problems is when those problems are so unignorable there's no longer any hope of fixing them.

The reason I've been so enamored of Barack Obama is that he seemed to be getting people to understand: what needs changing is not any particular policy (although they all need changing). What needs changing is the way we do politics. Young and old, left and right, people of all colors: if they could agree on anything, they ought to agree on that. Solutions, he seemed to be saying, will come from a gathering together of people of good intent from all points of view. The answers that we find will not be the verbatim policies of any candidate; those will only be a starting point, a set of priorities. It matters less what a candidate outlines in policy papers, than it does how he or she proposes to get there. But after the last few primaries, it's clear that voters haven't bought it. It's too complicated an idea; it doesn't fit on a bumper sticker. Even when the problems are so scary, old politics still works. The middle majority of voters really don't want to hear reality. They want politicians who give permission to look away. Scare and distract. Bait and switch. And if there's one thing we know about successful politicians -- McCain, Clinton, Gingrich, and their enablers, Limbaugh, O'Reilly, et al -- they're master baiters.

I'm convinced it ain't gonna happen. For this election, and so many more that it'll become impossible to reverse course, enough people will be influenced by the usual crap that they'll take us all down with them. Of that, I'm now sure. You see it in the polls, in what people say is important, the filthy ads and the reaction to them. The only thing I can't figure out is this: those purveyors of political porn; do they believe the shit they say and do, or are they the ultimate cynics? Tell people what they want to hear, because it still works. Take what they can get; rake it in while the getting's good; protect the status quo to make their pile and screw 'em all. And if that's who they are, could it be because they're convinced they'll still get raptured up, or is their religiosity just another gimmick, too: the megachurch of manipulation.

Unidextrous

2008-04-25T08:20:00.000-07:00

It'd be darn hard -- probably impossible -- for a one-handed person to be a surgeon. Virtually all technique we use is predicated on the use of two hands: traction, and counter-traction. Hold the scissors with one hand, use forceps in the other. (Or fingers. I love the way the fingers of my left hand seem to know exactly how to noodle the tissues around as I'm scissoring or otherwise instrumenting with my right.) It's nice to be able to switch hands, and I'd say most surgeons do, myself included. But I admit it: I'm better with my right than my left when it comes to the finer stuff.

There's nothing I do with my right hand in surgery that I haven't done with my left: place a stitch, cut, grab; and, of course, we all throw knots happily with either paw. Still, if I really want to be precise, where there's no wiggle room, I use my right hand. A completely ambidextrous surgeon, though not likely to rise above the pack on that alone, has an advantage; at least in terms of annoyances.

The reason I bring it up is that in response to a comment on a recent post, I mentioned the idea of centers of excellence, and a skeptical post I'd written on the subject. In my comment I suggested the time might come when you take your breast to Omaha and your gallbladder to Newark. It could even happen, I said, that you'd take your left breast to Omaha, and your right one to Cleveland. There's the tiniest kernel of truth. Very, very, very tiny, but enough to have produced this here post. As a right-handed person, it's actually a little bit easier to do a right mastectomy than a left.

It's an uncommon situation in which one holds dissecting scissors, which are curved at the tip, in such a way that the curve does not follow the natural arc of one's hand and fingers. (See how awkward it looks?) Without trying to describe the whole operative technique, suffice it to say that the classic approach to mastectomy is the removal of the breast and the lymph nodes under the arm en bloc, meaning in one continuous section. From the "axillary tail" (the upper outer portion) of the breast the dissection is carried into the axilla (underarm) along the axillary vein. With the patient lying on her (sometimes his) back, arm extended, the surgeon is standing to her right. The sweep of the dissection is very natural, holding scissors as they were meant to be held, moving forward in the natural direction for such things. On the left side, there's that awkwardness (even holding the scissors properly); the flow of the operation is against form, like water running uphill.

It's not a big deal, of course. We learn what we need to learn. There's no compromise in quality, no threat to doing the operation properly. It's just that it feels a little better, the one over the other. As a lover of the motion of surgery, the beauty that it can encompass, I simply take note of such things. And move on.

Last Call

2008-04-24T07:56:00.000-07:00

I'll be wrapping up my presentation of SurgeXperiences soon. It'll appear this Sunday. I'll take submissions till midnite Friday, Vulcan Standard Time. Removing one expectation unit (referring to hosting, not the quality of the essays) per hour from now until then ought to end up about right.

