Weekend by the Bay

Anyone remember this post? (To save you the trouble, it was about a friendship I made online, with a man who trained where I did about ten years earlier, and who eventually sent me a key to the fabled and loved Chief Resident room in the fabled and loved San Francisco General Hospital, of which I was the last occupier before it was torn down.) We've corresponded for over a year, but until Saturday, we'd never met.

This weekend in San Francisco a "distinguished professorship" in honor of one of the early Chiefs of Surgery at UCSF was celebrated. The professor died many years ago, while I was in training; in fact, I was a pall-bearer at his funeral. The professorship was financed by his daughter and her husband, the former being Dianne Feinstein, US Senator. Hosted by the two of them was a fancy dinner at a fancy hotel, with the attendees mostly surgeons who'd been trained by him, many years before me. There, I was the young guy.

Ordinarily I'd not be attracted to such a gathering; I feel out of place amongst strangers, especially those more glamorous than I (which includes pretty much everyone) and having connections to one another that don't include me. (We trained at the same place, but not at the same time.) But at the urging of JB -- the keymaster -- and with the knowledge that a couple of my old professors, now frail and failing and not likely to reappear, would be there, I took a one day trip to SF. Mostly, I'm glad I did, even though it began with a flight made stressful by that fearsome announcement midway to SFO: "If there is any medical person on board, please turn on your call light."

It wasn't the first time I've responded to such a plea. Stalling for a few seconds to see if any other lights went on, I chimed in with the reluctance that comes from fear of the unknown. A steward came and leaned to me (I'd noted his unusually cool and amusing delivery of the safety speech, and his friendly handling of the delay in takeoff occasioned by the usual SF morning weather.) "We have a lady who looks pretty gray. What sort of medical person are you," he asked. "I'm a physician," I replied. "A surgeon, actually. I could take out her appendix if needed." He smiled and led the way to the back of the plane.

In a seat leaning back as far as they go (meaning pretty much vertical) was a thirty-something woman looking indeed quite peaked, already with flimsy and ineffective-looking oxygen mask on her face but with an adequate albeit quite slow pulse, felt under the skin of a clammy wrist. I asked a few questions, determined that she was in prior fine health, no meds or allergies, no clots, had flown in the past with no problems. Ever notice how in the movies -- or even in televised fights of some kinds -- when a person goes down they sit him up, or even try to get him up walking? Pretty basic: when fainting or otherwise woozy, lie the hell down and stay there! Conveniently, the woman's seat was right across from the galley area. After the stewardess spent a couple minutes trying to remove the arm of the seat before discovering it wasn't designed to come off, I helped the lady (she was cognating marginally but able to supply a little leg work) over the armrest and onto the floor and kneeled down beside her, readjusted her silly mask and took the offered sphygmomanometer and stethoscope. There was, of course, no way to hear a damn thing in that rackety galley, but I checked her pressure by palpation and it was good enough. She'd picked up her pulse rate a little, too, complained that her fingers were tingling. About this time her friend came down the aisle and said they'd been out drinking a lot last night.

I was handed a headset. The crew had been in contact with the ground, connecting with some sort of emergency physician, with whom they wished me to speak. As I had when doing my required flying in Vietnam, sitting in the copilot seat and given control of stick and rudder, mic pressed against my lips properly near as confirmed by the frequent kissing of it (pilots did it, so I did, too, singing out "roger one-five-niner" and "rollout" while taking directions from the spies in the back of the plane), I donned the set and knowingly tucked the phone close to mouth. There was a button to push when talking. It was all so familiar... I gave my assessment, thumbing the button like a veteran, and the doc on earth said "sounds like a vagal thing." I agreed, but added that I thought there was a measure of dehydration, hung-overness, and hyperventilation.

"Think she can just check in with her own doc when she's on the ground?"

"Doubt it. She's better lying there, but I don't think she'll be getting up and out on her own power."

"OK, so you want EMTs there?"

"I think it's best."

After reassuring her that I was sure it wasn't serious, she was in no danger, there wasn't more I could do. Thought about getting her to drink some juice, but figured better to let her lie. I returned to my seat after filling out some forms; came back a couple of times to check on her. Interestingly, and rightly I'd say even though it probably broke some rules, they kept her lying there for the landing. We were held in our seats until the EMTs came aboard, checked her, exited and returned with a gurney/wheelchair hybrid (I felt vindicated at that point) and rolled her out. The stewardess thanked me earnestly, offered me a Starbuck's gift card as a reward. For five bucks.

A few hours later I met JB at my hotel. He was more compact and wiry than I'd have guessed. In his seventies, he bristled with contained energy, had a perfect voice: just grainy enough and quietly powerful, confident, in charge. He'd sat himself down with a couple of ladies in the lobby, unknown to him, and was chatting away when I came down, missing him at first, expecting him to be alone. His baldness was semi-encircled in the grandfatherly way. Obviously fit, wearing cowboy boots to the ball, and a Panama sort of hat sporting service medals and insigniae from his time in Vietnam (where, unlike me, he'd served as a fully trained surgeon, well in the thick of it, the real deal), he'd brought a copy of my book for signing. It was heavily annotated and curled from re-reading, underlined, with lists of questions at the back. I'd planned to tell him of my airborne adventure, but his stories were much better, and I lost mine in the moment. After the night's ceremonies and a detour into the bar for one more round, we parted company in a fully exchanged hug. Worth the trip. I want to spend more time with JB.

Scar Trek, The Next Generation

[Weekend rant, a day early because I may be out of touch tomorrow. This is about religion. Be warned.]






My reaction to the above video goes beyond anger: it makes me sick. These kids are deliberately being deceived. Brainwashed. And, yes, abused. In the name of some religion or other, they are being told to reject verifiable fact; told to ignore explanations that are literally right in front of their noses; given permission -- no, being required -- to reject the idea of thinking for themselves. Indoctrinated. In the guise of teaching, their idiot instructor is making them parrot a catechism of cluelessness. The bible says it. End of discussion.

