Surgeonsblog

On a pass through Kevin MD's website a while ago, I saw a reference to an article which reported a study on anger and healing. The report, at BBC online, said, in part: "The Brain Behavior and Immunity study indicates stress has a major impact on the body's ability to repair itself. Nearly 100 participants were asked to rate how well they could control their temper, and the speed at which they recovered from a blister was monitored. Hotheads were more than four times likely to take more than four days to heal than mild-mannered counterparts.... The team at Ohio State University gave participants blisters on one of their arms and then monitored how the wound healed over the course of eight days. They were asked to fill in a questionnaire which looked at how anger was expressed - whether externally, by shouting at others, for instance, or internally, when one rages insides but keeps a cool exterior." At the end of the article, there was this: "Steve Bloom, prof

Having nothing but time on his hands like any law student, esteemed reader Patrick sent me a link to a pdf containing the arbitration brief of a recent and widely publicized case. Far be it from me to beat a dead horse , but it seems a tidy argument for finding a way to provide health care without the need for dozens and scores of insurance companies. (And as an aside, a look at why, to some degree anyway, I've always been sort-of attracted to law as a profession: the orderliness, the linearity, the need for factual and logical thinking. Sometimes.) The case is that of a woman who, despite having perfectly good health insurance, was approached by a (predatory?) guy wanting to sell her a less-expensive policy. Forms were filled out. She evidently thought it was going to be some sort of automatic transfer, rather than an application. At some point, the number for her weight had been changed on the form; the change was initialed by the agent, not by the woman. The form went forward,

Do you have any idea how beautiful you are? Well, okay; maybe for some it's were . Before you got a little thick in the middle, smoked, or even just breathed city air for enough years, or drank a little, or did a few drugs, there was a time -- and maybe it's still true -- when you were knock-down, take-your-breath-away gorgeous. Many times while operating inside a belly I've stopped working and just looked, and then said to the others in the room, "C'mere everyone, look at this. Look how beautiful it is." Because it's true. Really, you should see yourself. Operating, as is our aim, on sick people, more often than not things aren't so pretty inside. Diabetic, or old, or overweight, or with concomitant diseases affecting various organs, typical surgical patients rarely retain the born-in beauty and peach-fuzz perfection with which they came into the world. But sometimes bad things happen to the well-kept or the young, and, in another of those paradoxical

[Another weekend non-medical rant. Warning: may be offensive to some, but not all, believers, in that it is generally anti-religious. It does represent how I feel; questions I've asked myself and answered over the years. In the same way that my religious views never affected my practice, or devotion to my patients (except in those rare instances when people said they thought God was working through me and I responded, "I'll do my very best" or something similar) I hope readers will be able to separate this sort of post from my writings about surgery and medicine. Or will bail now before going further.] I offer a comment on a TV show I didn't watch: having seen a preview is quite enough. The show "In God's Name" presents interviews with several heavy-hitting religious leaders, including the Pope, The Dali Lama (maybe it's unfair to lump him in, since Buddhism is about spirituality and not about deity), the Chief Rabbi of Somewhere, an Ayatollah,

Sorry, those of you on a RSS feed or something. I had another episode of premature epublijacation, and took it down. It'll appear, as intended, this weekend.

Couple of months ago I read an article about a guy who did a three or four simple un-fixes to his Subaru, took it to a bunch of repair places, and reported the results. Bottom line: only about twenty percent found the problems and provided the appropriate and easy repairs. The others suggested all manner of unneeded and very expensive work, and missed some things. Not a surprise. The article analogized to medical care: experts who have a stake in providing the care and charging for it may not always be trusted to give the best advice. It's not an entirely specious proposition. I was reminded of it recently. I get ongoing comments on posts from long ago; most particularly the gallbladder series. "I'm so glad to have found your blog," they say, and then proceed to tell me their saga of problematic diagnoses and/or recommendations, and they ask my advice. At some level it's flattering, until I realize they're probably pretty desperate to trust some guy on t

