Sampler

Moving this post 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

Fun With The Lung 
pink and soft.

You Are So Beautiful:
a look inside

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

What Cancer Looks Like:ugly as hell

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

Playing God
amen

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

Liking the Horrible:
the paradox that is surgery

When It Scared Me to Death:
a sick baby

When Things Get Tough:
the need to concentrate

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

On Surgical Complications:
one, two, three.

On Palliative Surgery:
difficult decisions.

Think slow:

shoot from the head.

Various Good Stuff

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

About Surgical Names and Anatomic Places:
here

Ever Have A Maneuver Named After You?
he did

Surgical Clips, And A Good Story:

blip, blip

"Alternative" Medicine And Why We Love It:

we're nuts

Strange Things In Strange Places:takes all kinds

Old Folks:
They take it in stride.

Word play:
Fun with new words.

Hospital Politics, And A Memo:

one, two, three, four

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

one, two, three

Thoughts On Health Care Issues:

Insurance Companies

Doctor Ripoffs?

The BFH

Rationing

Lying About Advance Directives

Solutions

More on Solutions

Bureaucrats

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

I guess this is a rant. It's about war and what it does to the kids who fight them. Some of the comments are worth reading, too.

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

Praying for a Child (this one caused a huge ruckus.)

A New Blog!!!

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

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

Public Option

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

Toons

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

Retort

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

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

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

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

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

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

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

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

The public be damned.

Grand Old Times

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

Stupid

Uuggggghhhhh.

Sorry.

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

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

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

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

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

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

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

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

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