Chill, Sid. It's religion. We have to respect it. Freedom of religion is a foundation of our country. Right. But I don't see a need to acquiesce silently to the hijacking of minds too unformed to understand religions, let alone choose among them; nor do I see a need to approve of intellecticide. Comforting make-believe is one thing. It's quite another deliberately to remove your children's reality-testing, to close off whole parts of their brains. Because in addition to harming them, it affects me; it affects us all. These people may grow up to become voters (if they don't also reject the science of medicine and the wisdom of looking both ways before crossing the street). They are being led to extremism which differs not from the kind that creates believers in paradise filled with virgins. And we know where that leads. (By the way, is their virginity self-renewing? Because eternity is a relatively long time. Seventy-seven copulations would be over -- by my reckoning -- in a decade or two. Then what? If sex with virgins is worth dying for, it seems sort of over-promised and under-thought. And seriously exaggerated, total-experience-pleasure-and-talent-wise.)

By "extremism" I mean thinking which willfully rejects fact; I mean belief that flies in the face of reality -- not to mention into buildings. The above-displayed sort of belief and that suicidal extremism differ only slightly, if at all. The one leads easily to the other. What is it but extremism that has these men trying to inculcate in children that which is demonstrably false? I don't doubt their motives: and that's the point. I'm sure those guys fully believe what they are saying, just as much as the 9/11 hijackers believed they were going to promiscuous paradise. They think that in getting children to reject rational thought, implanting in their brains blocks to thinking for themselves (which they describe, entertainingly, as "thinking for themselves") they are doing something wonderful. Saving them. Sincerely. Which is what's so sickening. The smug certainty. The rectitude of wrong.

There are people in the world (I know some!) who are religious and who find a way to reconcile their beliefs with wonder at the way the world is, as opposed to needing to bolster belief by harboring plainly incompatible and disprovable dogma. When religion requires one to deny the world -- no matter how sincerely -- and gleefully to dimish the ability of one's children to think for themselves, it endangers me. It pollutes our nation with people incapable of the clear-heading thinking required of a democracy that works. These are the people putting religious tests to our potential leaders, proclaiming their holiness above mine, placing more importance on the words of a person's pastor than on that person's own words, banning books and destroying public education. Rioting over cartoons. These are the people claiming our country needs more religion, even as their religion-above-all attitude is subverting the very foundations of our democracy and aiming us toward societal failure by substituting indoctrination for education. It worries me that there's no future in the future. So yeah. It makes me sick.

Cutting It Close

Shortly after I set up practice, my mom mentioned a little skin growth she wanted removed. Since she was part of paying for my college and med school (yes, I was one of the lucky ones!) I figured it was the least I could do. The lesion was a simple non-worrisome thing; removal was strictly cosmetic. But its orientation was such that I had to choose between a smaller excision, not in proper skin lines, versus a bigger one that might be less visible. For some reason, which I still can't understand thirty years later, I made the former choice, and it wasn't a very respectable scar. It did, however, lead me to pay much more attention to orientation; and to the realization that it had been under-emphasized in training. Little things like that are little things like that, when you are trying to learn how to remove half a liver.

But that's not my point. A recent post of mine, and comments thereon, led to thinking about operating on people to whom one is close. It's a close call. On several occasions I've operated on partners, or their family. I've operated on friends (it helps that I have few really close friends), and on people who came to me on the recommendation of friends. In-laws have been under my knife, if a small one. It's an interesting subject, a complicated one. To some extent, it depends on one's ability to compartmentalize. Or, more properly, to focus.

I've not considered it a matter of ethics; to me, it's about judgment. One of my commenters said she was taught in med school that caring for family is considered unethical; perhaps it's a semantic disagreement that we have. To me, "unethical" means submitting false charges, operating with no indications to collect the fee, taking kickbacks for using particular products (a matter of current investigation, evidently.) Were I to operate on someone close, the question is whether I could rise above emotion and make care decisions exactly in the way I would for a "normal" patient.

There's a strange implication here, when you think about it. I like getting to know my patients. Not only, as I've written, do I believe in the importance of establishing trust and confidence and a positive attitude, I just enjoy the relationship for its own sake. It could be said -- it is said, in fact -- that it's a mistake to have anything but a cold and distant relationship with one's patients. But if it's okay to reject that, if it's acceptable -- laudable, even, according to various patient advocates -- for doctors to establish and to have a connected relationship with their patients, then doesn't it follow that the idea of "professional distance" is a flawed one? Doesn't it imply I'd make better decisions when caring for a patient I don't like than for one I do? If not, then at best the idea of caring for a relative or close friend differs from caring for "regulars" only in degree; and a smaller degree, at that, than convention would suggest. Ethics, per se, are not the issue. Attitude is.

Perhaps I'm missing something, but I sort of reject the idea that I care less about my unrelated patients than I would about friends or family. Maybe I'm deluding myself in believing it, but when I enter the operating room I get into a zone of intensity and focus on the problem at hand that nearly obliterates everything else. Totally concerned about addressing the requirements of what I find, while I operate the personhood of my patient is no more and no less than that of the last one, or the next: I'm obliged to do my best. Period.

Of course, I'm not unaware of the temptation to think wishfully, to opt for a path less discomforting for a loved one; it's a possibility, to be sure, especially, perhaps, in after-care. Included in my "memorable patient" series is the story of operating, with only a couple of years of practice under my belt, on my partner. When I had to re-operate on him -- a decision which was harder in many ways than one to delay -- I deliberately chose as an assistant a surgeon out of my clinic, and told him ahead of time I wanted him to speak his mind. Not only was he among those that had suggested waiting, he also made a recommendation during the operation that I ended up rejecting. Later, he commended both of my decisions, and said he'd been wrong, twice. I was able, I'd argue, to think clearly about the needs of my patient irrespective of who he was.