Sinking Fast

2008-04-22T11:21:00.000-07:00

An article in today's paper incites a post, where none had been forthcoming. It's not news, really, in the sense that it's been well-known to many: us general surgeons are a dying breed. But it threatens to become very serious. There are many reasons, the mentioning of some of which could cause ire. The usual: doctors complaining about money and work. Sex, too.

It was just before I started training that California adopted a system for comparing one operation to another, payment-wise. Called the California Relative Value System (CRVS), and used or copied nationally, it purported to consider degree of difficulty, post-operative care, and, as I recall, a few other factors, in order to compare, say, a colon resection to a hernia repair; and, more interestingly, to a prostatectomy or hip replacement. Rumor had it that the general surgeon on the panel that came up with the scale was so busy he missed a lot of meetings. As a consequence, general surgery got screwed. The work of a colon resection was very unfavorably compared to that prostatectomy and pretty much everything else. The CRVS assigned "units:" if a hernia got, say, 11 units, (making that up; I don't recall the specifics and don't feel like looking it up), a colon resection got, say, 24. It was up to insurers, and medicaid, and medicare to assign dollars to units. Depending on who was paying, a unit might differ from institution to institution by many dollars; but the relative values were the same. The lowness (which translates to lowliness) of general surgical operations always annoyed me. The systems are different now, but the comparison remains: there are some quick outpatient eye operations, for example, that pay more than a Whipple procedure, which takes several hours, a boatload more skill, and requires many days of inpatient, and weeks of outpatient, care. Alas, poor me.

Add to the above the fact that emergency call for general surgeons can actually involve emergencies. This is, of course, true for other surgical specialties -- particularly orthopedics -- but in most communities there are fewer general surgeons than orthopods, so the frequency of call is greater. And the orthopedist fixes the bone and bolts (as it were); the general surgeon is left holding the bags. It's disruptive, it's hard, it's onerous. So it's not surprising that surgeons looking ahead, while looking back at the debt that trails them out of training, see options that are more remunerative and less demanding, and find the choice pretty clear. General surgery has its special attractions. No other field is as broad and deep. The variety of what we do is both rewarding and challenging; and the opportunity to have on-going relations with patients and families -- to be their "family surgeon" -- is something I cherished in my own practice. But there are limits... So, as we see in the initially-referenced article, the relative and actual numbers of general surgeons is heading down, dramatically. And there's another factor, not mentioned in the paper: girls.

I wrote recently about a trip I took back to UCSF, my training grounds, for a dinner honoring an old prof. Among the speakers was the chairperson of the surgery department, a very impressive and very talented woman. (Also, it was clear, a hell-raiser, in the best sense of the term.) With pride, she mentioned that for the first time the entire incoming group of surgery interns was female. The guest of honor, Senator Feinstein, seemed pleased. "Uh oh," was what I thought.

It's reality: women doctors are more likely to shorten careers for raising a family; or to seek opportunities for job-sharing; or to choose specialties which allow more flexibilty. One of my partners was a woman, and she quit entirely, and young, to be with her kids. The one hired after I left took several lengthy times off for maternity excursions. It's not that I object. I don't see any qualitative differences between boy surgeons and girl surgeons. It's just that it represents another -- and not-much-talked-about -- hole in the sinking ship of surgery. It will add to the shortage. Is all I'm saying.

You can't force people to become general surgeons (oh, I suppose you can, but I doubt it'd work out.) Solutions, if there are any, will be multi-faceted. Reimbursement inequities will need addressing. So will work hours. As I've said recently, the trend toward hospitalists might be a major boon; in fact, I don't see a solution that doesn't involve it. Meanwhile, look both ways when crossing the street, eat plenty of fiber, exercise, and don't swallow cherry pits.

Hell No!!

2008-04-20T08:15:00.000-07:00

[The recently usual warning: there follows a weekend rant, non-medical, and, in this case, against some manifestations of religion. Coming upon the included literary quote is what re-occasioned the thought.]

Among the things that most disturb me about the way some Christians view their god is the concept of eternal punishment. That a "just" (or any other adjectival attribute considered worship-worthy) god would consign, for all of forever, some people (his creations!) to such a fate is bad enough. That it could be for as meager a failing as rejecting him as one's savior despite living an otherwise exemplary life, is even worse. But worst of all is the absolute delight with which some people of that flavor of faith (including the ungrammatical zealot who made the above "artwork") contemplate the levying of their god's retribution on all those with whom they disagree. Sticking someone in the celestial slammer for an eon or two isn't enough for these lovers of their neighbors. It's forever, for infinity, for more time than anyone can possibly imagine. This, from a loving god, the arbiter of morality, the one single guide to right and wrong, without whom -- say the fantastically faithful -- non-believers surely wallow in an amoral morass.

