Tuesday, October 03, 2006

Almost famous

I was nearly famous. Coming this close to being on the PBS News Hour, I was fully prepared to receive love notes and hate mail, and probably would have. The subject was outpatient mastectomy, and I was for it. My patient made it on. I didn't.

Let's get this part out of the way right off the bat: there's no way I would EVER advocate that mastectomy should be considered an outpatient procedure in the sense that insurance companies would urge or require it. The default mode (as we computer-literate folk would say) is and ought always to be that it's done in the hospital. As with many things, I think that when there are options, women having the right to choose is a good thing. Having done many outpatient mastectomies, I can say with complete confidence that it's safe, amazingly well-tolerated, and, for some women, is better in all ways than being in the hospital. Especially in a hospital where the nurses are made to care for too many patients, or to rotate to specialty areas with which they aren't familiar.

First, some housekeeping basics. Clearly, for the woman having immediate reconstruction, outpatient mastectomy is not appropriate. Maybe in the near future I'll say why I have a mild bias in favor of deferring reconstruction ("mild" being the operative word -- it's a complicated matter which I don't want to get into now, but, as I think more about it, will definitely do so later.) And I'm painfully aware of how devastating the idea of mastectomy can be: even mentioning outpatient surgery as an option is something I've done very selectively. It's not for everyone. But physiologically speaking -- referring here to the impact on the body -- there are several operations that I'd consider more "severe," and which are quite often done as outpatient procedures: gallbladder surgery, gastric banding for obesity, various gynecological procedures.

Poking around inside the abdominal cavity has bigger implications than what is essentially a skin operation. OK: "skin operation" is a little glib. But really, the breast is a modified sweat gland. That lovely form, the symbol of femininity and the object of admiration by men and women alike, that most desirable (here I speak as a heterosexual male person and not as a physician!), soft and warm living poetry stinks like a locker room when you cut into it with an electrocautery device. And when you remove it, the operation is mainly on and under skin, leaving muscle -- where most of the pain comes from -- pretty much alone. The old days of removing the pectoralis major and/or minor, along with swaddling the patient in enormous restrictive dressings, are long gone. So, thankfully, are significant blood loss and hours of anesthesia.

Properly done, mastectomy ought not require blood use, and can be thoroughly carried out in well under an hour. My patients almost always woke up with no pain at all, because I had a way of injecting a long-acting local anesthetic into the field. But even when it wore off, most women were quite surprised at how comfortable they felt. (Nothing in medicine is 100%!) Of those that were hospitalized, the greatest number went home on the first day postop.

You get an idea when you see them: some women would rather not be in the hospital for any of a number of reasons. Privacy. Self-control. Whatever. And there was a time -- which is only marginally better today -- when nurses were so overworked and understaffed that patients didn't always get the sort of care they needed. Drains. Drove me crazy. Leave a drain or two in the area after mastectomy, expect them to be operated properly; otherwise, blood will build up (a "hematoma") and be a source of problems. I wanted them checked frequently and emptied properly; depending on the experience and workload of a given nurse, it might or might not happen. At home, with proper instruction, there was never a problem. So I did more than a few outpatient mastectomies, and neither I nor the women involved had reason to regret them.

In Connecticut, I think it was, a health insurance company is said to have announced it had designated mastectomy as an outpatient procedure. No reason it needed hospitalization; wouldn't pay for it in the hospital unless specifically excepted. People were, justifiably, outraged. There's some controversy as to whether it's actually true that the insurance company made the decision. But it's unquestioned that there has been an uproar, and that Congress has (huzzah) gotten involved, proposing legislation. "Drive-thru mastectomy" is what it came to be called, and it was a rallying cry for many advocacy groups. And, as happens when things get politicized, the truth got sort of swept away.

Once again, I'll say I fully agree: mastectomy has no place on the list of operations mandated as outpatient procedures. (Nor, in my opinion, does the one thing that is generally so mandated, and which is the most egregiously inappropriate: hemorrhoidectomy. Another topic, sometime.) But it absolutely can be done that way.

So, for some reason PBS got wind of it and of all places, it was in the Seattle area that they planned to do a segment on it, on the News Hour. And as luck would have it, the director of the surgery center at which I did most of my outpatient operations was contacted to see if she knew of anyone doing outpatient mastectomy. She gave them my name. I got a call and had a nice conversation with a producer of the show. Great, I thought. I could explain the realities; I made it clear to him that I thought it was very appropriate when the woman preferred it, but in no way should it be required. And, I figured, I'd get a chance to put in a plug for nurses: tell the country what the effect on quality care had been of the steady cuts in hospital reimbursement.