It's not my aim to suggest that doctors ought to start caring for their loved ones; nor am I implying (I don't think so!) that I have mystical powers of concentration absent in others. But it wouldn't be the first time conventional wisdom was found wanting; at the least, it's not crazy-stupid to wonder about it. It's not impossible to focus. Like the paranoid who actually does have enemies, some doctors who think they could provide better care than their colleagues, even to loved ones, might actually be right in some instances. When he was a baby, it looked like my son might have had a hernia. I really liked the way I fixed pedi-hernias; no one in the area did it as simply or with as tiny an incision, sez me. (Most of the pediatricians I knew sent all of their hernia patients to me, because they thought so, too.) Had my son turned up with one -- he didn't -- I'd have been sorely tempted to do it myself, believing it would be in his best interest. My wife told me several times that if she had breast cancer, she'd want me to do the surgery. And having seen my work and that of others, I'd have considered it; probably I wouldn't have done it, but I'm not sure. Happily, I never needed to make the decision. Nor am I unaware of the egotistical implications of the pre-penultimate sentence of this paragraph.

Greater than the risk of providing improper care, as I see it, would be the burden to bear if something went wrong. In that, there would be a difference. It's hard enough to forgive oneself for error or poor outcome under any circumstances. It might be more than I could take, in someone close. Which, of course, argues strongly against taking it on, if for reasons somewhat different that those generally offered.

Maybe there's a happy medium. Plastic surgeon and rabid blogger Ramona Bates responded to my original post with one of her own, and she gave examples of what a surgeon can do to help in meaningful ways, while avoiding the potential pitfalls. When my dad needed surgery of the sort that I did, I had him come to town and hooked him up with a hand-picked team. I stuck my head in the room a couple of times and transmitted the information to my wife and mom. Same when my son had an orthopedic procedure. I was unobtrusive in the OR, helpful to my family, and felt useful in a surgical sort of way. Dayenu. As they say.

Spendtacular Surgery

In order to remove an otherwise inoperable tumor, surgeons have extirpated more or less a woman's entire intestinal tract, taken away the tumor, and re-installed her guts. The operation took fifteen hours, at least two anesthesiologists, and who knows (because the article doesn't say) how many surgeons and nurses and aides. The extraordinary effort was required because of the location of the cancer, at the backside of the abdominal cavity, enwrapping itself amongst the blood supply to those gut organs. High fives all around.

It's not that it's not amazing. It's a salad of surgical steps steeped in transplantation techniques, and a melange of magic, making mayhem manageable. Had I done it, I'm sure I'd have found it exciting and dramatic, and I'd no doubt be impressed as hell with myself. TV cameras, interviews. I might even have convinced myself it was worth it; it's obvious the patient thinks so, and I don't mean to diminish that. She looks like a very nice person. (In the print version, there are pictures.)

Even forgetting for a moment that when a cancer insinuates itself into blood vessels it is almost certainly incurable (because in doing so it invades into the bloodstream and spreads elsewhere), I don't think it's unreasonable to be skeptical. Because it seems a good example of the dilemma of health care costs driving us into medical bankruptcy. In asking whether it's appropriate to do such a thing, am I out of bounds? Considering it -- given the finitude of resources -- a waste of money, am I heartless? Were I the patient, would I think differently? (Well, I think I can answer that last one in the negative: I happen to recoil [admitting the chips are not yet down] at the idea of that many people and that much money being devoted to the personal old fuck that is me, and I tell myself I'd not allow it.)

I guess it's a matter of the particular versus the abstract. The woman is a person whom many people no doubt know and love. Were she my friend or relative, were I looking her in the eye, I'd likely feel differently, and so might you. But as a matter of policy I find it troubling; or at least a good subject for discussion. I remember being outraged at Ronald Reagan (one of a bazillion times) when, shortly after demanding reduced federal funding for health care, he got all misty over a girl who'd just had (or maybe was asking for) a liver transplant (I think it was) and chipped in a few bucks for her fund. But it's how we think. Or don't think, depending on how you look at it. If we tear up in wonderment when we read such a story, then we must also be willing to pay: well up; pony up. But if we think it's an imbalance in equity, then we must also be willing to say so when it's grandma.

In my area there's an increasing crisis in hospital bed availability, and it extends to adjoining counties. Projections suggest impending shortages of surgeons nationwide. Medicare will go bust on its current trajectory. Looking at this spectacular (as in "spectacle") operation seems a good way to frame the debate: should it have been done? Should there be parameters: age, odds of cure, projected costs? Number of people required, or time taken up in an operating room? Are insurers obliged to cover such things? Is Medicare? If not, are we okay with "heroic" (I have a problem with that term, too) care being given only to those that can afford it?

I have opinions, but not answers. Answers can only come from confronting such questions straight up, in Congress and in the voting booth. Cost, benefit, society. Taxes, deficits. Priorities. In these times, of all times, it feels like the clock is ticking. Meanwhile, I wish the lady well.

Embarrassing

I need to say I'm very appreciative but, more than that, embarrassed by the comments I've gotten on my recent post about a horrible feeling. I nearly didn't publish it. Since a part of my aim here has been to convey what it's like to be a surgeon, and since the feelings I had on hearing the news were exactly as described, I went ahead, in the interest of honest blogging. But it did occur to me that it might be upsetting to some of my valued blog friends, and it seems it was. I'm not unaware that my reaction was based, in part, on the false sense of indispensability to which I referred in the post, and that it was narcissistic, as one commenter rightly said. Narcissism, particularly in the context of wanting to believe you're better than others at what you do, and that the world can't get along without you, may even be a necessary characteristic of surgeons. In any case, to the extent that it drives one to feel deeply responsible for one's actions, it's not all bad. But it also leads to thoughts such as were mine immediately upon hearing the news of my friend's death.

So to the extent that I made people feel bad for me, I'm sorry. I've been to a memorial ceremony, I've contributed to a scholarship fund, I'm not in mourning any more than any friend would be. I both wish I'd been there to do the operation, and am glad I wasn't. Since there are things I love about surgery and things I hate about it, my writing is sometimes ambivalent, and, in this case, ill-considered. But thank you.