So, to give the slightest inkling of what this really means; to provide a tiny basis on which to judge this judging god and those who judge him favorably; to give some context to the magnitude of the monstrosity in which these people love to believe, I present (soon, I promise) the words of James Joyce, in "A Portrait of the Artist as a Young Man," describing eternity. When reading it, consider whether eternal punishment, with no second chance, meted after but the briefest of sojourns on this planet (far less, in cosmic time, than the single vibration of an electron), no matter the grievance, bespeaks a just god (forget "loving!"); think about whether believing in this outcome makes one a party to malignancy. And my point, if it needs to be stated, is NOT that you better watch out and fall in line with God; it's that THIS view of god is one of someone whose justice is so horrible that the very acceptance of it makes one unworthy, whether the concept be true or not. Such punishment demands outrage from all thinking people. Silence is immorality. Think about it!

To me, this doctrine of eternal punishment is the worst kind of biblical literalism; even worse than the pensive pretzelling required to claim the earth is twelve thousand years old. To believe in it and not to call god out on it, not to march into the streets and shout on every corner at the injustice, is to be complicit in egregious behavior. Neither to reject the teaching nor to speak against it is far worse than keeping silent about Abu Ghraib, or slavery, or child abuse, or genocide. What does it say about those who accept it; or worse, who actually savor contemplating it? More tellingly: how, if it were actually true, could any decent person justify lounging around heaven knowing what was going on down below? In what kind of monster could the conscience lie at peace, or consider itself deserving the favor of such inequity, such iniquity? The smugness, the self-regard, the complicity seems so, oh I don't know, unChristian. Put down your damn harp, circulate petititons!

So here's Mr. Joyce, on how long is eternity in hell:

"For ever! For all eternity! Not for a year or for an age but for ever. Try to imagine the awful meaning of this. You have often seen the sand on the seashore. How fine are its tiny grains! And how many of those tiny little grains go to make up the small handful which a child grasps in its play. Now imagine a mountain of that sand, a million miles high, reaching from the earth to the farthest heavens, and a million miles broad, extending to remotest space, and a million miles in thickness; and imagine such an enormous mass of countless particles of sand multiplied as often as there are leaves in the forest, drops of water in the mighty ocean, feathers on birds, scales on fish, hairs on animals, atoms in the vast expanse of the air: and imagine that at the end of every million years a little bird came to that mountain and carried away in its beak a tiny grain of that sand. How many millions upon millions of centuries would pass before that bird had carried away even a square foot of that mountain, how many eons upon eons of ages before it had carried away all? Yet at the end of that immense stretch of time not even one instant of eternity could be said to have ended. At the end of all those billions and trillions of years eternity would have scarcely begun. And if that mountain rose again after it had been all carried away, and if the bird came again and carried it all away again grain by grain, and if it so rose and sank as many times as there are stars in the sky, atoms in the air, drops of water in the sea, leaves on the trees, feathers upon birds, scales upon fish, hairs upon animals, at the end of all those innumerable risings and sinkings of that immeasurably vast mountain not one single instant of eternity could be said to have ended; even then, at the end of such a period, after that eon of time the mere thought of which makes our very brain reel dizzily, eternity would scarcely have begun." [Wow! Whole comprehensible sentences in a row!! By James fricking Joyce!!!]

That's how long the Dalai Lama and Mahatma Gandhi (and maybe, for her doubts, Mother Teresa) will be in hell, according to the self-righteous. And only half as long as I will, despite having paid all my taxes and made rounds three or four times a day and having lain awake at night worrying about my patients, taking a shower and brushing my teeth when I got up. Flossing. And, lately, feeding a stray cat. To anyone who believes that's justice and who delights in it: you should be ashamed of yourself. And so should God.

This might be my last post for a while (other than the promised issue of SurgeXperiences), and although I'd hate to end on a rant, I figured I should let you know where I might be... eventually.