The man seemed quite sympathetic. What he wanted was to follow a woman through the whole thing: show a bit of the operation, film her at home. He needed someone within a fairly short time-frame, and although I saw several women with breast cancer -- as usual -- in the next couple of weeks, none was a candidate. I let the producer know, and asked if he'd like to talk to a patient who'd had it. He would. I contacted a couple of my patients and they were happy to offer themselves. If the piece was produced, I was assured, and if they included my patient, they'd schedule an interview with me, as well.

Time passed, silently vis a vis word from PBS. Until one day I got a call from someone telling me Mr. Producer wanted to let me know the show would be on tonight. What? No me? What about my three minutes of fame? My subsequent offers from Hollywood, the surge in my practice? Well, she said, it's on tonight.

It started well enough. The first patient profiled was mine, who said, among other things, that she'd had dental work that was a bigger deal. Her kids fought over who could empty her drain. She'd do it again in a heartbeat. Best decision she'd made. Like that. Then there were a couple of surgeons saying why it couldn't or shouldn't be done. Patients could never manage the bandages; things could happen that would lead to problems. It's a horrible and insensitive idea. Dangerous. And a couple of patients tearfully saying how they'd been hustled out of the hospital before they were ready. Had I been on, too, I suppose I'd have looked like an idiot. These docs were professors; I was just some country schmoe. And yet, they'd started with my patient saying what a breeze it was. Who, indeed, was the schmoe? If your patients can't handle a bandage, I thought, either you aren't instructing them well, or your bandages are too damn complicated. Bad things happen? Sure they do. But so they can with any outpatient procedure, or with brushing your teeth.

Surgeons -- myself included -- accept change with glacial speed. The things we were taught were pounded in with heavy hammers, and deviation was met with fire and spittle. To consider change is to face a nearly physical reaction and to hear your teachers shouting you down from the grave. It takes a conscious act -- an act of rebellion, really -- to consider the things you do and the instructions you give patients and to examine where they came from and the extent to which they actually make sense. "Don't lift more than ten pounds." Anyone do a study: this group, you lift five pounds; that group, you lift fifteen?

When I was in training there were a couple of old docs still practicing who'd been trained in the days when any person who'd had major abdominal surgery was required to stay in bed for two weeks. Pneumonia, pulmonary embolus -- they were just part of the deal. Get up, your guts'll fall out. Likewise, women who'd undergone mastectomy were told not to reach, not to lift, not to shower. Why, exactly? I was told -- very strenuously -- as a resident that everyone who underwent splenectomy needed a stomach tube for three days. Why? Because otherwise their stomach would dilate and pop the sutures off the short gastric veins. So that's what I did. Until I thought: wait a minute. I can tie a suture so it doesn't pop off. Do you suppose that it happened to one of his patients (or one of his teacher's -- or his teacher's teacher's) and led to a stone-carved rule?

My instructions to mastectomy patients -- no matter where they found themselves postop -- was to avoid things that hurt, and otherwise to do whatever they wanted. That simple. And, because I used a very small bandage covered in plastic, they could shower whenever they wanted. Yes, there was a drainage tube, connected to a bulb-like collection device. Hang it around your neck in the shower, like soap-on-a-rope, I'd say. And although I've seen the occasional hematoma develop in a hospitalized patient whose drain was ignored, it never happened in my outpatient people.

So what can we learn from all this? First, not everyone who speaks with confidence knows what the hell he/she is talking about. (This, of course, could just as well apply to me.) Second, health insurance companies -- no matter how soothing the music is in their TV ads -- are interested in the bottom line above all else and make decisions that are not necessarily in the interest of their subscribers. Third, doctors do lots of things because they were taught to do so and which have never been subjected to meaningful analysis to see if they actually make sense. Fourth, changing those things is incredibly difficult for lots of complicated reasons. Fifth, if -- and I hope you never are -- you are faced with the need for mastectomy and hate the idea of having to stay in the hospital, and your surgeon offers to do it as an outpatient, feel free!


No Acute Distress said...

Excellent aside on the dogmatism that plagues surgical practice. The dreaded variation is most readily revealed in the OR when the scrub people ask if you wan such and such, or you want to send a specimen of this or that - the way Dr. X does routinely. I repeatedly point out that inspite of the fact that Dr. X ALWAYS does it this way and that I NEVER do it this way we seem to get the same outcomes. I then ask the OR personnel to "do the math."

If you'd been given the opportunity on the PBS show, you could have posed a similiar challenge.

medstudentitis said...