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A Horrible Feeling

Probably I shouldn't write when I feel this way. I'm stunned by the death of a really good person, whom I've known for a long time. Our kids were friends. We spent lots of time on lots of sidelines of lots of athletic fields, watching our kids and talking about whatever parents talk about. Let's call her Mary. And the thing is, she died after an operation of a sort that I did all the time and which, had I still been in practice, I likely would have done for her. Which is, among other things, why I feel so bad.

I've always felt guilty about bailing out a few years younger than I'd intended. I tell myself -- because it's true -- that in my foreshortened practice I did more surgery by far, and saw more patients by the thousands, than most surgeons do in many more years. That's, of course, one of the reasons I burned out. But the guilt has until now been sort of generic. Today, in a bizarre and (I know) entirely unrealistic way, my guilt is personal. I feel like I let Mary down by not being there.

There's no reason for me to think mistakes were made; in fact, they most probably weren't. But I find it nearly impossible not to think that had I done the operation, and had I done it the way I always did, Mary would have done fine. I never had such a thing happen to my patients, and I've done many more than the surgeon who did hers. Of course, bad outcomes can happen no matter what; and had it ocurred if I operated, I'd be feeling immeasurably worse.

One of the corollaries to being able to dramatic good as a surgeon is the potential to do devastating harm. I've had operations turn out badly even when done well. It's an awful thing. But this is the first time I've felt like this: a sick feeling at the loss of a friend, compounded by a hard-to-suppress sense that had I had the (what is the word? Character?) to stay in practice longer, it wouldn't have happened. I wish I'd been there. Perhaps it's not so much guilt as helplessness in the face of tragedy.

The tragedy is not mine. It's Mary's wonderful family's. But as her husband told me the sad saga, in my mind I was shaking my head and screaming in exasperation. Maybe it's just an example of a false sense of indispensability in the way I used to believe it. But, for whatever reasons good or bad, I feel deeply sorry right now, for Mary and her family, and in some perverse way, for myself. It's painful and embarrassing to admit it.

Hot Stuff

A word or two about applying heat to treat inflammation or infections of body parts. Based on absolutely no current research other than what I've learned and observed, this is my take on it. The reason I mention it: I'm applying a little heat to the area of me which is most in contact with my bicycle saddle. Let's keep that between you and me.

Why is heat useful? Because it increases circulation to the area in question: capillaries dilate, blood flows in, which is good in two ways. It carries with it the body's own defenses (ie, white blood cells of various types), and, assuming you might be on antibiotics, it brings more of that, too.

Why "moist" heat? Nothing magic about moisture, per se. It doesn't get below a couple of cell layers, after all. It's about conforming to the part you're trying to heat: a moist cloth will lay entirely against the skin, whereas a heating pad has gaps in its contact.

What's a Koch-Mason dressing? Wow, where did you hear of that? I can't even find it on Google. It's an old-style multi-layer dressing intended to apply continuous heat: on the skin, a warm moist cloth of some sort; then plastic wrap; then some variety of heating pad; then a dry towel above that. In the olden days, we used them, in the hospital, for some people with cellulitis. You need to be careful about the heating pad. The hospital kinds use warm water circulating in the pad. Electric ones pose hazards, both from the electricity and from over-heating.

What's your secret, Sid? Well, you asked, so here it is. If you want to apply constant heat to an extremity, and don't want to be tied down by an electric cord (most assuredly, this is not a fetish blog) do this: cover the area with a nice warm moist cloth, then wrap with plastic wrap, then follow with a dry towel, and tape it all in place. The insulation will keep the heat in, and you can be up and around. The area will be significantly warmer than the rest of you. Because of the moisture, it's good to remove the whole thing every few hours to prevent dishpan hands of the leg, or whatever.

There's always a catch: applying heat to an extremity that has circulatory compromise can be dangerous. Even if you have a minor booboo, don't be using heat when there are vascular problems without having your doctor in the loop.

Time For Tears, Tears For Time

Palliative surgery is tough stuff. Nobody wins much, and it often challenges one's ability to think clearly, let alone to tell the truth. Sometimes, I think, it borders on the deceptive; it makes me wonder who's the object of comfort. And yet, when there's nothing else to do, it's often just the right thing. I hate it.

To be clear: we're talking about surgery to relieve some sort of specific problem, to reduce pain, to improve quality of life or to prolong it, when it's apparent that cure is out of the question and that life will end within a shortened amount of time. Most frequently the diagnosis is cancer, and the problem is one of tumor blocking something, or pressing on something, or causing pain. The surgeon -- who would much rather be riding a white horse, victorious and lauded -- is called upon to ameliorate a lousy situation; incrementally, briefly, often minimally, maybe even with a near-equal risk of making things worse. I abhor it.

As it is with even the worst of situations, there is narrow pleasure to be found, sometimes. The solutions to specific anatomic problems can be ingenious in their simplicity, or rewarding in their technical demands or need for creative problem-solving. In someone very sick from obstructive jaundice due to an unresectable pancreatic cancer, you can make a small incision, reach in, and sew a loop of upper intestine to hugely distended gallbladder, providing instant relief. In addition, you might staple or sew a couple of places, keeping food out of the biliary system. (In choosing that approach, you will have rejected, based on many impossible calculations, a more complicated but possibly more long-lasting operation: removing the gallbladder and sewing the bowel to the main bile duct. You will also have opted against the endoscopic placing of a stent, which is non-operative, but carries some increased risk of infection, and is prone to earlier failure.)

When there are multiple tumors in multiple places in the gut, if you can find a way to work around, hook this to that, leaving enough bowel in the circuit to maintain nutrition, you can feel -- in some small way -- satisfied. And then... well, and then what? To what sort of life have you consigned that person? Will there be gratitude, or regret? If it's true -- and it is -- that virtually every decision a physician makes is no more than a (hopefully) sophisticated game of odds-playing, that game is at its most intense and ephemeral and unruled when it comes to palliation, looking beyond the surgical options and possible outcomes. I loathe it.

