Skin to Skin

Above all, interns love the fast surgeons. The longer an operation takes, the less time to do your work when finally released from the tiled temple. A whole OR day with a plodder guarantees a night without sleep. There are other reasons to appreciate fast surgery, and to consider why some surgeons are so much faster than others. But before doing so, let this be made clear: speed, per se, is not a sine qua non (or even the sine qua not much) of good surgery. Doing it right is paramount; a slow and careful surgeon is better than a fast and sloppy one.

An operation done fast, when done well, is better than a proper but slow one. Not often, necessarily: but given the ill effects of anesthesia, the additive impact of tissue trauma, fluid shifts, exposure of uncovered tissues to the elements, all other things being equal, the less time in the OR the better. Over a lifetime of procedures, I think it fair to say fast surgeons will have fewer complications than slow ones. Especially with critically ill or elderly patients.

Although I like much better the other images it conjures, "skin to skin" refers to the actual time of an operation -- from cutting the skin to finishing sewing it up. (Total OR time is longer -- often much longer -- depending on OAFAT and other issues.) Usually only invoked when it's good news, it's like this: "How'd the Whipple go?" "Two hours, skin to skin!" When not so good, it's "Oh man, it took forever..." Skin to skin -- as it should -- connotes goodness.

Vic Richards was the fastest surgeon I'd known. (Lots more about him in my book.) Former chief of surgery at the Stanford program when it was still in San Francisco, he'd gotten his MD at age 19 (!) and was chairman at age 30. Right after getting his degree, too young to do much else, he worked in an anatomy research lab, where he ended up teaching surgery residents much older than he. In the process, he figured out subtleties of anatomy previously not well-known, and thought about how to do things in the operating room based on his anatomic insights.

By the time I knew him he was well-established as one of San Franciso's premier surgeons, loosely associated with UCSF, where I was training. I spent some months with him as chief resident, and he opened my eyes -- although I think it wasn't until I'd been in practice at least a couple of years that I really understood what he'd shown me. "Slow down, Dockie," he'd say. "You're going too fast. I'm the slowest surgeon in town...." In one sense, he was: his hands were not a blur; he didn't tie knots so fast you couldn't see the moves, didn't flash his knife like a Ninja. His speed -- usually he took half the time of the professors who'd theretofore taught me -- came from his head, not his hands.

I can't quantify it. Fast surgery is greater than the sum of many important parts. Every move ought to make sense, and flow logically from the previous one. For that to be true, you need a global idea of what it is you need to do, and the idea has to be a good one. That's for starters. Clearly, you need certain basic skills; you need to understand the relevant anatomy; but also you need -- here it gets a little nebulous -- an instinct for economy of movement and for what makes sense. To clarify what I mean (if not necessarily to shed more light): I've assisted many surgeons on complex operations wherein we came to a point at which I felt I knew what the next move ought to be, only to see the surgeon go somewhere else. "Look at that!; isn't that something?; he had it and he lost it! He's not seeing it!"

That's what Vic would have said, in his non-stop running commentary on everything I was doing under his tutelage. Assisting, in those early practice days, I'd say nothing and do what I could to help with the new path. Eventually, the paths converge. It's not as if there is one and only one sequence of events for a given operation. The surgeons who take four steps where one might suffice are not bad surgeons, generally. We all benefit from the incredible resilience of the human body. If we get things pretty close, it'll do the rest.

But little things add up. Some surgeons are so wedded to specific instruments, for example, that if it's not available they'll stop everything in the middle of an operation while someone gets it. It's almost always the case that something else would do. It's desirable to have a predictable routine for any operation; it's not desirable to be unable to deviate from it. On the other hand, some routines themselves are counterproductive. You can make a midline abdominal incision, as an example, and be into the peritoneal cavity literally in a minute or less; or you can do it in a way that takes ten, using cautery, slow-cooking your way through the fat, leaving non-viable (yeah, but non-bleeding, they'll tell you) tissue in your wake. Any operation provides many such opportunities.

Maybe most important of all, and least understood, is knowing when you are in exactly the right plane, as opposed to close enough. The interface between tissues is (absent prior surgery or other damage) subtle but distinct: soft, easily separable, and comparatively bloodless: it will allow you in and welcome you like the gentlest of innkeepers on a cold night. If in exactly the right place, you can separate things easily, in ways that seem indelicate but are in fact the opposite. A few cell layers can make all the difference. When perfectly positioned, you can use your finger, the back end of a scalpel, the closed tips of scissors, and expose your target in a flash. Off by a bit, you'll need to dissect, probe, stop a bleeder here or there, be a little rough, before you've conquered the intended area. And never know the difference! You can spend a whole career unaware there's another way. The gods of surgery will let you pass; but they won't be singing you through the gate.

I've said before, and I'd say again: doing surgery is not really mysterious: those of us who do it are not extraordinary. People can learn it. But I think some are fortunate enough to have certain cerebral software that allows them to see the operative field more clearly; to understand instinctively how to avoid struggling. Among the good point guards (and mid-fielders! -- but you probably don't like soccer as much as I do), some just seem always to make the right pass at the right time: they see the whole game as it's being played out, know what's about to happen. A coach would say that can't be taught. Some just have it.

To a small extent, surgery and surgeons separate along similar lines. Can I say that I had some, without sounding too self-absorbed? The irony is that it surprised me to find it out. I didn't sense it when I chose to become a surgeon, or even as I was learning it. Like a rosebud, it opened with time. And in other ways, surgery was a poor fit for me: it drove me crazy because I couldn't stand imperfection to any degree: even a keloid scar made me feel like a failure. Every night, I lay awake stewing; I was overly paranoid. But I could do the operative work; that I could do.

I owe a lot to the fact that when I first started practice I was in a semi-lousy situation: a town with way too many surgeons. As the new guy, it took a long time to get a following. On the other hand, for lack of much else to do, I assisted every other surgeon in town, many times. Having trained in an in-bred place (meaning the majority of attendings had trained there) I was well-trained but exposed to a narrow range of techniques and surgical philosophies. In my first practice experience, I saw things I'd not seen before; both good and bad. My operative approach became an amalgamation of ideas I picked up from many sources; and as time passed, I added my own.

Because of Vic, I placed a nearly obsessive premium on efficiency, on considering everything I did from the point of view of whether it made sense -- whether there might be a better way. And over the years, I found some. I won't list them, but I was always either figuring out or stealing little tricks here and there for every operation I did, all for the better. Most surgeons do, I'd add.

So yeah, I was one of the fast ones. Faster, eventually, than Vic himself. Sure, I tie knots ok, but you'd definitely be able to see the fingers without blurring. I admit it: I liked being fast. Hearing people mention it. Appreciation from anesthesia people, scrub nurses. Taking some sick patient to the OR from the ICU, doing something serious, wheeling the gurney back to the Unit myself, hearing the nurses say, "Wow, you're back already?!" Being able to do more surgery in my assigned block of hours than anyone else. (That, of course, has obvious remunerative benefits as well.)

There were times I actually delayed talking to families in the waiting room because I figured they'd either wonder if I took some sort of dangerous shortcut, or decide the operation was so easy I shouldn't be charging for it. One of those times was when I removed a gallbladder, including taking an intra-operative bile-duct Xray (cholangiogram) in twelve minutes. Skin to skin.

Anatomy Lesson

OK, I'm switching from bitterroot to cotton candy: let's talk TV. If confession is purifying, then it should help me to admit I watch medical shows: "Grey's Anatomy," "ER," even the ridiculous "House, M.D."

Readers of this blog know it, I'm sure; but I wonder how many people who watch Grey's Anatomy are aware of the word-play on the name of medicine's most famous anatomy text. Just asking. It's about the only way in which the show bears resemblance to reality, especially as applies to surgery training. I assume these shows have medical consultants. Wonder how much they get paid, and why the producers haven't called me...

Let's start with something mundane (OK, it's all mundane), but which I always find amusing. (Oh yeah: I also watch "Scrubs," and have wondered from the beginning why in the opening sequence JD puts the chest Xray up backwards. That's amusing, too; and puzzling. I'm thinking it's so obvious that they're doing it on purpose. But why.....?) The classic portrayal of surgery -- the actual act of operating -- is to show a surgeon (I particularly note that chief resident lady) sewing something. And without fail that surgeon tightens the suture by pulling the needle and needle-holder high above his/her head -- a regular quilting bee. In real life, raising one's hand that high is never done: for one thing, you're likely to whack it into an overhead surgical light. For another, it's clumsy as hell. Surgery is about control and stability. Which is why it's also a kick to watch the other enactments of operating: see how they hold instruments? High up on the handles, with their elbows out, hands far from the patient, as if stirring some mysterious stew? I doubt you even carve your steak that way.

In the operating room, a surgeon's hands are almost never flapping around like that. You want to rest them on something firm; if not the whole hand, then at least the pinkie, like a cane. Elbows in, hands and fingers close as possible to the patient. In fact, many surgeons avoid putting fingers in the "finger-holes" of instruments, placing that part in their palm, thumb on the mid-shaft and index finger nearly all the way to the end of the instrument. You can click and unclick the lock with the pad at the base of the thumb (the thenar eminence) opposing the middle or ring finger. (Naturally, some of my teachers were adamant that you NEVER do it that way....) I'll give them this much: it's pretty rare any more to see the actors at the scrub sink with the masks off their faces. Or contaminating their hands by washing backwards.