Yugoslavs, Urine, and Me

2008-04-17T06:50:00.000-07:00

As the summer of my second year in med school approached, an announcement was posted (on a bulletin board I had previously made infamous, but that's another story) advertising need for a student who spoke Serbo-Croatian, to spend a summer in Yugoslavia helping on a research project. Since it was a requirement of graduation that we engage in some form of research, and since my fluency (at the time) in Russian was as close as they could come, I got the job, and off to Yugoslavia I went.

There's a mysterious illness over there. In very specific spots in several Balkan countries are pockets of a devastating kidney disease, known as the Balkan Nephropathy, or the Balkan Endemic Nephropathy, BEN. In many villages lots of people have died of it, young. Because of his expertise in streptococcal kidney disease, a professor at my med school had been asked to look into that possibility, and although he'd long since disproved any connection with strep, a lab remained in a small Bosnian town and a couple of our docs continued the school's involvement. So there I was.

Bijelina (pronounced "bYELL eenuh") is in the northeastern corner of Bosnia, near the junction of the Sava and Drina rivers. Of very mixed ethnicity, with churches and mosques cohabiting the place in peace (years later the city was "ethically cleansed," a scene of many crimes during the implosion of the country), in the late sixties Bijelina seemed to have a foot in each century. Horses and carts outnumbered cars, the central park was full of people at night, with smells of grilled meats and sounds of bands mixing magically in the muggy night air. The park was very near the little hospital in which I lived in a tiny room near the lab. Every night I walked the park, eating raznjici (razNEEchee, with a trill of the "r") and cevapcici (chuhVAHPcheechee) and drinking rich strawberry or cherry juices, or chewy dark beer, talking to folks in my mixture of Russian and local phrases. Dobr dahn. Lahku noch. Preeyatnuh. In the morning I'd go to the lab where a pretty young tech made Turkish coffee thick as paste, sweet, and strong enough to grate away any remnant of sleep.

With a Yugoslav medical student, I drove an old Land Rover every day to a tiny farm village, Velina Selo, where many people had contracted the disease. There, all the farming was done by horse-drawn wooden plow; the homes were huts of sun-dried mud bricks, most with a well, one or two with a single light-bulb, all with a grape-arbor for shade and a fence keeping the chickens in. And, always, a barrel of fermenting plums, for making the ubiquitous and painfully raw slivovic. In the village was a beautiful brass still, on a wooden cart, pulled from home to home by an elderly man who, in return for a piece of the action, distilled the festering and fly-fed mash into the brandy. I had more than one round, still warm, fresh from the still, aged in the time it took to bend my elbow. And no, it doesn't cause the disease. Not that one, anyway.

Our job was to gather information from each villager: where they farmed, from what source did they get their water. What did they eat in the fields, how often did they get food or water from outside the village. Other questions I don't remember. While my fellow student asked the questions in Serbo-Croatian, I wrote down the answers -- I could understand enough to do so without the need for translation. Then we collected urine samples from everyone, later to be analyzed for protein content and distribution of albumin and globulins: electrophorectic patterns had been correlated to early signs of the disease. And we made maps of drinking water as related to protein patterns.

I had an additional project. Because it had been noted that many children in the endemic areas had an unusual pattern of albumin in their urine, the question had been raised whether this was just a form of exercise proteinuria (heavy exertion is known to cause spillage of albumin into urine) or whether it was a marker for this (or some other) disease. So I put together a bicycle race. Gathering urine samples before and after the event, I organized a couple dozen young kids to race a few kilometers on their bikes, with the winner to get a few dinars (a hundred, I think. Or was it a thousand?), with everyone else to get some, too. Exercise, it turns out, produces the same pattern in them as it does in you and me, which answered -- to my satisfaction, anyway -- the question. (A paper was published that included my results, but not my name. PW Hall, whose name is included, was my supervisor, back in the USA most of the time.) Forty years later, the meaning, the cause, the solution remain elusive (although there's recent suggestion of connection with a chemical from local vegetation.)

The villagers were extremely grateful that we were there trying to help. They vied with each other for the privilege of feeding us. Every noon we'd find ourselves sitting under another arbor while chickens pecked our shoelaces, kids came from the fields bearing fresh vegetables and watermelons, and the mom produced an invariably amazing meal from within her meager home. Spicy chicken, stews, bread from heaven, salads, and pastries that belied their simple source. It was embarrassing, really, the effort that was made to please us. I doubt it was every-day fare we were being offered.