And yet, if ever there is a situation that requires everything a good surgeon has to offer beyond mere technique, this is it. It's not about "what can I do." It's about "what ought I do." It gets to the essence of our craft and of who we are. Of course, there's no archetype, no algorithm or manual. Each situation is as unique as the person within it. Age, general condition, stage of tumor, predictability (such as it is) of prognosis. Most important: the person's (and the family's) wishes. Less tangible, less easy to apply: how realistic are those wishes. Clearly -- and I think this is the core of it -- what happens going in and coming out will vary not only with all of the preceding factors, but with the surgeon who answers the call. In that, I embrace it.

There are no more difficult conversations. There are none that require more ability and willingness to find balance among counsel and comfort, guidance and openness, realism and fantasy, hope and despair. One's own and one's patients needs. Dogmatism, that staple of surgical stereotype, serves none but the surgeon. One person's futility is another's possibility. For some, the ability to do something -- anything at all -- always trumps the option of comfort care, no matter the situation. For others, the idea of prolonging life can demand a profound look inward. And outward. Sometimes, as I wrote, it works out much better than expected. Other times, it makes you and your patient wish you'd not tried. The decision, affirmative or negative, is often easily made; when it isn't, your values are tested along with your skills.

If I were giving advice to those coming this way, I'd say to remember (and to convince yourself it's true) that your obligation is to your patient, and not to your own discomforts. To me, that means looking beyond personal prejudices, be they religious or societal. "Always" and "never" comprise the easy way out: prolong life at all costs; "no one should die with a bowel obstruction;" "I refuse to..." Many physicians feel safest only when enumerating options and staying completely out of the process of choosing. To me, that's abdication. It's our obligation to state as clearly as possible what we think the situation is, what the options are -- including all forms of intervention and non-intervention -- and then to find a way into the thoughts of the patient and family. I think most want guidance; they need our best sense of likely outcomes, based on experience and knowledge. And of course they need to understand that there's virtually never a way to be certain. In most cases, I think it's possible to discern to what extent they want direction; sometimes it's as simple as asking.

It's imperative both to lead and to follow. In many conversations with families of a person with minimal prospects, I've sensed that there's no desire to prolong the inevitable, but none wants to bear the responsibility of making the decision. There can be relief when the surgeon -- or any of the involved doctors -- takes the lead in turning toward comfort care. But in virtually none of those situations would I close the door on going for that one-in-a-thousand chance if that's the direction desired. And yet: it's exactly that situation in which I have the most discomfort and uncertainty. A part of me wants to say it's foolishness and to refuse to do the operation; another recognizes that the thought of not doing everything possible is one with which some of those left behind would have trouble living. Which gets back to the beginning: who am I treating, and why?

(It may be obvious: the time is coming, I think, when such choices will no longer be available. When the string is fully run out on reimbursement cuts, this most costly of all areas -- namely futile and end-of-life care -- will have to be addressed philosophically and economically. Lines will be drawn. The question will be where, and by whom. For now, it's still between us; and we must dig deeply.)

Everything's Fine

[Another weekend political rant. Go no further if you came here for surgery.]


Like John McCain, I'm not especially knowledgeable about the economy. Unlike him, evidently, I can think in a straight line. Nothing could be more obvious: George Bush has ruined the economy in ways so disastrous that the necessary fixes are, very possibly, politically undoable. But John McCain has already pledged to keep the faith (which is exactly what it is.) He's promised "no tax hikes." Since he'll be the next president, as the Democrats self-immolate and the electorate inevitably votes once again on fear of terrorism -- despite the fact that Bush's war, which McCain loves more than his traveling team of lobbyists, has made us less safe -- we're screwed.

In the comments on a previous post, we had a bit of a back and forth about the concept that lowering taxes increases government revenues; let's think about it some more. Following the logic to its extreme, eliminating all taxes should make revenue infinite. Can we agree that's not possible? Likewise, I'll concede that taxing at 100% would end all commerce and life as we know it. So it must be that for a given set of circumstances there's a "sweet spot." And it's also obvious that Bush hasn't found it any more than he found WMD in Iraq. (Help me out here: wasn't there a guy in recent memory who raised taxes, balanced the budget, and saw the economy roar forward?)

The current budget deficit is more than 400 billion. The forward costs of the war are estimated to be two to three TRILLION (by Joe Stiglitz -- whom I knew in college -- who won a Nobel Prize in economics, and whose methods and predictions have yet to be refuted, or even, far as I can tell, criticized.) We have sold our future to the Chinese and the Saudis, who own most of our debt, with payment due from our kids and our kids' kids. The value of the dollar is at an all-time low, oil at an all-time high. (George Bush, when running in 2000, decried the fact that under Clinton the price of oil had climbed to thirty bucks a barrel; said it was a shocking failure. It's approaching quadruple that now.) From another website: "The federal debt has increased 54 percent since President Bush took office, from approximately $5.6 trillion at the end of 2000 to an estimated $8.6 trillion at the end of 2006. By 2011, the President’s budget would increase the public debt to $11.8 trillion. (U.S. Department of the Treasury, Bureau of Public Debt)" Calling Bush's economic policy a failure is like comparing the tsunami of 2004 to a flooded basement. Housing. Banks. Jobs. Oil. "No tax hikes." McCain thinks he can scratch behind his earmarks and find the money to solve the problem. Straight talk, indeed.*

That the myth of tax cuts persists can only be explained by the efforts of those who are beyond danger -- i.e. rich enough -- to convince those who are fodder to buy into it. Or to look away. To inveigle people into focusing on abortion and gay marriage, and fear of terrorists, rather than on that which is actually destroying us. It's political prestidigitation: look at my left hand while I reach into your kids' pockets with my right. (And when I have all I need, screw you.) It works like a 600 hp, dual overhead cam, supercharged V-10. With cup holders.