Watching "Grey's Anatomy," you'd conclude that surgery interns hang around together until some interesting case comes up, and then they fight for who gets to be involved. Heart, belly, uterus, whatever is next. In reality, you're assigned for a given time to a given service -- vascular, cardiac, ortho, several other options -- and that's what you do until you move on in a month or two or three. And you'll likely never see anyone who's not assigned there with you, except at big conferences.

Nor will you spend much time sitting around discussing (or performing) sex, or anything else. You'll be doing the work of admitting six or ten patients, in many of whose operations you'll likely not participate. You'll be running around collecting lab data, old records, Xrays. Into the wee hours, you'll be charting, writing orders, checking pre- and postop patients, taking calls for sleeping pills. Paging your superiors. And not only will you not be directly assisting the operating surgeon (and sure as hell you won't be doing the delicate parts of his operation so no one will notice his disability!! "We're a great team," he says. Give me a friggin' break, say I!), you'll be at least one body away from the action.

If you live with a bunch of fellow interns, your intercourse will consist mainly of leaving notes asking whoever ate your peanut butter to please replace it. I was one of twelve surgery interns, who rotated serially through the services, like a trunk/tail elephant parade. About half were one-intern shows, which meant I neither saw any of my fellows nor my apartment for a couple of weeks at a time. On the two-intern services, I shared with the same two all year: Wendell at the front end, and Mike at the back end of each two-month alloquot. Hardly knew the others at all. Sure as hell didn't screw any of them. Or my professors. Despite that "front end - back end" reference. Not a lot of lady surgeons, them days.

Will someone please enlighten me: what the hell sort of doctors are House and his groupies? I'm not talking about assholery: that part is clear enough. I mean specialty. In no big hospital that I know of would the same people sitting around thinking off over a patient be the ones to do all those procedures. Biopsies. Radiologic interventions. Of late they've tapered off a bit from their routine breaking and entering of their patients' homes; but they still seem to be doing pretty much everything else. Moreover, what exactly is their relationship? The groupies are too old to be residents, plus the black guy was once assigned to mentor House himself. So why do they spend all that time being lectured to and ordered around? Don't they ever have something else to do?

And really: I know poor ol' House is more drug-addled of late, but c'mon: not even stoned would any doctor mistake anything for four-limb necrotizing fasciitis. (Not only is there virtually no mechanism for getting it simultaneously in all four extremities, the patient would be dead too soon for a story line to develop.) It's inventive that the guy is a junkie. But after a while the formula wears thin: doctor-prick treats the patient like crap, makes about three wrong diagnoses, does a few unnecessary tests, putting the poor soul near the brink of death, then comes up with the right answer right before the closing credits. Every week, same damn thing. And yet: popular as pumpkin pie.

A quantum leap in realism was brought to the small screen with the advent of "ER," what with the roving camera and long takes; the failures, the confusion. But damn! With great regularity those patients seem to remain in the ER forever. Intubated, drugs dripping in. Like they're admitted there. Unless the ICU and recovery rooms are all overloaded, that just doesn't happen. Those guys have even opened bellies in their ER -- as big a no-no as there is. And let's not even talk about how often guns, bombs, and other disasters strike that place. Bad ju-ju. They need to see if it's built on an ancient cemetery or something.

Of course, it's all about entertainment, and not reality, and since when is reality all that entertaining anyway? In the grand order of things, it's a speck in the collective eye. But geez, aren't we doctors and nurses exciting enough that you could have a good show without just making shit up out of whole cloth?

I like everything about "Scrubs." Even the Xray.

You Gotta Think...

One could describe the relationship between surgeons and medical types as prickly. Oil and water. Farmers and cowboys. The friction isn't so deep as to prevent friendships or cooperation; in fact one of the revelations of private practice (as opposed to the more poisoned atmosphere in training) was the pleasure of the collegial relationships therein. Most of my friends among colleagues were medical docs. But certain differences are inevitable, undoubtedly deriving in part from the divergent personality types that choose among the various fields, and in large measure from the built-in resentments over who works harder, who deserves more money -- who, in short, is more admirable, more deserving, more worthy. You can't blame the medical docs, really, for resenting the glory attributed to surgery and surgeons. (However, you gotta admit it is indeed pretty glorious.)

And so there will ever be acrimony when it comes to reimbursement issues. In fact, the burrs don't reside exclusively under medical saddles: surgeons themselves can get a bit testy when considering, say, how much a urologist gets for a prostatectomy, vs what a general surgeon gets for a colon resection. [Historical note: it was when I was in training in California that a system was put in place to regulate and quantify relative reimbursement for all operations. Called the CRVS, for "California Relative Value System," it came to be pretty much universally accepted across the country by payors, and by surgeons establishing their fees. It didn't dictate the actual fee; rather, it set up a relative scale. If a hernia repair was one unit, then a heart-valve replacement was ten (guessing, but probably not too far off). Surgeons would decide how much they'd charge for a unit, and the numbers fell out accordingly. Whether they'd get paid that amount or not was another matter entirely. Some might be surprised to learn that general surgeons got screwed: that transurethral prostatectomy I mentioned was judged more value-worthy than a colon resection, despite the fact that to do the former you sit on your ass while peering through a scope and sliding your finger back and forth, and send the patient home the next day, and a colon resection may take a couple of hours or longer, sewing bowel together, seeing the patient through a several hospital days. (Surgical fees include part of the pre-op work, the operation, all hospital care, and a few post-op office visits.) Rumor had it -- because the meetings that set up the scale were occurring while I was there, and we knew the general surgeon representative -- that the guy representing general surgery was so busy he missed most of the meetings. We general surgeons, we of the broadest surgical repertoire, we who considered ourselves "internists who can operate," we found our work relatively undervalued.] (Boo fricking hoo, say the medical docs.) So fiscal friction isn't limited to surgical - medical conflagrations; but it's where most of the fire is generated.

Attributing relative value, no matter what occupations you compare, strikes me as impossible in any meaningful and agreed-upon sense. As a matter of fact, I've always felt that the general public health would be much more adversely affected if garbage were not picked up than if doctors disappeared; so how much should a refuse-nik get? Nor can I calculate how much surgeons ought to make relative to medical docs, other than to believe strongly that surgery is a lot harder than general medicine: time to learn it, hours of work, stress, liability, family sacrifice, yada yada. How much that means in dollars, I have no idea. [Funny story: a colleague sat on a fee-setting committee for a local insurance company. He tells me one of the older family docs who still did lots of surgery (badly), came to the committee arguing that surgical fees for family docs should be higher than for surgeons. "Because the operations are harder for us to do." The new definition of chutzpah.] I really am sympathetic to the plight of the primary docs, and (not kidding here) think they are relatively undervalued. But the way they like to frame the argument pisses me off exceedingly. The problem, the irritant, the casus explosi is the use of the term "cognitive work," and it once led to the re-convening of the SUC Committee.

It may well be true that procedures are overpaid relative to, relative to.... what? Office work? Health management? Primary care? You name it. But don't call it "cognitive" work, if by that you mean that surgery is non-cognitive. The view that surgeons are just technicians, that surgery is all about mechanics and nothing else, that primary care doctors deserve more because they THINK more -- well, that view SUCs.

"We surgeons are sympathetic to our medical brethren," began the memo I produced in the name of the non-existent Surgical Utilization Committee. "We find the argument persuasive that cognitive work is relatively under-compensated, and herein suggest a method by which the issue can be addressed. We think it possible to separate cognitive work from procedural work, to the benefit of all physicians and their patients. As an example, we propose the following reimbursement scale:

ACTIVITY: FEE

Colon resection

• comprehensive: $1,975.00
• no consideration of indications: $1,150.00
• above, and no pre-op planning: $825.00
• above, and no intra operative thinking: $675.00
• above, and no post-op thinking: $249.00
• above, and no thinking if complications: $9.95

Anesthesia care for colon resection

• comprehensive: $1000.00
• no pre-op planning: $505.00
• above, and no looking at monitors: $298.00
• above, and no monitors in room: $7.95

Using this model, we are confident that cognition can be given proper recognition and compensation; in fact, we stand ready to argue strenuously for significant and substantial increase in payment for cognitive services, and for putting procedures in their proper place, relatively speaking. Please join us.
Surgical Utilization Committee (SUC)"

Family Matters

Don't get me wrong: I admire family practice docs. I recognize what a tough and undervalued job they have; and the ones I know do it well. It's just that it was not always the case, either in terms of my admiration or their job performance. There was a time, of course, when all doctors were generalists. We can long for those days, or not; they drove their Model Ts to the farmhouse, passed out potions, delivered a baby or two, cut off a dead toe, comforted the dying. I might like to have a Model T to drive on special occasions. But for regular use, I'm glad I have a nice radio, air conditioning, and traction control. Thanks, but no thanks. The concept applies generally.