Enlarging on a footnote in my book , I share the story of a magical picnic: Toward the end of my year in Vietnam, as the North Vietnamese Army marched ever more successfully downhill toward Danang, we had to bug out to Thailand. We shuttled to a barely re-opened base at which our "hospital" consisted at first of cots and bare walls, and where my office was furnished with boxes. My arrival was met with delight by a fully-trained surgeon who had not been allowed to leave until I (having had only a surgical internship's worth of training) got there. When he left, the portable OR and the anesthetist went with him: such was the logic of the military. There was a small town nearby, which grew rapidly, putting up bars and other establishments more quickly than we fixed up our facilities. One of my fellow docs found himself a Thai girlfriend, with whom he moved in, part-time at least, downtown and in short order. My friend thought her an amazing young woman, and wanted me to meet

From my prior comments about my love for bowel surgery and for the old-fashion method of hooking the ends together, one might draw the erroneous conclusion that I eschew all forms of operative shortcuts. Untrue. While not the top priority, speed is an issue, and I've written about that, too. My reasons for preferring hand-sewing over staples -- aesthetics, cost savings, connection to the history of surgery -- don't apply when it comes to clamping and tying blood vessels. Surgical clips, particularly the old-style individually loaded ones (as opposed to the fancy disposable multi-fire guns) are cheap as dirt, simple as hell, and save lots of time. For the first thousand years or so, surgical clips were made of stainless steel. More recently, and mainly because of concerns about clips being pulled off by MRI machines, they come in titanium or, most lately, are made of absorbable material. Whatever the composition, the idea is straightforward: shaped like the marriage-bed issu

My political rants have gotten a mixture of comments, as well they should. Clicking on the name of one of my commenters led to the discovery of the following cartoon. Although it doesn't reflect any plans of mine, at least for now, it's definitely worth sharing:

[This post is another of my forewarned weekend rants, written in part a while ago, during my outage.] The New York Times recently ran an article that hits home. For a variety of reasons, I've been feeling pretty depressed; if you put my mood on a pie-chart, the state of our nation and world occupies a large part of the dark areas. The rest, well, it's just who I am, and not worth sharing. If anything, the article doesn't plumb deeply enough. The world IS depressing; and to the extent that some people don't see it that way, well, that's depressing, too. Where to start? OK, how about the war in Iraq? I accept that some don't see it as the worst mistake ever made by a US president since the beginning of the Republic. It most certainly was, but that not everyone agrees isn't what disturbs me. What does, is that the argument for ending the war is characterized by all the Republican candidates as "surrender," as a great victory for al Queda. But it see

In response to outbreaks of MRSA and c.difficile , hospitals in England have instituted various hygiene policies, including the need for medical staff to have bare arms, which they must wash to the elbows. Muslim female medical students are refusing , on grounds of immodesty inconsistent with Muslim law. When mentioned on the website Pharyngula , among the comments thereon was this: Many moons ago I lived with a Bedouin hill tribe near Petra in Jordan. One winter I got terribly sick with pneumonia and had to receive treatment by a Muslim doctor in Petra. Whilst he was a lovely man and their training is first rate he still had to adhere to the silly requirements of his religion. As such, sick as a dog, I could only be examined from the other side of a sheet held up by his two giggling nurses. I explained that it didn't worry me to be examined and to go ahead, lift up my top and listen to my lungs, but no, still had to have that damn sheet. I was in that clinic for a week and all I

Blogging a little over one and a half years, it seems I recently passed the half-million mark in page views (small potatoes by the standards of the big boys; but to me, significant.) I discovered the joys and perversions and obsessions of site counters only after having been doing it for a while, but the arithmetic would seem correct. I find it amazing. As time has passed there's been an increasing sense that I'm blogging not just for myself; and whereas that could be considered overly self-important, I mean to say that it's gratifying and thrilling that people actually read my tappings from a laptop situated in a small town in a small corner of the planet. And find use for them! As I said on Dr A's radio show , I hadn't considered when I started, nor was even aware of the many unexpected and entirely pleasant ramifications of blogging. It's very cool. I've gotten only a few insults, and more than a lot of really nice comments; even a little outside notice