Because religiously insane people flew into buildings and might do so again, we are willingly looking the other way at policies that most inarguably have made us less safe. Because of George Bush's idiotic response to the threat, we are more in debt, more dependent on the providers of oil who are the very basis for that threat, more unable to respond militarily if the need arose, are witnessing rising terrorism worldwide and the reconstitution of al Queda in the very place from which they directed the attack. But when scare comes to shitless, we vote for more of the same. Raise taxes to pay for the war and the troops coming home, and to reduce deficits and solidify the dollar? Heh. People would scream and run to emergency rooms (where, it seems, they'll be greeted with sympathy.) (If you go to that link, you must also go to this one -- the one that's mine.)

Democrats will be no less happy about indexing Social Security and Medicare than Republicans will be about raising taxes. But both will have to happen, and not very much in the future. Liberals won't like looking into safer nuclear power, and conservatives will deny there are problems with depending on and burning carbon. But they're both wrong. Democrats at least talk about the danger to our economy and our planet; Republicans see danger only when they look into caves (or into non-white faces.) Invading countries that have little or nothing to do with terrorism won't stop terrorism. Republicans don't want to hear that. To protect ourselves from attacks, we need both high-tech and low-tech intelligence gathering. Some Democrats would rather not hear that. (Although for most, myself included, it's only about doing it legally, with a little oversight, which ought not be all that big a hurdle, once George and his Dick are gone.)

So what's my point? This: we really are in existential trouble, but it has much less to do with guys in caves (other than the fact that they suckered us into slitting our own wrists) than it does with problems of our own making: economic, strategic, energetic, Constitutional. Because people don't want to hear it, and because politicians (with, I'd like to hope, some exceptions) are too cynical and weak to say it (they know that after thirty-five years of being fed bumper-sticker phrases, most people have stopped thinking), the chances of fixing it are slipping away. It's only if the electorate were to grow up, smarten up, and demand it that there's any hope at all. But the old guard of both parties, who have too much invested (quite literally) in the old ways are seeing to it that that hope is smothered in its crib, while the masses acquiesce: enablers, deniers, diggers of holes for their heads.

On the left, too many heads are in the clouds; on the right, in the sand. I'd rather be the former, because at least they are seeing the problems from up there. The modus operandi of the right is to believe that which is no longer -- nor ever was -- believable. Faith-based problem avoidance. If there's hope, I'm not seeing it any more.

*One of the more amazing things about our current state of mind is the ho-hum that people evince over deficits. Fifty years or so ago, Senator Everett Dirksen is famously said to have said "A billion here, a billion there.... pretty soon you're talking about real money." Today, nobody blinks at the idea of twelve billion a month spent on the war, deficits of hundreds of billions, or debt in the trillions. I guess we're overloaded; no doubt it's intentional. So it's useful once in a while to consider what a trillion dollars really is. Not that even such analogies really make it grokable, but here's a few: here, here, and here. Bush has been right about everything else, so when he says the economy is fine, I believe him. And so, evidently, does John McCain.

Smoke Scream

My parents were smokers; in the case of my dad, it was three or four packs a day for forty years before he just up and quit one day, cold turkey, many years ago (not soon enough to avoid the need for home oxygen at the end of his life. But still...) Mom smoked far less, and quit the same day he did. After my grandfather's heart attack, he quit, too; but usually kept an unlit Tareyton in his mouth -- the kind with the cardboard tube on the end -- to chew on. Until his stroke.

Of course I took it up. Stole packs from my dad's pockets and sneaked with eighth-grade friends down to the swamp behind Reed College, smoked and coughed until we got the hang of it, and proceeded to be cool. I blew great smoke rings, learned the "French Inhale," could light a match in a matchbook with one hand, pop a flame with my fingernail, or on my shoe. I didn't smoke much until college, and then it was only five or ten sticks a day. I kept it up, I'm embarrassed to say, through med school and even -- more's the shame -- while a surgical intern. Somewhere there's a picture of me at the VA Hospital, working on a chart, wearing my whites, cigarette polluting coolly from my hand.

On the day I got married I quit but began again three months later, when I shipped off to Vietnam. Cigarettes were so cheap over there, I really couldn't afford not to. The last cigarette I ever had was when the stewardess (flights back to The World were on Pan Am jets -- "Freedom Birds," we called them) announced we were about to land at Travis AFB. Skrunked it out, and that was that.

I mention all this to confer authority when I say what a terrible thing it is to do. How easy it is to tell smokers when operating, and when caring for them afterwards. Not to mention when first seeing them from across the room, or hearing them. Lady who looks twice her age, facial skin wrinkled like a scrotum in winter, voice sounding like shifting gears without the clutch. Guy with a chest over-expanded by trapped air, honking up crud into a brown and stiff tissue. Holding it with yellow fingers.

Put smokers to sleep, they cough on their breathing tubes; the gooey crap that needs to be sucked out of their lungs to keep their oxygen levels up looks rotten, thick in pus. Brown, or green, or black. Or red, sometimes. The corruption thus vacuumed out streaks the tubing for a foot or two, slime from a dying slug. A smoker bucks like a horse untamed when waking up, straining sutures scarily. Many a time I've leaned on an incision to keep it from coming apart, a desperate sort of single-stroke CPR, waiting for the anesthetist to get them calmed down. When still in training, I had a smoker-patient wake up with such a convulsive cough that it popped every single stitch, pk-pk-pk-pk-pk-pk, like a tommy-gun, which is what led to taking up the leaning maneuver (as well as a change in suturing methods.)

Smoking retards healing. It increases the risk of leaks where we sew bowel, and of wound dehiscence or late herniation. If you want much in the way of cosmetic surgery and you're a smoker, fergit it until you quit. The chance of successful limb-salvage surgery -- bypass grafts around blockages and hooked to small distal vessels -- is greatly reduced in smokers; welcome to Stumptown. (I used to live there.) In hospitals, particularly on surgical floors and in ICUs, evidence of the hazards of smoking is everywhere. Opening a chest and seeing a normal lung, pink as a baby's tongue, fluffy as a feather, is as rare as it is beautiful.