Years ago, family docs expected to assist in surgery for the patients they referred. Internists, who early on made up the bulk of my referring docs, hadn't the slightest desire to do so; was it because they didn't care as much about their patients? Did their patients, for some reason, not need the comfort obtained from knowing ol' Doc'd be there? Self-selection by patients, or self-delusion by doctors? I have an opinion. Whatever the answer, I can say without equivocation that having the family doc assist in surgery was an enormous pain in the ass. It began with scheduling, and got inexorably worse. The doc could only be there at such a date and such a time, usually first thing in the morning. Since I had certain reserved times in the operating rooms, and since I usually had people scheduled well in advance, signing up the FP patients meant making lots of calls to rearrange my other patients, along with a bunch of calls to the doc's office to make sure he/she knew the final arrangements. Ordinarily, such calls weren't necessary, because I had my own assistant; highly skilled, totally familiar with how I liked to do things, there from start to finish. People who really understand surgery (or people who've read my book) know how excellent it is to have an experienced team working together in surgery. People who spent a few weeks rotating through surgery during training do not understand surgery. If they did, and if they really cared about their "whole patient," they'd INSIST that the surgeon to whom they sent their beloved patient use his best and most experienced team when cutting on them. They'd know without being told that the best team decidedly did NOT include them. But we're talking about knowing limits, and about knowing what you DON'T know...

So after rearranging my list several times, and making calls and followup calls to the doc's office, invariably that doc would show up late. Regular readers of this blog know how I feel about lateness. (For a short operation, their lateness sometimes allowed me the pleasure of finishing before they showed up.) If they made it into the OR in time for the incision, they'd arm themselves with the cautery pencil and start buzzing the tiny skin bleeders as soon as my knife moved on. Drove me crazy: those things stop bleeding; cooking them probably adds to scarring, and I'd have to stand there while they got off on their workmanship. They also loved to tie knots. Slowly. Deliberately. Feeling surgical.

None of this is particularly critical: I'd get the operation done just fine, if a little less quickly, and with a little less of the pleasure one gets from an operation done rhythmically and artfully. If being annoying assistants in the OR was the only problem, I might not be writing this.

It's puzzling. How much familiarity with a thing is necessary to know how unfamiliar one is? Where's the dividing line between understanding and kidding oneself? What's the responsibility of a training program to make the delineation clear? What I do know is that seven years elapsed between getting my MD and finishing my surgical training; and that during that time I'd gone from knowing nothing to knowing a hell of a lot. And a lot of what I knew was that I didn't know everything. For example, when I first went into practice my partner asked me if I wanted to do vascular surgery. I told him I didn't think I'd had enough experience in it. (I trained right at the time of transition: earlier, all vascular surgery was done by general surgeons. In my time, vascular fellowships were appearing, and at my institution, which included one of the premier vascular departments in the country, general surgery residents were doing fewer vascular cases, as fellow were doing more.) My partner offered to observe and mentor me until I was more confident. To me, that seemed like a deception to a patient: I've always believed if I were to operate on people, I should be able truthfully to tell them I thought I could do it as well as anyone. I knew how to do those operations; yet I would not have and did not feel right passing myself off as a vascular surgeon. I knew enough to know that ability to sew a graft was only a small part of vascular surgery. And were a complication to occur, I don't know how I'd live with myself. So how is it that family practice docs were coming to town, right out of training, and asking to do (click warning: gross, NC 17) hernia repairs, C-sections, and tubal ligations? Tracheostomies! What did it say about them, and about their training? Since, as I eventually learned, these are good people, I think it says their training sucked. They learned from teachers with an inflated sense of the primacy of primary care, and a deflated sense of what's involved in surgery. They were told that the more they did themselves for their patients the better it is, and to the extent that they referred to specialists, they were letting their patients down -- subjecting them to narrowly focused monomaniacs who didn't care. Whereas my training was characterized by the constant reminder of how little I knew, by the public out-hanging of every error big or small, theirs must have been the opposite: the paltry time you spent on a surgical rotation, doing OB, is enough to have given you everything you need to know. (Again: this was a while back, when the holy grail, the salvation of American healthcare, was the gatekeeper.) A few examples may serve to explain why I felt that way: (most of these refer to incidents in my community but not in my clinic, I hasten to add.)

A) Fresh out of training, a young FP asks for tubal ligation privileges, and is denied by the OB department. She goes to the hospital board, threatening suit. Over the resignation of the OB chairman, she's given privileges. At the independent surgery center, which grants privileges based on the hospital's, she does her first procedure, assisted by her slightly more experienced partner. Pathology report from the right tube: "normal appendix." A general surgeon handles the subsequent admission for sepsis, from which the patient recovers without sequellae.

B) I'm referred a patient with a hernia, repaired by his young family doc. The doc assists as I repair it, finding the original operation was one I thought universally abandoned because of its well-known high recurrence rate. I didn't hide my surprise. "Well, that's what Joe taught me," he said. Joe was his senior partner, an older guy grandfathered into pretty broad surgical privileges, having learned most of what he knew from HIS senior partner, long since retired. Joe usually managed to get general surgeons, to whom he referred those cases he didn't do, whorishly to help on his own operations. I wasn't on his list.

C) Another young study of Joe hacks into the femoral artery during a hernia repair. (Trust me, that's pretty damn hard to do.) He does have the sense to hold a finger on it while awaiting the arrival of a surgeon.

D) Called to see a man hospitalized with a bowel obstruction, I find a FP had admitted and cared for him without consult for several days. The dead bowel I removed wasn't enough to leave him nutritionally affected, and he did fine after several more days. Consultation on admission would, I'm certain, have led to a quick operation with no dead bowel, and many days fewer in the hospital.

E) I run into one of my old mentors at a meeting; he's a trauma guru, and a strong advocate for surgeons managing ICU patients. In training, I did manage those patients, with their ventilators, cardiotonic drugs, their multi-organ failures. In practice, I thankfully dealt with such critically ill people far less frequently. Intensivists, I tell Don, are much better at it than I'd become. "Don't give up your role," he says, strenuously. "You don't understand what it's like in the real world," I tell him. "I'm not as good at it anymore." He glowers.

F) While I'm serving on the board of my ever-expanding clinic, in the midst of the gate-keeper frenzy, a family doc presents a form he's planning to send along with his patients to every specialist, requiring specific enumeration of reasons for every test, every procedure proposed. He'll not authorize anything without its return and personal review. After some possibly ill-chosen words, I resign from the board.

G) Having saved a woman who'd showed up in the ER with a perforated stomach due to cancer, requiring emergency gastrectomy (and washing her belly with distilled water to kill any cancer cells that were spread by the perforation), I ordered tests after she recovered which showed a solitary metastasis in the left lobe of her liver. Liver resectionally, the left lobe is more or less a piece of cake; but I hadn't been doing elective liver surgery because it just didn't come up much. Despite her strong desire to stick with me, and despite knowing how to do the operation, I referred the patient to a more experienced liver-surgeon (who fucked it up royally, I must say.)

It wasn't fair: taking young docs right out of too-brief training and immediately telling them they must be in charge of everything. Even if they knew at some level they weren't ready, they really weren't in a position to say no. And I think, because of their training, many didn't think they weren't ready. Until they found out, the hard way. At the time, I could fathom neither the training that sent them into the world so misinformed, nor the system that demanded it of them; nor especially the fact that many seemed not to have the warning mechanisms built in to have kept them above water.

Other realities settled in: for one thing, as reimbursement for surgery steadily declined, and as the assisting fees did likewise, it became clear to most family docs that it simply wasn't cost-effective for them to be out of their offices. I guess their patients' need for knowing ol' doc was there disappeared at just the right time. Meanwhile, pre-paid healthcare, with its extraordinary pressure on primary docs and its placing them in direct conflict with their patients, came to be seen as a false profit. (Good one!) So family docs began, perhaps first of necessity, but eventually as a matter of reality-testing, to realize they could with impunity leave specialty care to specialists. Most are even giving up OB, if sadly.

I can't say if I was right about what they were told then in training, or if it's different now. I can say that most family practice doctors now have practices mainly in their offices, and that I think it's a good thing. I don't think their surgical patients are any worse off for their doctors' absence from the OR. And whereas I think it's true that the referring docs with whom I worked -- if for no other reason than being in a contained group with frequent interaction -- eventually came to trust me with their patients without having to throw up roadblocks, it's also the case that I came to understand what an important and difficult job family docs have. They're the central clearing house, the entryway, the providers of continuity; and they still have pressure to do as much as possible themselves. They need all the love they can get.

Postscript: It's not as if I think surgeons don't make errors. I have. They do. But I can honestly say I've never made one because I over-reached; never because I failed to recognize when I was in over my head. Such errors ought, in my mind, never occur. Inculcating the sense of limits, giving doctors and nurses the intuition and knowledge to know what they don't know, and when they don't know it, is the single most important mission of training, as I see it. Nor am I absolutely certain it can be taught. I think it can, and I know for sure doctors (and nurses) who don't have those mechanisms ought not be in the business. Maybe there's a way to pre-test for it... And based on experience, I can say it's surgical training that comes at all close to the mark, with the medical specialties not far behind. For a while there, family practice was decidedly (bringing) up the rear. I'm guessing not all readers will agree.

Testing the Limits

If surgery training, with its brutality, inculcates a saving sense of limitations, of knowing when you're about to get in over your head, family practice training does the opposite. That's what I thought a few years ago, and the reason I thought so was that at the time, it was true. Things have changed, and so has my opinion. But there was a period in my practice when I believed the worse thing you could do was choose as your doctor a family practitioner. And that was AFTER I'd happily and with no subsequent regrets chosen as my doctor -- and that of my wife and son -- a family practitioner.