Not many surgeons nowadays would want t0 operate without an electrosurgery unit , but it wasn't all that many years ago that everyone did. In fact, when dinosaurs roamed the earth and I was still in training, a couple of my teachers refused to use it at all. So I learned both ways. Cutting only with a knife, and controlling bleeding only with clamps and ties and sutures has a certain elegance; grace, even, as tying a small vessel requires gentleness and coordination of the fingers so as not to avulse the knot from the bleeder. But it can also be tedious. I wear size 8 1/2 or 9 gloves. An electrician or physicist I'm not, so I can only say that electrosurgery refers to any of several devices that provide the surgeon with a pencil-like hand unit, connected to some sort of magic box which sends little electrons or something to that hand unit, which then arc to the patient in at least two different modes: one that's best suited for cutting, and one that serves to cauterize; ie

In my local newspaper there was recently a letter to the editor, the gist of which was that people who indicate they'd be an organ donor (we have a place on our driver's license to do so) ought to go to the head of the waiting list were they ever to need one; and conversely, those that don't so indicate go to the back of the line. It would, he said, go a long way toward solving the shortage of available organs. And so it might. It's been many years since I was involved in a very busy transplant program. Way back then, there were, in some localities, committees set up to decide the relative worthiness of potential recipients. Doctors, nurses, social workers, clergy, lay people met to hash it out, to prioritize recipients of those scarce bits of flesh based on highly subjective considerations of people's relative value. To someone. Far as I know, such deliberations no longer occur. The ideal, of course, is that one's place on the list is determined only by medical

[I can't help myself: I write political posts, but more often than not, I haven't posted them. But what the heck. There are some things I believe strongly, and in these most consequential of political times, where, as far as I'm concerned, the existence of the US is literally in the balance, I'm gonna post them. It's not like it'll make any difference, other than pissing off some of my readers; which is decidedly NOT what I want to do. So, as a compromise, I've decided that from now on when I post these screeds, I'll do it on weekends, when not as many people drop by. It's in no way my intention to turn this into a political blog: my goal remains to provide insight, information and hopefully some humor as it relates to the practice of surgery. But on some things, I can't hold my tongue.] President Bush told the world, "The United States does not torture." (I did NOT..Have..Abusive... Relations...with that prisoner... Mister Zubayda...)

I went to an Obamarama today: he spoke in Seattle, at Key Arena, which is where concerts are held and where the Sonics play. Yesterday Hillary spoke to about five thousand people. Today when we arrived the line stretched for countless blocks; holding seventeen thousand, the place was filled and doors were closed while thousands of us remained in line. The media said it was three thousand who stayed to hear the speeches piped out to us; it looked like more, and it was after thousands left as soon as the news came that the place was full (it was cold and windy and a little rainy.) Obama arrived after quite a wait, but when he did, he stopped before going in and addressed us lockedoutenfolk, which was thoughtful. In his speech he said all the things a candidate for whom I'd vote would have needed to say, and many others. It was worth the wait, even if I received some negative feedback from my bladder. But here's the kicker: I'd been contacted recently by the woman who runs Wa

I thoroughly enjoyed myself on last night's radio show. Listening later, I cringed a couple of times, and wished I'd stammered a little less, and said "y'know" more infrequently. Still, it was great fun. Most particularly, I appreciated the people who honored me with their calls: bongi , Rob , Enrico , Seaspray , Eric . How great to talk to you all! And when I say honored, I really mean it! The chat room was populated with lots of my cyberfriends and was, according to my wife who watched the scrolling words, lively and highly entertaining. I wish THAT were archived! Most of all, I'm grateful to the inventive Dr Anonymous , who has pioneered that aspect of the blogosphere, for having me on. This whole blogging thing is quite amazing: the connections around the world being at the top of the list of the unexpected pleasures. Thanks, everyone. For anyone who missed it and has an hour to waste, it's archived here .