When I worked at that VA hospital, I saw guys holding cigarettes in stubs of former fingers, sucking smoke into a tracheostomy. Rules be damned: people sneak out to stair wells or onto fire escapes to smoke after surgery. And lie about it after, oblivious to their smell. It's rough. The good news is that, in regards to surgery and anesthesia, the effects are lessened to some degree even with a week of abstention. Much longer is much better.

My advocacy does have limits. I thought it cruel and stupid when an attending refused to let a patient, dying of lung cancer, have the pleasure of a smoke. What's done is done. Give a guy a break.


[The post was written a while back, before this.]

Quick Healer

In response to comments and questions I sometimes get, and in followup to a recent post, I'll say something I frequently said to my patients, usually when asked if it's normal not to be fully recovered from surgery in such-and-such a time. As a corollary, I've often heard "I'm a quick healer," or "I'm a slow healer." Whereas there's no doubt that many things affect healing time, such as general health, age, nutritional status, and maybe, as we heard, attitude/emotional status, healing is a complex, organized, and orderly process which proceeds as it will, over many months. I acknowledge I wrote about this in a slightly different context, here. (In blogging, any old idea is better than none. Isn't it? Plus, I still get questions about it; so either they aren't scouring the archives or I'm a bad explainer...)

I liked to point out to patients that the healing process takes three weeks just to crank into gear. As in the above-referenced post about the healing ridge, so it is that inside, where you can't see it, operated tissues thicken up over time, become hard and unyielding: the places where bowel is sewed or stapled may become a little tight for a while, like a donut swelling and making its hole smaller. Everywhere we worked -- the place where the gallbladder used to be, the surfaces from which we pulled up the bowel -- these changes are going on and rendering those tissues distinctly abnormal. And although these things begin to recede within a few weeks, it's a year or more before the last vestiges of healing are entirely quiescent (which, as I pointed out previously, is why an incision usually remains reddish for that long.) All this requires energy. That means the burning of extra calories; the body is at work inside. So yeah: it's normal to feel tired after surgery for several weeks.

There's no doubt some people recover more quickly than others. To figure out why is probably impossible: factors such as "attitude" (referred to in a recent post) are hard to quantify; and it could be that little things going on inside, such as subclinical (meaning not enough to be diagnosed) infection, or having more beat-up tissues requiring repair or resorption, could account for some differences. It may be splitting hairs, but I'd suggest there's a difference between "healing" and "recovery." Healing goes in in pretty much the same way for most people, absent adverse factors: at any given time from surgery, a biopsy of a wound (for example) would show the same changes in anyone. But some will be back at work or roller skating, and some won't. When people asked how long it'd take to be fully healed, I tended to take the question literally, and give them a mini-dose of the physiological spiel -- but briefly, since I knew it wasn't what they were really asking. Then we'd talk about recovery, and I'd tell them what to expect.

It's a small point. Strictly speaking, I reject the concept of a "quick healer." You can't speed the endogenous process. But there's no doubt some people make a more rapid recovery than others. To them I'd often say, "I wish I could figure out what you have and bottle it, and give it to some of my other patients."


[See, the dog is a Blue Heeler.]

Different Cloth

I've written about my stint as a surgical hospitalist. It so happens that I've been contacted about doing it again. Potential obstacles aside, I'm giving it serious consideration; I found it fun and satisfying. Other than the inability to establish in-depth relationships with my patients, it was -- free from much of the para-practice frustration -- surgery at its purest, in some ways at least.

The hospitalist concept is a window into the future, the perfect extrapolation from themes that are regularly discussed in the medblogosphere of late: the implications of the eighty-hour work week restrictions in training; the differing expectations and priorities -- and demands -- of the recently trained; what it says about the prospects for medicine in general, and the practice of surgery in particular. The person who called me was refreshingly candid.

My work in the last few years has been surgical assisting. The guys with whom I've been associated are both much younger men whom I'd (with concurrence of other partners) hired to join my clinic practice. After putting up with the rigors and frustrations and reimbursement cuts and ER calls for exceedingly fewer years than I (in the case of one, it was less than five), they bailed and opened an exclusively bariatric practice, which they run almost entirely in a non-hospital setting, free from the associated agonies and exempted from taking emergency calls from any but their own patients. And the young surgeon who called recently to inquire after my interest had given up his classical-style practice for that of a hospitalist, after completing the usual training plus a fellowship, and then less than four years in practice! In candor, he said, "Those of us coming out of training now are cut of a different cloth than your generation." So they are. And why shouldn't they be?

He joined my clinic a couple of years after I left, and was given an income guarantee, no matter how much production, higher than I'd made in any of my years, though I'd worked harder and harder and produced more and more in each of them. His call burden, while often busy during the nights he worked, occurred only once in seven or ten days. For most of my career, it was every three (when people were gone it was every two). Even with more money and less call, he found it not worth the struggle, the sacrifice of family, the placing of job far above anything else. After only a couple of weeks in his hospitalist job, he told me, "My young son said, 'Daddy, I like you better now.' That's when I knew I'd done the right thing." Who can argue?

In their graves, many of the old guard will turn over, prop on a gamy elbow, and say "Damn right I argue with that!" The current Bulletin of the American College of Surgeons has an article in which a surgeon (well, a former surgeon: she recently gave it up quite young to be a writer!) recalls how an old professor stood in the way of a fellow resident aiming to leave one evening. "Son," the old guy uttered most firmly, "Once you lay your hands on a patient, that patient is yours." That's how I was. Those days -- see it how you will -- are dead: most thoroughly, most Edselly, most sincerely dead. (Lest I be seen as hypocritical, since I gave it up too, let me point out that I hung in there for twenty-five years; I acknowledge that's less than many, but it's literally true that during the last many of my years I was doing at least twice as many operations as the national average, while earning at or below the average and seeing a thousand more patients per year than either of my partners. So, in my mind at least, I'm allowed my spouting.)