It was a perfect storm: the confluence of the concept of the "gatekeeper," and the idea that specialists were overvalued, and the shift in emphasis of medical schools toward cranking out more primary care doctors. A darker view would be that it was the fruition of the belief by all the various healthcare payors that the more you pit doctors against one another, the easier it is to get them to work harder for less money. But I digress.

During my training, the only contact I'd had with family practice docs was at the county hospital, which provided them a residency program. It was only in the emergency department that we intersected: they had no role nor spent any time on the surgical service, which seemed fine. Why would they need to? In the ED, as interns we were the same: grab the next chart and deal with the problem at hand, among those of the countless souls waiting for help. Sore throat, vomiting, belly-ache, discharges and drips. See and sort. We were all pretty much interchangeable at that level, but I noticed all the male FPs had beards, and liked to spend too much time (given the seemingly self-fertilizing piles of charts waiting) convincing drunks they should stop drinking. Surgeons -- by decree -- were clean-shaven, and we tended to focus on turning the crank as fast as possible. After internship, my dealings with medical types were entirely with practitioners of the fields involved in internal medicine. Family practice folk were, I must have assumed, office docs.

Before arriving in my current location, I spent five years in a small clinic in Oregon. Adjacent to my office was that of the family practice doc who became my friend and my doc. He was about my age, but because of the shorter length of his training and having escaped military service (unlike me) he'd been in practice for several years. He had broad knowledge of adult and pediatric medicine, giving excellent and devoted care to his patients, and referring to specialists when any sort of procedure or complex hospitalization was required. So did his three compatriots. It so happened that the hospital had rules prohibiting FPs from doing any operations, and even from admitting to the ICU/CCU. I'd understood they were adopted not without acrimony; but my clinic-mates never expressed a desire to be doing more than they were. They liked to assist on the operations I did on their patients; that was about it.

I joined a much larger clinic when I moved. Initially, we were a FP-free zone. Unlike the smaller clinic in Oregon, this clinic had figured out that multi-specialty groups couldn't survive forever without a broad primary care base, for the simple reason that docs who weren't in a clinic preferred to refer patients to specialists who were also not so aligned. In the years prior to my arrival, and for the first few after, the expansion of primary care had been in the form of general internists, pediatricians, and OB/GYNs. But family practice had developed momentum in the public arena: caring for the "whole patient" had a certain logic to it. Why leave your kidneys here, your heart there, and your gallbladder god-knows-where? Those specialists: all they care about is a few organs and a lot of dollars. So our leaders told us that in addition to having opened walk-in clinics, extended hours to seven days a week, emphasizing access, we needed to hire family doctors, because that's what the demographic studies were saying. It was controversial.

Being a relative newbie, I didn't speak up much; plus, my prior experience with family practice had been positive. Probably overly snooty, it was the general reaction that the clinic had promoted itself on the basis of specialty care and expertise, and that hiring family practice would be a downgrade. Would they be allowed to deliver babies, the OBs wanted to know. How would we survive, asked the internists? Still a work in progress, turf-wise, the family practice department was brought to life. In the long run, it's worked out great: the clinic is one of the most successful doctor-run ones in the country, still growing at a staggering rate, and thriving. When I came there were about thirty-five docs; now there are around two hundred fifty. It's gone from one main office and one satellite, to around ten satellites, all happily staffed with FPs among the internists, pedipods, and OB/GYNs. It has two MRIs, at least two CT scanners, a comprehensive lab, its own nucular medicine department, two surgical centers, fully electronic medical records, patients up the wazoo. But the family practice idea didn't start entirely well.

Let's take a moment to set the scene: this was all happening at the time of early focus on the skyrocketing costs of healthcare. (It should be obvious that there are still no really comprehensive solutions; in one guise or another, it's still just about cutting payments to doctors and hospitals.) But for a while the hot idea was that of primary care doctor as gate-keeper, with or without pre-paid care. Not only the insurers, but the companies that paid the premiums bought the concept; and it's not without a certain purity of logic. Left to their own devices, specialists will do what they do, unrestrained (certainly not by conscience, ethics, or a sense of propriety. Surely not.) Put the primary care doctor -- clearly the only one in the equation who truly has the patients' best interest at heart! -- in charge of deciding when a specialist is necessary and what procedures that specialist is authorized to do. Clean, and tidy. Economical. And if you really want to see an end to unnecessary care, give all the money to the primary care doc, pre-paid based on how many patients he/she has, and make that doc pay for the specialist care out of that stash. Perfect. My clinic, in another overly snooty bit of self-delusion, figured if anyone knew how to monitor and control costs and to deliver highly efficient care, it was us. We bought the pre-paid, gate-keeper run model, hooker, line-item, and stinker. Nor did it occur to us that if we were going to entrust that responsibility (not to mention the huge pressure and implicit conflict-of-interest) to people, they ought to have some preparation and experience in the matter. Which gets us back to the training issue.

My first clue came with the first call. Within weeks of hiring a couple of family practice doctors (fresh out of training, shiny as a new penny) I got a call from one, asking if I did pediatric hernia repairs. I did. At which hospital? At a surgery center, outpatient. Well, I'd like to refer you a baby, and I need to be there to assist. Uh, I generally don't need or use an assistant for a pedi-hernia; you're welcome to be there, but I really wouldn't want there to be a charge for an assist. Well, I think the family would feel better if I were there...

OK, not a real big deal. But my thought was, this isn't exactly good ol' Doc Jones who delivered three generations of the same family on the kitchen table. This person has been in town all of three weeks, and can't possibly have the sort of relationship with the family from which that sort of comfort derives. So it's got to be the training: you, they must be told, are the only thing standing between your patient and mayhem. No specialist (certainly no pea-brained, slash and cut, think-with-his-wallet surgeon, fergodsakes) will ever have the patient's interest at heart the way you do. Maybe I'm a little paranoid. Maybe even more then than now. But I wondered about the larger implications: if, after three weeks out of the oven, this doc believes he has the rapport, the knowledge, the TRAINING to run interference between his patient and me, what other delusions might he have? And where might it lead? I'd had five more years of training than he, and more than five years in practice. Maybe he was the most brilliant guy on the planet, or maybe those FP residencies had actually found a way to fill brains to the max with all the info in all the specialties -- as opposed to mine, which took three times the years to fill me up with only one specialty, and left me needing a little time in the world to feel competent. Was I making too much of it? It was just a request to be there, after all. But it seemed to bespeak a mindset: whereas I'd had grinding, lengthy, browbeating, comprehensive, non-stop 24/7 training that left me able to do very complex operations and evaluations but still wondering if I knew a damn thing, these guys had had a few weeks each in several specialties and were evidently told they knew everything. Was I wrong? We'll see....

Right Here in River City

Somewhere in my previous post, written in full jet-lag mode, there was a point trying to work its way to the surface. You couldn't have figured it out from reading it, but I'm pretty sure I'd eventually have found my way out of my wearied writing, my sleepy similes, and gotten there. You must understand that I'd been riding in the New York subways, passing stations, making complex connections, stumbling in subterranean stupor owing to a couple of night's sleep interrupted. In the first case it was because the hotel saw fit to register someone into our room, at three a.m. Suffice it to say it was startling to all concerned. The fire alarm the next night was minor compared to that. My point, had I gotten around to it, was to consider the ways in which doctors do or do not consult each other when they should, or shouldn't. Got that? As I recall, I'd said something about really liking the challenge involved in carving out a piece of colon with bladder attached to it, and feeling quite capable of handling it myself, without the help of a urologist...

It's actually a complicated and interesting subject, flavored with many important elements of the safe practice of medicine: knowing one's limits, sensing when to call for help, controlling ego; as well as surrendering to medico-legal reality. Covering one's ass, whether it's naked or not. Maybe a few examples will be edifying:

1) A colleague recently accepted in transfer a patient that had been hospitalized elsewhere with a bowel obstruction. At that hospital, the policy is that bowel obstructions get admitted to the medical hospitalists, who call surgeons only if the patient doesn't get better. In this case, "not better" meant being behind about eight liters of fluid, with all the accompanying signs and symptoms of severe dehydration.

2) During a complicated hysterectomy, a gynecologist made a tear in the rectum; I was immediately called and, despite the absence of prior bowel-prep, closed the hole directly, placed a pelvic drain and a trans-anal rectal tube and the patient recovered uneventfully.

3) Operating on a man with multiple gunshot wounds, I repaired several intestinal holes and explored the left kidney which had a through-and-through injury. I called the on-call urologist, told him what I planned to do, offered him the opportunity to come in an check it out himself. He no-thanked me.

4) The first and only time I injured a common duct (the main tube carrying bile from the liver to the intestine) was the very first operation I did in practice where I had the referring family doc instead of a surgeon helping me. I called in my senior partner, excused the family doc and repaired the duct with no long-term consequences.

5) A patient with a colovesical fistula is referred to me. I operate and fix it.

6) A patient with a colovesical fistula is referred to a urologist, who works him up and sends him to me. I do the colon part, and let the urologist fix the bladder, if he wants to.

7) A young family practice doc was doing a routine hernia repair (there was a time in my community when family docs were allowed to and liked to do quite a range of operations.) More or less inexplicably (it's really hard to imagine how), he cut the femoral artery, held his finger on it until help arrived.



