Truthteller

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

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

False Start

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

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

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

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

Oldies But Goodies

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

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

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

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

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

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

The NYT article points out some ways in which the geriatric population differs from the younger. (It also makes the very good point that whereas all med students do time in pediatrics, obstetrics, etc, there's no requirement for geriatrics. Older folks aren't just wrinkly.) It's certainly true in terms of length of recovery time, healing issues, complications from accompanying disease. I wish there were objective ways to measure risk, to predict outcomes. Absent that, I always found a couple of reliable -- if unscientific -- predictors: people do like they look. An eighty year old who looks fifty will recover like a fifty year old; a fifty year old who looks eighty will recover like eighty. And, no matter what age, anyone who walks a mile or two every day will do just fine.

Not Guilty

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

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

Excessive links, indeed!

Insult

This morning in my email was the following message:

Hello,

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

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

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

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

Sincerely,

The Blogger Team

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

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

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

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

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

Trauma Call

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

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

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

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

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

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

And I can do without it just fine.

Gotcha. Not.

From a commenter:

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

Regards,
A Better Angel

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

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

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

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

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

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

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

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

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

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

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

Yeah.

Right.

Why It Won't Happen

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

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

Simple as that.

Progress

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

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

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

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

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

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

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

The Nubbin



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

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

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

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

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

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

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

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

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

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

Fee For Service

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

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

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

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

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

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

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

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

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

Well, of course, I can.

Reform School

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

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

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.
.

A New Blog!!!

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

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

Sampler

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.

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

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

Solutions

More on Solutions

The Future

Reflecting on Past and Future (some excellent comments on this post)

The Personals: People In My Life

My amazing aunt

My grandpa

Watching My Dad

The Father I Could Never See

My Oldest Friend

My Newest Friend

Rants: (most of these are decidedly non-medical, so be warned)

My first rant, on the anniversary of 9/11.

This is the only medical one

Torture

OK, this is medical too, and "religious."

Politics and War

God is who?

Politics and Lapel Pins

Politics and Politics

Ignoring the Obvious

Immigrants and the American Dream

Hell and God

Same-Sex Marriage

Alternate Universe

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

I may have to speak up.

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

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

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

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

I mean, come ON!!!!

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

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

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

The Bed In Which They Lie

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

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

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

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

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

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

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

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

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

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

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

Nation; Tubes; Down

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

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

And it's working. 

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

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

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

And it's working.

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

And it's working.

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

We're

Milestone or Finish Line?

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

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

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

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

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

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

Food For Thought

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

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

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

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

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

Old Time Doc

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

I liked the whole idea of it.

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

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

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

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

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

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

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

ER, Uh...

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

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

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

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

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

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

Delete "Elite," Tout de Suite

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


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

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

Or something.

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

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

Ignore RSS

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

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

Empath

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

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

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

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

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

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

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

To Sleep, Perchance...

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

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

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

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

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

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

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

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

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

Love and Marriage

[Weekend rant. Homophobics and those uncomfortable with their own sexuality ought not read further.]

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

Here are a few things that I consider inarguable.

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

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

Third: There is no argument against gay rights other than religious. In order to oppose gay rights, you have to believe one thing that's demonstrably wrong, and another that's unproveable; that is, you have to believe both that homosexuality is a choice, and that it is an abomination in the eyes of your particular version of the Person- or Persons-in-the-Sky. But on this planet there are lots of views of the sky-people and what they do and don't want. One is entitled to one's, but not to foist it on others. "Defense of Marriage" is a bogus argument of the bumper sticker variety: I've seen no discussion, nor any attempt to have one, other than simple declaration, that explains why my heterosexual marriage of thirty-seven years is in any way threatened or diminished in value if gays are allowed to marry. None. What evidence there is on the subject is to the contrary: in Massachusetts there has been no decline in heterosexual marriage since gay marriage was approved. The same is true in countries that allow it. (The opposite, in fact, seems to be the case.) Which is, of course, exactly as expected: there simply is no line that can be drawn between allowing gays to marry and the decline of heterosexual marriage. Nor need it be said: heterosexual marriage has been on the decline for decades; gay marriage appears only recently.

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

I don't like anything about brussels sprouts. I don't even like looking at them. Yet it doesn't threaten me that others do; nor do I feel the need for a law to keep others from eating them. From a secular point of view, there is no reason to oppose gay marriage. It has no impact on society, one way or the other. Objections are based on religion, or on personal discomfort, neither of which are the business of civil law. Unless it can be shown that gay marriage is in some way a threat to our country (it can't), there is no justification for passing laws to prevent it. (Asking questions about gay adoption is legitimate, I'd say; but it's a separate issue. It's fair to ask if there's harm to kids living in a gay household. But the evidence is to the contrary. Which is also intuitive: growing up in a love-filled home ought to be good for any kid. (How many kids are in homes where they're not wanted?) And since sexual preference is biologic, it would be expected to have no impact on that of the child. Questions? Sure. Grow up more tolerant? The horror! Moreover, the logical extension of preventing it would be to forbid lesbian women from having babies. I'd think even religious conservatives would recoil from the state mandating who can bear children. Right? Right?...)

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

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

Stick that on your bumper!

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

Credit Where Credit Is Due

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

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

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


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

Arrrrrggggghhhhh!

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





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

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

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

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

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

Stem the Cell?

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

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

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

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

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

The Question We Cannot Ask

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


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

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

From innumerable McCain appearances:

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

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

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

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

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

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

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