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Showing posts from November, 2006

Skin to Skin

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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

Anatomy Lesson

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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

You Gotta Think...

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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 e

Family Matters

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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 c

Testing the Limits

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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 i

Right Here in River City

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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

Pisser

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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 p

Rectifying, Redux

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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,

Rectifying

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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 sens

Losing My Virginity; Part Three

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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 oper

Losing My Virginity; Part Two

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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 clos

Losing My Virginity; Part One

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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