Rather than go on for pages and pages, which I easily could do, allow me to comment on each of the above:

1) Such a policy could, I'd think, only exist with the approval or acquiescence of the surgeons. It's unthinkable to me. At the very least, every patient with a diagnosis of bowel obstruction (the diagnosis is wrong more often than you'd think) ought to have a surgical consult at the time of admission. Medical docs -- with some exceptions -- simply can't diagnose or evaluate (let alone treat) bowel obstructions, and have nary a clue about "surgical" fluid requirements. And shame on surgeons who'd abdicate the responsibility.

2) Things happen. She called right away, I was glad to help, the patient suffered no harm and everyone was happy.

3) Had this been in residency I'd not have called. In private practice, even I felt the need in some way to cover my ass.

4) The classic situation: a seemingly easy-as-pie gallbladder operation. I think there are fewer injuries that happen in really difficult dissections; in this case, the patient had virtually no cystic duct (the tube between gallbladder and common duct) and a tiny common duct. I thought I was dissecting out the cystic duct until I found myself in the pancreas. I was young then. I don't know who was more horrified: me or the referring doc. I do know he was happy to get the hell out of there. Nothing about the repair specifically required another pair of surgeon-hands, but I wanted them anyway. Being out of training only about three months, after repairing the injury over a T-tube, I wrote to my former professor to ask how long he'd leave the tube in (a tiny tube in a tiny duct.) The way I put it in the letter was "I was recently called upon to repair a common-duct injury...." I wonder if he saw through the fog machine...

5) It's the way it should be.

6) It's the way of the world.

7) This is wrong on so many levels, and I hasten to add that it's from a while back -- but not as long as you might think. It's pretty rare that a family practice doc coming out of training currently would delude him- or herself into thinking that he/she knew enough about surgery (having spent a few weeks on the service) to attempt a hernia repair; nor to have so little sense of limits as to be willing to take it on. (Nor are there many places where it would be allowed!) But it denotes a fundamental problem that faces any physician -- not to mention all health-care professionals: knowing when you're in over your head; knowing how to sense it before wading into the deep end of the pool; and, failing that, knowing when to call for help. It reveals, I think, a fundamental difference between the training of surgeons and pretty much everyone else. Sick and brutal as it may be, the constant haranguing of trainees -- the endless reminding them that they know nothing, that they're a bunch of screwups, that there's a chain of command they must follow, that if something goes wrong they are responsible -- all that stuff that's unique in its severity in surgical training makes for a deep and abiding sense of limits. More than anything else, that's what keeps patients safe and their doctors out of trouble. And having recently posted on the travesty of the current malpractice climate, I'll also say (as I implied in my final post on the subject) that one worthwhile outgrowth of that cesspool is the forcing of doctors to address their limitations. A few years ago, it sure as hell wasn't happening in some training programs. I'll post more about that little tidbit, soon.

Pisser

I suppose under the right circumstances, a person might think he was peeing champagne. Maybe if it happened early New Year's day, after intense celebration. Perhaps the hangover would dull the senses enough to make it seem like no big deal to piss air bubbles. Most people, though, find it disconcerting.

Colovesical fistula is the term for a connection between the colon and the urinary bladder, and pneumaturia is the name for air in the urine. It's most commonly due to diverticulits. In that circumstance, the sigmoid colon would have developed an abscess which plastered itself against the bladder and eventually eroded into it, creating a connection between the two organs, leading to leakage of air and stool from the one into the other. A similar connection can be made due to a cancer in the colon. In either case, rather than peeing champagne, the signs may be subtle for awhile: recurrent urinary infections are a frequent scenario. But for some people, the first sign of a problem is the passing of air in the urine. If it weren't scary, I'd think it would be sort of cool: "Hey, lookie here, honey! My dick's a damn bubble machine." "I don't care if it lights up like a Roman candle and plays the Star Spangled Banner, Charlie. Y'ain't getting any tonight."

I know I shouldn't make light of a serious situation, but the fact is fixing a colovesical fistula is fun. One of my favorite -- if uncommon -- operations, matter of fact. And it's a nice way to explain a couple of things along the way. Things like how different surgical specialties help one another; or foist themselves upon one another, depending how you look at it. And it's a literary vehicle for explaining the mysteries of complicated colon surgery.

General surgery is, we must agree, the queen of the surgical sciences, the fount from which all others have flowed. There may still be living (but likely no longer practicing) some icons from the day when a general surgeon was the only kind there was: drill heads, screw together bones, lift out uteri, remove a lung, repair an artery, while not otherwise occupied fixing hernias, taking out gallbladders, resecting colons. Our training still has us rotating through the various specialties, in part to give a taste on the basis of which to choose our future; but no less, I'd say, to give us the tools we need to handle things that have a way of arising in the course of an operation. After committing to general surgery, while still in training, we'd think nothing of removing a kidney, repairing a ureter, even yanking a uterus if it were attached, say, to an offending colon. And why not? They're all in or damn near in the belly; and the belly is the prime territory over which the general surgeon claims dominion. You simply can't be a general surgeon and not know the techniques involved in operating on any kind of tissue. The same cannot be said for other specialties; or at least for some who practice them. As I said in my book, with enough bananas you could teach a chimp to take out an ovary. If you only do a couple of operations, you could (can, in fact) learn to get through them without every really mastering certain subtleties. It's like this: I'm fairly sure a sculptor, if blessed with great patience, could teach me to chisel out something that might pass for a given body part. "Left index finger Schwab," they might call me. But there's no way in hell I'd be called Michaelangelo.

Brother Angelo, of course, made a hell of a left index finger. So I'm not saying if all you do is a couple of operations you don't know how to operate. I know some gynecologists who can handle pretty much any surgical surprises they encounter; others who call for help at the first sign of a fibroblast (the scar-tissue forming cells.) The same goes for urologists (a certain uroblogger, I have no doubt, is in the former category.) Nevertheless, it ought to surprise no one that it bugs the hell out of me to have a urologist assist me with the colovesical fistula, and to let him close up the bladder. Same guys who've, on occasion, called me in to find the ureter (the ureter!! the only tube in the whole damn body they need to know a thing about!!), or who needed bailing out after getting into the colon during a bladder removal, making their own colostomy without asking for help, and brought the wrong end out to the skin! (Yep.)( And yike.)

You'll pardon a second reference to my book. After it was too late, I thought that instead of calling it "Cutting Remarks" I should have used "Delicate Brutality," which is a phrase I conjured up in the writing. I meant it to describe the very technique needed when addressing a colovesical fistula. Most surgery is better when done delicately. Tissues like that, even though most of the time you can't tell if delicacy was used or not. Resecting a colon, for example, you can clamp a wad of fat and blood vessels and tie them off like a cowboy trussing a calf. I know a few who do. Or you can tease away the fat, see the important vessels and ligate them cleanly. The brutal method, in addition to being less artful and pleasing, leaves a lot of tissue beyond the suture to die. I'm not aware of any studies -- nor do I think they could be constructed -- that address it; but I think the more dead stuff for the body to deal with in the healing process, the less good it is. On the other hand, there are times when delicacy is simply impossible and if attempted has its own downside, in unnecessarily prolonging the anesthesia time. There's such a thing as brutality rendered with delicacy and gentle purpose. Delicate brutality.

For the most part, it seems the body was designed with surgeons in mind, like a Honda engine vis a vis a mechanic, as opposed to a crazy Italian car. There are ways to get to and around every organ in the body; planes exist -- even if subtly -- that separate one thing from another, so that it's nearly always possible to find your way around without poking holes in wrong places, or causing bleeding or other calamity. The ability to separate things gently is a very thrilling aspect of being a surgeon; knowing the little tricks that allow it. On the other hand, all bets are off when it comes to inflammation or big tumors; which is what causes today's subject. Approaching a colovesical fistula, you can expect a mess, complete with obliterated planes, unrecognizable and distorted tissues, often with the omentum having interloped its way into the mass-mess. A generation ago, it was considered so difficult and dangerous that the problem was solved in two or three stages: colostomy to keep stool from getting in the bladder, then remove the diseased section and close the bladder, then get rid of the colostomy. Now it's a one step procedure, if a little gross.

As messy as it occasionally can be, for some reason I really like slogging through a mess of colon; probably because I've managed to do it without disaster. Maybe "like" is the wrong word: I'm ok with it, because I always feel I'll be able to unravel the mystery. Instead of tidy dissection with scissors, as you get where the action is, usually you're insinuating a finger into the area, wiggling your way into non-planes, pinching between your fingers to thin things out: it's not likely you'd be able to pinch through something important. Or you're using the end of a suction catheter, or the unopened jaws of those scissors. As wooden as it can often be, an amazing fact is that practically without exception, when you get beyond the inflammatory mass attached to the bladder, at some point you will work your way to soft and normal upper rectum, to which it's going to be possible safely to sew or staple the other end of the colon.

I got an email the other day about blogging, asking on what basis I decide how long a post should be. When do I break it into more than one day? I just got back from New York a couple of hours ago. Feeling behind in my writing, I started writing this on the plane. Now, I'm going to bed. No editorial reason. Tired. I hope when I read this tomorrow, I'll know where to pick it up, and won't wonder what the hell I had in mind when I began this convoluted mess....

Rectifying, Redux

I remember reading in a surgical journal some years ago about the extraction of a jar of maraschino cherries from a man's rectum. Being a glass jar, and large, there were problems getting purchase (in the grasping, not the monetary sense: presumably it had already been paid for), and there was concern about breaking it. Performing some sort of version maneuver, they unscrewed the cap, emptied out the cherries, and grabbed the lip of the jar for a successful end of the case. The icing on the cake, the cherry on top.