Each day we visited several homes, covering the entire village over the summer. Knowing our expected schedule for the next day, farmers would interrupt their work to be there. They were particularly excited that I was an American. Sleeves were pulled back, tattoos from the German prisoner-of-war camps were shown to me, with the words, quietly, looking into my eyes, many times, "It was Americans soldiers who freed me."

Fading Memories

2008-04-15T08:10:00.000-07:00

As Alzheimer's disease relentlessly robs my mother of her memories, and me of her, I think of opportunity lost. Youth, rightfully, is centered on itself. It's a rare young person (and I wasn't one of them) who recognizes the wellspring of history and of connection that resides in the minds of one's elders; by the time we do, it's often too late. I wasn't entirely tardy with my parents; I pried some stories loose before they were gone forever. But about my grandparents I have many questions, and, now, no way to find the answers. It's hard to flesh out the details in family lore. But there are some good stories. (Other than the mention of a disease in the opening line, there's not much medical here. My muse is meditating. Or worse.)

I only knew one grandfather beyond my childhood. Born in Russia around 1890, he went to Moscow as a teenager, where he got some sort of degree from an agricultural school (he kept it, must have brought it on the boat, and I saw it once.) While there, so the story goes, he caught wind of the revolutionary whispers and brought them back to his village. Down with the tyranny of the Tsars! Fortunately for him, his father -- the village Rabbi -- was friends with the chief of police who came to him one evening saying he had orders to arrest my grandfather the next day. Get him out of town tonight. So -- and this is the part I'd love to know more about, including the truth of it -- he up and left, in haste, around sixteen years old, somehow finding his way to a port. Somewhere. With money from whom? Getting a ticket how? Still in his teens, he shipped to America (in steerage? In a cabin?), checking in through Ellis Island, spending a while (how long? In what sort of place? A tenement? With whom?) in New York City. He made a friend (Polish? Jewish? Met how?) and (somehow) the two of them got a job on a farm in Pennsylvania, owned by former US Senator Flynn. After a period of time, he and his friend, the westering spirit filling them, saw an ad in a newspaper for help wanted on a ranch in California, and hopped a train (hoboes? Scraped together the money? Confirmed the job before they left?) to Valley of the Moon. The ad was placed by, and Grandpa was hired on by, none other than Jack London.

Some stories I recall hearing from Grandpa himself: he became a trusted hand -- livestock foreman -- of Jack London, and rode the range with him, chasing and shooting coyotes. Many times he showed me the pistol given him by Mr. London: a five-shooter Smith and Wesson (or was it a Colt?), kept in a leather box and clean, oiled, beautiful. He'd let me break it open, an umbrella-like contraption lifting up from the center of the cylinder to pop out the spent shells (never saw any bullets.) The gun has disappeared, as have letters to Grandpa from Jack London when in Alaska. The story goes that while away, London entrusted Grandpa with looking after his wife, a young beauty, his former secretary, named Charmain (after whom he named his yacht, on which my grandfather sailed a few times.) Staying as he did in the bunkhouse, he got a call one night from the main house, from Charmain, asking Grandpa to come there. The knocked-on the door was answered by the lady, fully unclothed. I believed Grandpa (because he was an impeccably honorable man) when he said (or was the story told to me by my mom?) that he repaired immediately back to the bunkhouse and never mentioned it to Jack.

After Jack London's premature death, my grandfather made his way to Portland, Oregon, where he got a job (how, exactly?) with Metropolitan Life. Trustworthy from the first knowing, he became a successful salesman, eventually ending up manager of the office there, after having been sent first to Montana, and then San Francisco. He met my grandmother in Portland, where she'd been born; that's a whole other story, with many gaps. She, among other things, was (so it's said) the first president of the Oregon League of Women Voters, and somewhere there's a picture of her with FDR.

Impeccable he was, and immaculate. I never saw him in an unpressed shirt, or absent a necktie. Rarely without a hat. Even after his first stroke, he walked perfectly erect. My mother says he could sit a penny on a saddle and ride at full gallop, returning with the coin still in place. He lived a few blocks from us and when he came to visit, he'd first head to our garage, where he'd oil the doors on my dad's car and attend to my brother's and my bikes, with one of those old-fashion oil cans. Thumbing the bottom, clickaglug, clickaglug. He remembered very little Russian, but sang Russian folk songs with relish, boomingly. The love of hearing them is what led me to study Russian in high school and college. There was almost no phrase you could utter that wouldn't spring him into song; he had one for every occasion, mostly in English.