[If you don't get the reference, I ain't explaining.] I have some memories of the first time I did a rectal exam as a student. I even seem to recall that we were made to do it to each other, before inserting ourselves into the affairs of patients. Embarrassing, to be sure, there was also a sense of gratitude and bemusement that people would agree to such a thing, while surely knowing it was of no benefit to them. They allowed students, overtly unsure and explicitly unskilled, to prod them for the sake of furthering education. Much maligned, and stereotyped as a physician's perverted pleasure; the (obvious word here) of comedians' jokes, rectal exam is in fact an important intervention. Especially, I'd propose, for surgeons. Like a Swiss Army Knife , it's an all-purpose tool. Many things in one. E probicus, unum. (Not that anyone would put a Swiss...) For most doctors, it's a matter of poking around for a little stool to test for blood, and, half the time,

As previously announced, I'll be on Dr Anonymous' blog talk radio show tonight. I'll try not to embarrass myself (I have a cold, which will either make my voice sexy, or absent). Join in if you can, here . The show starts at 9 pm Eastern, but the chat room (requires a simple and free login) will get going a little before that. On the website is a number for calling in, which anyone can do. Be there, or be... sensible. (The shows are archived there, so if you wake up tomorrow and smack your head in a V-8 sort of way, you can still hear it, non-participat-orally.)

Or help 'em. Those, it seems, are the philosophical options in the funding of health care nowadays. In order to balance the budget, George Bush wants major cuts in Medicare and Medicaid. Primarily, his plan is to cut back on payments to hospitals and nursing homes. There is also on the table a pending cut of ten percent in reimbursements to physicians, but I'll not make this post about that except to say the obvious: there's only so much blood in that turnip. Somewhere there's a floor below which doctors can't and won't go. We're there, in my opinion. Care will become less available. But I'm out of the provider loop nowadays. So let's talk about recipients. What do you do with people who can't, for whatever reason, afford medical care? You either bar the door, or you let them in. F*ck 'em, in other words, or help 'em. And if you help them, but don't pay hospitals enough to cover the costs, then in order to stay afloat, hospitals must

Brief note to those who, seeing a couple of posts disappear of late, including one that was up for three seconds a few minutes ago: I haven't lost my mind. A few minutes ago I hit the "publish" button instead of "save" for a post not yet ready. And the others a couple of days ago involved the posting of a moving video (OK, it was about Barack Obama) which kept getting made unavailabe so I gave up. It's (probably) still available here .

Well, here's a new one: it's reported that women who have lumpectomy for breast cancer are more likely to have radiation therapy afterwards if their surgeon is female. Once again , I'm stumped. As a surgeon of the scrotumnal sort, I'm trying to figure it out. In the article, you'd see the differences weren't huge; and that there were other independent characteristics which seemed to matter at about the same level: that the surgeon was an MD, and that s/he was US-trained. (Chauvinistic in ways other than sexual, I'm not surprised by those two.) It's hard to imagine any properly-trained surgeon who doesn't know of the need for adjunctive breast irradiation after lumpectomy. As always, there's room for some judgment: from a few very elderly and frail women I've removed a cancerous lump under local anesthesia and elected -- fully consulting with patient and family about options -- simply to follow along with no other treatment except, for some,

The always amazing bongi (I could also characterize him as shiftless, but not everyone would get it) has a post that led me to think about how doctors juggle patients in their brains, and how bizarre it is. The need to switch gears rapidly and completely among clients, customers, or patrons of one sort or another surely isn't unique to physicians. It's just that, given the stakes, with docs it might be the most jarring and otherworldly. I've always tried to be mindful of -- and here I'm just making up a term -- "disproportionate impression." I walk into a patient's hospital room, or see someone in my office, and it may well be the most important and impactful minutes of that person's day. For me, it's one of many similar encounters, some pretty routine, others of horrendous import. I'm the only surgeon each patient has; each is but one of many for me. My words and reactions likely reverberate in each room for hours or days; but I must move on

Far as I know, I'm scheduled to be on Dr. Anonymous ' internet radio show next week, Thursday February 7. It's at 9 pm Eastern. In addition to listening -- a good way to waste an hour -- people can call in. I'd love to hear the voices of some of the regulars around here. Also, there's a live chat-room associated with the show. That requires a free log-in, but listening doesn't. Calling in is not toll-free. The shows are archived, for those who don't make it live. Information is here . I'll put up another reminder as the time approaches, since, from what I've heard, you're pretty busy.