But it wasn't the process that impressed me; it was the apparent credulity with which the authors reported the mechanism of entry in the first place. The man, so they explained, had been camping and had, in answering the call of his lower intestine, sat on a branch to perform the evacuation. The branch broke, and, as luck would have it, he'd been unknowingly positioned exactly above an upright jar of cherries, and landed orificially straight upon it.

Yeah, right.

I suppose were I to sit upon a branch to perform the needed function I'd never think of looking at what was below, and I'm quite certain I'd completely overlook a jar of cherries. Nor would I wonder what the hell it was doing there, perfectly upright under a branch in the middle of the wild, nor move it. Does a bear shit in the woods? Of course he does. And he marks the territory with the fixings for a sundae.

People who people their recti with foreign objects tend to obfuscate. "No idea. Passed out at a party, woke up with the (insert insertion here) up my ass." That's what the man told me when he showed up with a candle in place. No ordinary candle this: probably three inches in diameter, it was over a foot long. How his colon accepted it without tearing, I can't say; I'd guess it had had practice. The upper end of the candle disappeared behind the lower edge of his ribs. Prodigious. A quick rectal exam in the ER clarified that there'd be no way to remove it without anesthesia.

More often than not, we do such a thing under spinal anesthesia, both to avoid regurgitation if there's a full stomach, and because it very nicely relaxes the sphincter muscles. In this case, perhaps presciently, the man requested going to sleep. Good choice. It turned into a sort of monumental episode. Wick-ed tough.

Imagine a broad piece of brittle wax, lubricated, obscured at its bottom (as it were) end by tender tissues; slippery by its nature, ungraspable by its geometry. I sat between the man's legs for a goodly amount of time, trying everything of which I could think: big tongs chipped off pieces of wax and the candle squirted headward. I slid a balloon-tipped catheter along side and as high as I could wriggle it, inflated the balloon and withdrew without success. I heated a round-tipped probe thinking I could melt it in, let things cool, and pull it out. Because the north end of the candle was well above the man's ribs, I couldn't apply counter pressure to squeeze it downward. I could stretch his sphincter enough to insert most of my fingers, but the sheer size of a hand grasping a three-inch wide waxy thing and sliding back out was impossible. Even given a certain pre-existing laxity.

There were a couple of other operations going on at that late hour, and as the other surgeons finished up they drifted into my room, suggesting various orthopedic instruments unknown to me, making many and varied and uniformly unsatisfactory recommendations. After a while, it was as if I were in a Greek tragedy, with a murmuring Chorus behind me. I knew I had the ultimate option, but deferred as long as I could, trying everything up with which anyone could come.

Finally, I did what I had to do: made an incision in the man's lower belly, grabbed his colon and its content with my left hand, and pushed it downward while guiding anally with my right. Took a minute, slipped it out. I'd not wanted to give the man an incision, admit him to the hospital, subject him to the embarrassment of having to explain himself to a few shifts of nurses. But I'd run out the string. I'd never claim to be great, but that night no other surgeon held a candle to me.

Not every person who packed objects was as demure. As I described in my book, one brave fellow with a vibrator lodged in the sun-free zone had great grace. Awake under a spinal anesthetic, when presented by me with the retrieved vibrator and asked "Here it is Mr Jones. What would you like us to do with it?" Calmly, he said, "Oh, how about you replace the batteries and put it back in?"

It was a rare occasion when we were able to unburden a person in the ER; it almost always required an anesthetic, since those that didn't usually would have been handled by the owner. On the one occasion we were successful, we decided to send the item to the pathology lab. The report remained posted in the ER for some time: "Normal cucumber, with feces."

FFA, before my residency, stood in my mind for "Future Farmers of America." I learned another meaning in San Francisco, after meeting a couple of members and reading their impressively well-produced monthly magazine. The first F stood for "fist." The glossy and professional pictures had at least two people in them, and generally a can of Crisco. One upper extremity was quite hidden, pretty much completely below the elbow. I don't know if their organization required dues, or if they had a secret handshake. If so, it would have been done carefully, I'd think. The one member with whom I became involved professionally required a colostomy. Let's leave it at that.

Rectifying

I'm in New York City and have been for a couple of days. In a previous post, I mentioned the death of the son of very good friends. Last night one of the dance clubs where he did his DJ work put on a memorial dance in his honor, and we came. It was memorable in many ways.

I'll be a little short on the blogging, I guess, until we return home. Meanwhile, I've been thinking it's time to turn on the lightness light for a while, having gone dark in the last three posts. Unrelated, I'd say, to the fact that we're in NYC, I've been thinking about a few adventures I've had in the rectum. Turns out, it gets used for much more than the blueprints specify, container-wise.

So let me get off to a brief start, in the form of an anecdote about a partner of mine. When I arrived in my present location, all those years ago, my impression of that partner was that he was taciturn and indrawn; a good surgeon, but closed up. I completely missed his dry and incisive sense of humor, until another partner told me this:

In the middle of some night, Partner B was operating on a man who'd ripped a hole in his upper rectum (the part in the abdominal cavity) as a result of, let's see, pleasuring himself with a baseball bat. Needing an extra pair of hands in those wee hours, he called in A who arrived promptly and before scrubbing up, stuck his head into the OR and said "B! I didn't know you did sports medicine!"

Rim shot.

OK, a meek start. But I've got some more.

Losing My Virginity; Part Three

The aspect of malpractice suits that lawyers seem congenitally unable to understand is how devastating it is. "Ho hum," says a lawyer who read my first two posts in this series. "Get out the violins." It's as if, because I make my living operating on diseases, I were to say to my patients crying in my office about their cancer diagnoses, "yada, yada, get a life..." That such a thing is devastating is not, from my point of view, a reason for derision. If you make a living suing doctors, fine. It's what you do. But why laugh it off?

From the moment I found out about the suit, I felt branded. It was in the papers. People were saying awful things, in writing. In my mind, there was a visible stain on me, surely evident to every patient I faced. In no small measure, of course, it was because no matter what the facts were, I felt awful about the outcome of the case. "The case." How tidy a term... I'm absolutely certain that if I'd operated six hours earlier the outcome would have been the same -- and so were all the experts and colleagues I consulted afterward. But whenever I remind myself about it -- and this series of posts is a hell of a reminder -- I wish to God I'd operated at midnight. (Nor do I doubt that if I had, there'd be a lawyer/doctor team claiming that by going in before fully rehydrating, I set the stage for the clot to form...)

After the first few months, during which the afore-described papers trickled in (each arriving in a large envelope marked "Personal and Confidential," handed to me with trepidation by my nurse, and having been through the hands [so it seemed to me] of half the employees in the clinic before it got to me), there began a long period of chess-playing, carefully (I'm sure) crafted to provoke the greatest possible anxiety and disruption, aiming to make my life as miserable and uncertain as possible. The better, naturally, to till the soil of capitulation.

Trial dates were announced, my schedule was cleared for that week, and then within a few days of the date, it was canceled and rescheduled. Once again my schedule would be cleared, once again the day would approach, and be canceled once again. It wreaks havoc with a practice, in obvious ways. Lawyers, conceivably, are no more stupid than the rest of us (well, there's a bell-curve); I'm sure it was a game well-played. With each cancellation, there came notification that the amount of money being sought was lowered. Sometime after the prayer (that's the official term for the amount of money in play: "prayer." Hmm.) was lowered to well within the limits of my coverage, I heard from the "personal" attorney I'd hired. He wanted me to request settlement. Hey, wait a damn minute!! Much as the idea of being hammered on a witness stand frightened me, I'd long since gotten to the point of anger-fueled certainty that I'd prevail (well, that's too strong a word: not certainty, but resolution to proceed), and settlement was the last thing on my mind. The reason, he told me, was that since I'd originally been sued for more than my coverage, if it were to go to trial and I were to lose, and if the judgment were for more than my coverage, then, having requested settlement, I'd be able to demand full payment by the insurer. Well, I told him, I'm not sure. I don't want to settle this thing. This is about your self-interest, he told me. It's what you should do. He sent me a letter, and, feeling sick at it, I signed and sent it.

More trial dates. Couple of trips to Oregon to meet with the main attorney. "Stick to the facts, don't let him bait you, let me handle it...." sort of stuff. It dragged on for over a year, more setups and cancellations, more envelopes with flashing neon identifiers. Then, a call from the attorney. "I've got great news," he said. Unbelievable, I thought. They tossed it, finally. "We settled," is what he said. Thud. Stunned. Not relieved: pissed. The amount of settlement was paltry, particularly compared to the original "prayer." And given the amount the attorney would carve out, the family would get a pittance. To what end? What had been the point? The point, it's clear, is that everyone made out but me. The system was gamed perfectly: find a case, pay an opinion-for-price "expert," sue for more than the doctor's coverage, play a master baiting game for a year or so, make a few bucks. Pretty much guaranteed. Every lawyer, and that street-walking doctor got paid.

I suppose, after the set-up of the first two posts here, it's a let-down. I got off easy, except for the feeling I'd been played like a fish, by people who made the rules for their own benefit, who have seen to it that they'll get theirs.