His English was perfect, florid, and just enough accented to be mysterious and charming. When I was about ten or twelve, he had me memorize something that I'm quite sure he wrote himself (I've searched and have found it nowhere else.) There was some sort of reward involved: a dollar? I did as I was ordered, and I still remember it. Overwrought, too wordy, but a connection to him that remains. It's how he talked, because he loved his adopted language. And here it is:

"Whatever we dwell upon most, mentally, we bring ourselves in closest contact with. That is why it so often occurs that we get most of what we most dislike, because our aversions and fears occupy so large a part of our secret meditations, even when we keep them out of our general conversation. Concentration on that which we most desire is the surest way to bring it to us; but there must be no excitement or agitation in connection with our anticipation."

The power of positive (and calm) thinking, is what it is. He seems to have lived it.

Still Trying, Rantwise

2008-04-14T12:17:00.000-07:00

For anyone interested in taking the time, here's a lengthy post by a person actually present when Obama spoke his scurrilous San Francisan words. In context, as I said in my rant, they are the thoughtful words of a person interested in the big picture, and uninterested in politics as usual. But given the effort (and willingness) required to see it (William "the war will be easy" Kristol concludes he's a Marxist), no minds are likely to be changed. Can't hurt to try.

SurgeXperiences

2008-04-14T08:00:00.000-07:00

By appealing to my baser instincts, namely susceptibility to flattery, Jeffrey Leow has cajoled or tricked me into agreeing to host the next SurgeXperiences. So consider this a call for submissions (in the other sense, as opposed to how I submitted to Jeffrey's third or fourth entreaty.) Here is an official announcement (ripped off and slightly modified from Suture for a Living):

"SurgeXperiences is a blog carnival about surgically-related blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit. The next edition will be on April 27th. The deadline for submissions will be April 25th. Please submit your posts here."

Having complained previously about themed blog carnivals (while acknowledging that people have a perfect right to do it however they choose), I'm making no suggestions other than getting your entries in on time. Unless an unprecedented deluge leads to more than I can handle, I plan to link 'em all up. So feel free, and freed. And please: lower your expectations.

The Truth Will Set Us... Upon Ourselves

2008-04-12T20:27:00.000-07:00

[Another weekend political rant. Stay away. It's all downhill from here.]

How many people would agree that the Republicans have been brilliant at getting the average person to vote against his or her own interests? (Hint: I would.) Knowing that their actual agenda of giveaways to the wealthy wouldn't fly on its own, they've managed to get people to think that this country will live or die over gay marriage and gun laws. So along comes a politician who points this out, and it becomes 24-hour news, drowning out the fact that the president admits, finally, that he authorized torture; wiping off the public consciousness the deficits, the war, the health care problems. Barack Obama said something that takes more than two seconds to explain, and the media and his opposing politicians go crazy.

I'm not sure about John McCain, but I do think Hillary Clinton is smart enough to understand what he said. The talking heads on radio and TV? Part stupidity and part cynicism. But Hillary knows, and plows ahead anyway. And what was it that Senator Obama actually said?

Government has failed to deliver to the average person, he said. It makes people frustrated and angry. By exploiting those feelings, politicians manage to get people to look away from their leaders' failings or their plutocratic agenda and to vote for them anyway, by sleight of hand. When people feel bad about their situation, they tend to look for issues to make them feel better. Immigrations, guns, gays. Is this untrue?

Okay, I admit he said it awkwardly. He's admitted it, too. But his words were "elitist" or "out of touch" only to those who willfully or stupidly misconstrued them. In the case of Hillary and her supporters, it's willful. Nor did he make stuff up out of whole cloth, like, say, bullets in Bosnia. He made a sophisticated point about how people think and how the political system exploits it. If anything shows how much change is needed, it's his words and the bullshit-filled reactions to them.

The spectacle of CNN and its ilk making 24 hour shrieking punditry out if it, finding it more important than all the problems facing us, is dispiriting beyond my ability to tell it. Between the cynicism of our politicians and the mendacity of our media, the American political system has become incapable of self-correction. We have, ultimately, no one to blame but ourselves. We elect the idiots, we watch the networks. Comes a person who actually thinks it's possible to change how we do our national business, and he's set upon by those for whom the status quo is their life-blood, while the people who have most to gain or lose are too complacent, or too burnt out, or too disappointed to make the effort to push back. They buy the crap because they've stopped believing there's anything else. More's the pity. The audacity of hope meets the beat-down of burnout.