As much as I, as a medical student, wish there were hard and fast rules in medicine, I also appreciate that no two patients are the same. I think that giving people the choice of whether to go home or not is empowering and helps them stay engaged in their care. It's too bad there wasn't a very fair representation of the topic on the news report, but as someone above said, you're getting your side heard now!

Greg P said...

Whenever an opportunity seems to arise when I might be interviewed by someone, I am always grateful when it doesn't work out.
Even with the best intentions (if there is such a thing) the editing is frightful, the message distorted, and as you say, you end up looking like an idiot.

beajerry said...

Doc-in-the-box mentality of insurance co.'s will probably get worse before it gets better.

Cathy said...

When I had my G/B removed alot of the surgeons were sending patients home the same day. Mine wasn't. I stayed until the next afternoon..My Doc. used a JP drain for the first 24 hrs. But, as far as surgeries goes, I will say this lap GB one was about the easiest one (to recover from)I ever had. I went back to work at 4 days post op. I had very little recovery pain.

I remember when my mom and sister had their GBs out before they started being done lap.. Man, oh man, they were laid up for about 6-7 weeks.

Anonymous said...

I have four letters for you: MRSA

There is no way I'd stay in a hospital if I didn't have to. You would think I had OCD the number of times I wash my hands/use antibacterial goop, not because of me, per se, but to not spread anything to my patients.

I guess being a nurse, it would be easier for me to recouperate at home. The medical care isn't the issue, I don't want to be at the mercy of a nursing staffing office who decides how many nurses my floor will get!

And, um....I don't think I'll ever look at my, uh, boobs the same way again....

Anonymous said...

I had a Modified Radical Mastectomy, Port Insertion and Tram Delay. It was done in the afternoon. NO I could not have gone home that night. I was up the next morning and probably could have and should have gone home. Fewer germs-less chaos. I was in little pain-OTC pain meds handled my pain. I was young though and had two small kids. I frankly had to tell them to get the oncall surgeon to release me since I had not seen a dr that day.

I do have mixed emotions on this matter. I was fine emotionally. Some women need more time. I needed to be home with my kids and family.

I was 40 with a 2 yr old and a 7 yr old at home. I had 2 drains to deal with, but holding my kids let me heal faster.

Anonymous said...

Dr. Schwab ... you're probably right about being better off that they didn't interview you after all. Your message would quite likely have come across a bit differently than you intended.

This was great information ... thank you for sharing it!

mstjames said...

I am having a drive-thru mastectomy tomorrow and was happy to read Dr. Schwab's blog. I want to get out of the hospital environment as soon as possible and back to my normal life and now I have confidence that will happen. Hope to be back at work next week. Thanks, Dr. Schwab, for setting my mind at ease.

Anonymous said...

I tend to disagree a bit with the outpatient procedure. The statistics show that most patients who get mastectomies have medicare or medicaid (meaning over 65). They tend to have more complicated issues with other health problems, difficulty getting transportation and difficulty getting home care in a short staffed nursing world. I just don't think it should be classified as outpatient but can be if the patient does great post op.

Anonymous said...

I recently received yet another of those 'sign the petition to eliminate 'drive-thru' mastectomies, and wondering if this was just one more of those women's issues that had been blown out of all proportion, I decided to google the phrase, and ended up here. Glad I did, and I appreciate the info you revealed on this subject. Yes, there's always another, and more complete, side of things, and I appreciate you bringing that side to light. Thanks, Tina

Carolie Graddon said...

Dr. Schwab! I saw your name on an AOL feature today and I thought, "I know him! I adore that man!" I wondered if there was a way for me to contact you and thank you again for your wonderful medical care and for LISTENING to my questions and concerns. But I figured you wouldn't remember me . . . it has been 17 years since you operated on me. So I did a little searching around and found your blog and lo and behold, you DO remember me! I was the patient who appeared on the PBS NewsHour. I'm sorry you didn't get your 3 minutes of fame, but I'm happy I got mine -- LOL! I remember you with great fondness. You were a wonderful doctor.

Sid Schwab said...

Wow! Great to hear from you, and to bathe in such wonderful words.

Now I have to see if I can figure out what the AOL thing was...

Anyhow, thanks very much for your comment; it's good to know you're doing well.

Sid Schwab said...

P.S: Just found out the AOL reference. It's a long story, but I got invited to be on a "community panel" for Huffington Post Live, and periodically they ask if I'll participate. The subjects aren't known until just before going live, and, so far they've been mostly fluff stuff and embarrassing...


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, i...