And here's the point: there IS such a thing as malpractice. When it happens, the patient is, without question, entitled to compensation. But the system does not distinguish between bad outcomes -- which are inevitable, given that in complex situations there is NO decision we make whereby the result is guaranteed -- and bad care. In my mind, malpractice means sloppy care, decisions made with obvious ignorance of the situation; refusing to respond; failing to follow accepted practice in the evaluation or treatment of a condition; clearly making the wrong surgical move: there are many items on the list. Approaching a difficult situation with well-reasoned choices, conducting the care properly and carefully, yet ending up with a bad result -- whatever that is, it's not malpractice. And there needs to be a distinction. Not just for the doctors' sake; for the patients'. As is, it's an all-or nothing lottery jackpot, with the lawyers -- over the long haul -- the ones most likely to cash in. People who suffer harm from proper care are, I'd say, usually deserving of or in need of some sort of help. Surely it's possible to design a system in which help can happen. You are offered collision damage coverage when you rent a car; extra flight insurance; title insurance (ok, that last one is a ripoff). Ought it not be imaginable that some sort of parallel coverage to augment health insurance could be designed? Paid for in part, perhaps, by malpractice insurers? Ought it not be conceivable that there'd be a way to track such situations into a non-adversarial process, leaving true malpractice to be dealt with as it should?

I'm not blind. I'd be the seventeenth to say that the era of widespread malpractice litigation has accomplished some good: there are now in place universally (or nearly) controls and committees and processes by which doctors and their product are scrutinized much more effectively than when I first toe-dipped into the pool. That's a good thing. And I'm told most cases are decided in favor of doctors. Whoopee. But I'd say that's just an indicator of how broken is the system: surely when actual malpractice occurs, the odds ought to favor the patient. So if most cases result in verdicts for doctors, to me it means that most cases that go to court aren't actual malpractice. Trial lawyers, I'm sure, will say it's because of the conspiracy among doctors: cover up each other's mistakes. I never saw the contract. I haven't signed on to such a thing. Were I to see an instance of malpractice, I'd say so.

In the thirty-six years since I began surgical training, I've had two more cases in which money changed hands, while doing literally two and a half times as many operations yearly as the national average (national average: 250 [I'm pretty sure]. Me: 700). In one, I'd saved the life of a six-month-old with the right operation at the right time, and ordered the right dose and delivery of narcotic for post-op pain. When the nurse saw redness in the vein after injection, she called the pediatrician instead of me, and the order was changed to a different drug but at the wrong dose. Unaware of the change, when I got a call in the wee hours that the baby seemed painful between doses, I asked how long it had been and was told "three hours." The pediatrician had properly switched drugs, but improperly ordered IV dosing as if it were IM (in the muscle instead of the vein, which needs a higher dose at longer intervals.) Unknowing, I said it could be given hourly. After a couple of doses, the baby stopped breathing. He was revived quickly, and had no injury; yet I was sued over giving the order, and despite the fact that the insurer's team admitted it was not I that had erred (the hospital had, as well, in not informing me of the change nor of reviewing the dosing) I was asked to "take one for the team," rather than get into a finger-pointing session, since the parents were willing to settle for five grand. I wish I hadn't, because it's on my record, but I did. The other was a man with an extremely rare anatomic problem with his esophagus, which I fixed. He developed swallowing difficulties later, ultimately seeing another surgeon who was sure I must have screwed something up and reoperated, finding nothing. Around that time the patient was diagnosed with Parkinson's Disease, and neurologists and gastroenterologists who saw him agreed the swallowing disorder was most likely due to Parkinson's. Yet I was sued, and because the man was by now in a wheelchair and miserable from his disease, making a sympathetic witness, and since the original problem had been so unusual that there was no uniform literature on how to address it, the insurer recommended settlement, and that's what happened.

I've never been on a witness stand. Like going to Vietnam -- which I didn't enjoy but which I've always been glad I did because it was the seminal event of my generation -- I sort of wish I'd had the experience. From my brushes with the law, I'm left with an extremely discouraged view of it: patients who are deserving get less than they need from a system designed by and for lawyers, who get plenty, abetted by whoring "doctors" who become professional testifiers because they can't make a living practicing medicine. Good doctors are aggrieved -- to put it mildly -- by a process that as part of the gameplan seeks to destroy them mentally in order to create a result, making no distinction between care well-rendered (which is usually the case) and incompetence. I simply don't accept that even with trial lawyers having much to lose it's impossible to find a way to help those in need without harassing doctors: patients are doubly screwed, as they fail to get what they often deserve, and as they suffer the effects of doctors bailing out of their careers, or choosing less litigious arenas in which to practice. But I ain't holding my breath for the solution.

Losing My Virginity; Part Two

I realized I was entering into a process the rules of which were entirely separate from normal human interaction when it hit me that news of the lawsuit was in the newspaper before anyone had had the decency to contact me. What kind of people act like that? Civilized behavior, respectfulness -- in short, all the ways in which you'd think nice people would behave -- are as out of place in the medical malpractice arena as are gardenias in a cesspool. I realize that by definition it's an adversarial process. But why must it be completely devoid of decency, let alone ethical behavior? Sure: I'm an aggrieved doctor. How could I possibly see with a clear head? Well, I think I can. And what I see is a system where anything goes, and the people pulling the levers not only feel free to cross any line, it simply doesn't occur to them that there could be any other way to do business. Maybe I just encountered the worst of the lot; I hope so. The guys I dealt with seemed to be closer to reptilian than human, and they seemed perfectly happy to occupy that stratum. Loved it, I'd say. And whereas attorneys are the lizard-pimps, they have their snake-whores in the form of a pack of willing sleazy doctors. Am I making myself clear?

One part of the saga (and only one) was actually civilized and smart, and happened as scheduled. The Oregon Board of Medical Examiners, in conjunction with the insurance company, had a policy of convening a hearing for cases involving a certain level of money. In this case, a panel of bright and independent surgeons reviewed the case in detail, and called upon me to appear before them to explain and defend myself. Their purpose was to make a recommendation to the insurer either to settle or fight, based on their assessment of me and my care. It happened early in the timeline, on the day and time scheduled (by a long shot, nothing else did!); I got a thorough grilling after a comprehensive look at the records. Their conclusion was that I'd acted properly and the case should be defended vigorously. After the session, for a very brief time I felt pretty good.

Early in the process I became aware that I was being sued for about twice the amount of my coverage. In addition to scaring me to death, raising the specter of total financial ruin and life-long indebtedness, and causing me to awaken in a cold sweat nightly, this led to the suggestion by my insurance company that it might be in my interest to engage my own attorney. (They provide one, of course; I don't fully understand the recommendation, but I gather it's standard stuff. Among other things, it has the effect of raising the tension exponentially, which is, I'm sure, exactly what the plaintiff's attorney has in mind.) My dad told me it made sense, and hooked me up with a guy. Fees, of course, were not covered by my insurance. It was at this point that I got an inkling that I was being played like a harp, everyone enjoying the music but me.

Reams of paperwork began to arrive. Among the first was the report from a physician hired by the plaintiff to review the records. He claimed to be a surgeon, somewhere in California. I've since become aware that there are virtual clearing-houses for such scumbags, advertised in legal journals: "Need a surgeon, a neurologist, a pediatrician to say whatever you want? We got 'em. Give us a call." I read what this person had written, and was literally sick to my stomach. "In all my years of case reviews," this professional testifier said, "I've never seen such wanton disregard for standards of care..." Among his more laughable (if it had been funny) statements was "the large bowel is not really larger than the small bowel." Most astounding was this: "The surgeon describes his operation as ileocolostomy (in the previous post, recall, I told you to remember that term), yet he sewed the ends together. If he doesn't even know what he did, how can we believe anything else he says?" This supposed surgeon, this idiot-for-hire, doesn't know surgical terminology; yet he's the reason the suit goes forward: with an "expert" certifying that malpractice had occurred, the judge can't toss the case out. It has to be adjudicated in some way. That's the sick complicity of plaintiff's attorneys and these docs who make a living as testifiers. We had engaged several legitimate and credible experts, including the chief of surgery at the University of Oregon to defend my care. They had only this guy. But it was enough. The case had legs.

I'll say this: the attorney provided me by the insurance company was a great guy, and it was he with whom I mostly interacted. I never actually met the one I "hired" for myself; we exchanged a few phone calls and letters. The one from the insurer was an experienced and young guy, and he always tried to make me feel ok. When I'd pointed out to him the many ways in which the plaintiff's expert had his head up his ass, he just said he could hardly wait to get him on the witness stand.

My next lesson in the way of the world was when the records arrived from the referring family doc. The last entry in his notes from the time of transfer was "Situation critical. Urgent surgery advised." WTF? It had been a couple of years, but I knew I'd remember such a statement had it been in the notes I received with the patient. Poor Doctor FP: he must not have remembered that he'd sent copies of his notes with the patient at the time of transfer and that they'd be included in the hospital records. Clear as day, the son of a bitch had altered his notes later, to cover his ass once again. What did he care? I wasn't in his area any more. If I had been, if I'd ever seen him again, I might have tried to punch him in the nose (he was an old guy: I think I could have taken him.) But a former colleague trying to slit my throat: that wasn't the half of it.

Something of which I'd not been aware until the suit was that during the wee hours, the nurse taking care of my patient had had trouble measuring his blood pressure, and had to ask for help. Another nurse had brought in a doppler apparatus to facilitate the measurement, and eventually they'd gotten a number; a low one. For some reason, they did not see fit to call me. In fact -- it was later revealed -- the man's mom had spent the night at his bedside and when the blood pressure problem had arisen, she'd asked the nurse to call me. She didn't, saying she didn't want to disturb the head nurse (at the time, calls to doctors after midnight had to be cleared through the nursing supervisor.) Amazingly enough -- and unknown to the nurses at the time -- the mom had kept a detailed diary during her watch, including her rejected request. That became important later. Particularly (this would make a ridiculously unbelievable novel) because the nurse taking care of my patient had died of cancer a couple of years later, before the lawsuit was filed.

The hospital was also being sued, and they had their own lawyer. So now there were four attorneys with their meters running, all playing their roles as if it made some sort of sense. (I have no doubt that had it been possible for the me and the man's family and the insurance companies been able to sit together in a room like people who wanted fairness, had we talked directly without fear of consequences and without lawyers, we'd have come to a proper result years sooner with the money going where it was needed, instead of being spread among the attorneys.) The hospital counsel, it turns out, was the ultimate sleaze bag. Somewhere along the line he came out from under his rock long enough to interview a bunch of nurses:

Dear departed nursie was a good nurse, wasn't she?
Oh yes, she was.
Wasn't she the sort who'd call a doctor about low blood pressure?
Well, sure, I guess she must have been.
Do you think it's possible she called Dr Schwab and just forgot to write it down?
Gee, I guess it is.
Likely? Do you think it likely she called him?
I suppose so....

Copies of the depositions were sent to me, and that's pretty close to verbatim, taking into account the passage of time, the dulling of memory, and the festering wound. And the hate; oh yeah, the hate. It took me from scared to death, to mad as hell. Don't know if that's a good thing; it didn't help me sleep any better, but it made me ready to face the prospect of testifying. I wanted to see that asshole myself, and show the world what kind of scum he was. I hoped that -- Perry Masonically -- my attorney could spring the diary on him, without prior warning, in court. Maybe have it brought in by an efficient and attractive personal assistant, entered into evidence to the murmurs of the gallery. On the other hand -- so my attorney told me -- the prospect of the two defendants (me, and the hospital) at each other's throats would be a delight for the plaintiffs. And with what little I understand about the legal rules of warfare, I'd guess that this "testimony" would have been objected to and rejected.

So the players are lined up and doing their worst: a lying doctor and an incompetent one; two attorneys on the other side, one happily hiring a whore and the other suborning perjury (so it seemed to me) from a group of innocent nurses; and me, with my two lawyers, watching helplessly as people who don't know me worked gleefully to ruin my reputation, my self-respect, my financial future, caring nothing whatever about facts or fairness, cruising above it all in their slipstream of slime, thinking that's the way it should be because that's just the way it is. How could any good come of it...?

Losing My Virginity; Part One

In all my years of practice, my dad called me at the office only twice. The second was to inform me of a horrible family tragedy. The first -- well, I guess in a small way you could say it was the same.

"I hear you joined the club," he said.
"What?"
I had no idea what he was talking about. I'd recently moved from Oregon and was early in my new practice. I thought maybe he was talking about the local country club -- I'd left my first job in part because I'd not gotten as busy as I'd hoped. I was in a very small clinic, and when I'd suggested they needed to hire more primary care docs (Note to self: this aspect of clinic practice might be fertile ground for future posts), they'd told me if I wasn't busy enough I should join the country club. ("Nice golf swing, doc!! How 'bout taking out my gallbladder?") First problem: not only do I not golf, I'm definitely not the country club type. Second problem: same goes for my wife. Third problem: what an idiotic idea of how a surgeon gets referrals.) So, I thought, maybe my dad had wrongly heard I'd sunk to a new low to shill for work in my new job.

"I hear you joined the club," he repeated. "I read in the paper today you're being sued." I nearly dropped the phone and fell over. It was a local paper in Oregon to which he referred, no longer part of my world. I'd heard not a damn thing about it; didn't know by whom or over what. But it hit me like... well, it hit me like a lawsuit. And it was only the first blow in a series that lasted over a couple of years, wrenching me back and forth, up and down, tearing me apart in every possible way. Robbing my sleep, souring my outlook, breaking my cherry in the most bloody of ways. At the time my dad was Chief Judge of the Oregon Court of Appeals. My brother was (and is) a very big-time lawyer. Neither of them ever understood how or why it was so deeply painful. "Why are you taking it so personally," they'd ask, completely seriously. "It's just the way the system works."

I forget how long it was between the phone call and the time when a county sheriff strode into my office and, in front of the patients in the waiting room, asked my receptionist where I was. "Sorry, doc," he said as he handed me a subpoena. I absolutely do remember how my hands shook as I opened it. "Wanton... willful... malicious... gross negligence...," I read, my heart both racing and sinking (where we now live there are hydroplane races every year. I'm aware it's possible both to race and to sink.)

So now I knew: it was a horrible case, the worst case ever, one which gave me and will always give me nightmares, whether I'd been sued or not. I'd been called one evening by a family doc in a nearby town, asking to transfer a patient he'd been caring for for a couple of days. A man in his forties, he'd been admitted with vomiting, some diarrhea, minimal pain, and treated for presumed gastroenteritis. After a two or three days with no improvement, he was transferred to me late one night. I first saw him after midnight, at which time his vital signs were OK except for a slightly rapid pulse, consistent with his obvious dehydration. His belly was distended but not remarkably tender; lab work not scary other than signs of dehydration; and his Xray looked like an early bowel obstruction. I decided he needed an NG tube (yep, that's the one time when it's really indicated!) and vigorous rehydration, and a recheck in a few hours. When I saw him at six a.m. he hadn't decompressed his belly in any way, and his vital signs were worse (pulse up, blood pressure down.) I called the OR and got him there as fast as possible.

Having had another abdominal operation only a couple of months earlier, somewhere else, it had been a reasonable assumption that his obstruction was due to adhesions therefrom (in fact, his doc hadn't mentioned the recent surgery when he'd called me, perhaps to justify his diagnosis of stomach-flu.) So it was a big surprise to find volvulus of the right colon (cecum); shocking in fact. Cecal volvulus has a quite characteristic appearance on XRay, and there had been no sign of it on his. Dusky and congested, the colon nevertheless looked viable: the options are to untwist it and see if it is OK after re-perfusion, or to remove it. "How's he doing?" I asked the anesthesiologist: I didn't want to resect and reattach if the man was shocky -- more chance of healing problems. "He's OK," I was told. "Making lots of urine, good oxygenation." As is the case with volvulus, the right colon was nice and floppy, meaning a piece of cake to remove it. Also, avoiding untwisting it meant preventing accumulated bad stuff from being washed back into the circulation -- and it also would guarantee against recurrence. I clamped off the twisted blood supply, snipped out the right colon quickly and easily, and sewed the end of the small bowel (ileum) to the transverse colon beyond the point of resection. Sewing ileum to colon is called "ileocolostomy." (Keep that word in mind, would you?)

"Nice work," my partner said. "He's going to thank you for it. He should do great." He didn't. His blood pressure had, it turned out, been low during the whole operation: the anesthesiologist hadn't mentioned it because every other parameter had been fine (not that it would have changed much in the long run had I known.) And it remained low for the rest of his life, which was about five days. From the recovery room I transferred him to ICU; got consults from every specialty imaginable. Remaining profoundly hypotensive, he required massive amounts of fluids which ultimately ended up in his tissues, swelling him beyond recognition as a human being. All supportive measures -- ventilation, antibiotics, blood-pressure drugs -- failed to bring a response. His family was dumb-struck, as was I. His degree of sepsis didn't make sense under the circumstances, until an Xray a day or two later showed air in his portal vein. The portal vein drains blood from the gut and into the liver. Very rarely, in the face of infection in the belly, the vein can become clotted and infected, essentially a universally fatal condition called "suppurative pyelephlebitis." It's the only case I've seen, despite caring for people with massive intra-abdominal infections, large portions of dead bowel, conditions way worse than this man's.

Every hour of the day and night when I wasn't required elsewhere, I was at his side in the ICU or at his family's. It was agonizing for everyone, and it was soon clear there was no chance of survival. When he died, I felt drained for weeks.

The main issue in my mind was whether I should have operated immediately when I saw him: did I miss the volvulus on the Xrays? Would those few hours have made the difference? I went over the Xrays with every radiologist in town; I discussed every aspect of the case with every surgeon. The films, they agreed, didn't show it. And they all felt the seeds had been sewn during his hospitalization before the transfer. Undoubtedly the portal vein was developing clot even then: it was one of those rare and awful things for which there'd been no solution by the time I first saw him. Small comfort, even if true.

It was and remains the worst case of my career: a death in a previously healthy person (he was probably an undiagnosed diabetic, according to labs during his hospitalization -- it might have increased his susceptibility) from an initial condition that shouldn't have been fatal, for which the operation itself was smooth as could be, and about which there will always be questions in my mind. I've lost other patients; but never so unexpectedly, so frustratingly, so hauntingly. It would have been on my mind forever, no matter what. But with the lawsuit, I found myself in a battle against people I thought were my allies: the referring doc, the hospital, a battery of lawyers, nurses. It opened my eyes, I suppose, to the realities of the world of medical malpractice. Knowing reality is good, so they say. But it also shut my heart part way to the love I'd had for what I do. In the next couple of posts, I'll try to tell you how....