For physicians -- medical and surgical alike -- the hospitalist model is a clear WIN-WIN. For patients, it's more like win-win. The win-win for surgeons lies in the freedom from emergency cases and the ease of call whereby, presumably, one would only need to be available on the phone to one's own patients and could, if desired, let the hospitalists take care of middle-of-the-night need to hospitalize them. The ability to plans one's days and nights translates into a considerable lowering of stress. In the case of hospitalists, it means absolutely predictable work hours and the elimination of all calls when not at work. For patients, it's trickier. It's the future, though, without doubt.

First, let's clarify: if you have an elective (meaning non-emergency) operation, you'll see your surgeon in his/her office as usual, be operated by him/her, and he or she will care for you while you're hospitalized. The hospitalist is there for the person who shows up in a doc's office or the ER in need of urgent surgical care, or who is in the hospital under medical care and has need for surgical consult while there. Trading off for the fact that under those circumstances you likely wouldn't be able to see the surgeon who took out your gallbladder last year and whom you just love, is the fact that the surgical consult you get will be approximately immediate, and there'll be a surgeon in house every hour you're there. Not the same one, as it could change every twelve hours, but some one. For patients who present in emergency situations, that's worth something. Isn't it?

At the extremes of every bell-shaped curve there are outliers. I don't doubt there will always be surgeons and primary care docs willing to sacrifice their personal lives in the name of their practices. But the days of the iron men and women are over, and it's happened in the blink of an eye, in a quarter of a generation. I reject that it's because this is the first generation to value life outside of work, or that they're just selfish. The explanation, I think, lies in the changes that have gone before and around them. The profession is under stress in many areas. To maintain income -- at whatever level -- in the face of steadily decreasing reimbursement, docs must work ever harder. They're increasingly bogged down in paperwork and bureaucratic demands, many of which are predicated -- so it feels -- on the notion that a physician is an thoughtless, careless, and incompetent screwup. (Comments on some of my related posts would seem to confirm that apprehension.) Not a week goes by without a notice from the hospital, the insurers, the malpractice carriers announcing the latest requirements for form-filling, order-justification, chart-polishing. Why, the new generation is asking, knock yourself out in such an environment? "Calling" isn't a word you hear much any more. Other than calling for help.

I've said it before -- and I'll point out that it no longer affects me, as a provider at least, so the axe I'm grinding is not my own: the inevitable result of the trend to control healthcare costs only by cutting reimbursement, along with adding more and more onerous bureaucratic demands is to select for an entirely different sort of practitioner than we've had. People willing to work hard and to strive for excellence but who expect some sort of recognition of it will look elsewhere than in the field of medicine. Will look? Already are! And the ones that haven't heard, bolt like my compadres when they get the full taste of it.

Since it's less and less likely I'll have a surgeon like me if I need one (I don't live in Cleveland or South Africa), my plan is to remain healthy, and then drop dead.

The Mendacity of Dumb

[Weekend rant to follow: my thoughts on the Tuesday primaries. Misery multiplies.]

Well, for a while there I actually allowed myself to think there was a chance things could change. I guess I was the stupid one. All along I've acknowledged that I could be kidding myself; but it felt good, really good, if only for a minute. Like a gentle touch under cool sheets. Until someone busted in and turned on the lights.

Living in the pacific-most and northwest-most corner of the Pacific Northwest, where the air is liberal and the coffee frothy, some might excuse me for thinking the idea of issue-based politics could take hold. Hanging with people who, like me, are information junkies and politically obsessed, I could even be forgiven for concluding that people were ready to reject the oldest and most Rovian ways of winning elections. Overlooking for a moment the reality that we are a nation of people who can't identify whole continents on maps, who can't list the three branches of government, who can't name the first president, I actually let myself imagine civil discourse and energetic attention to the important issues of our time -- now, finally, when it matters most. What an imbecile I am. You'd think the last person I'd delude would be me. (Yeah, like that's never happened before...)

I guess you can't blame Hillary for doing whatever it takes. Her campaign was floundering, and salvation was hanging there like rotten fruit on the lowest branch. Stating the obvious, she told herself it has always worked and is still there for the taking -- one man's call for the contrary to the contrary. So, like any smart politician -- and if nothing else, she's surely that -- she reached into the toilet of time and threw handsfull. He's not a Muslim.... far as I know. The phone at three a.m. Stuff that, while clearly false and fear-based (in what way, exactly, has she been "tested" to handle that call?) appeals to those who need short answers to long questions. You win elections by assuming the worst of us, not the best.

Now she claims both she and McCain have "crossed the Commander-in-Chief threshold." How, exactly? In the single most important military decision ever made, they were both wrong. Sleeping in the White House (on the other side of the bed from "the phone") is no more qualification, ipso facto, than is bleeding in the Hanoi Hilton. In fact McCain, who says his experiences have taught him what war is, not only agreed to the disaster but didn't speak up when he was told by the Army Chief of Staff that far more troops would be needed. Not until it was well past too late. Saying you're qualified doesn't make it so. Showing judgment when the chips are down might. I can see no objective measure by which Senator Clinton has a claim on the mantle more than Senator Obama. There just isn't one. But there is a reason the Constitution makes the Commander-in-Chief a civilian: he or she is supposed to be able think independently and separately from the military mind. One did. Two didn't.

Oil prices have more than tripled since Bush took office. The dollar is at an all-time low, and falling. Deficits -- and foreign ownership thereof -- are rising unsustainably. Yet people are convinced the over-riding issue is what happens at three a.m. in some imaginary scenario. The real danger, the very possible destruction of our economy from within -- which not only has more capacity to damage us than any terrorist, but is already under way, not imaginary at all -- gets no mention. We are treated like idiots. And like idiots we respond.

Yes, after these years of despair at what the old politics hath wrought, it turns out it still works, and, no doubt, always will, until we're entirely past the tipping point. And by then, waking up won't matter. Bullshit carries the day. So why the hell not? Other than the fact, of course, that Hillary Clinton has poisoned the pool and then drowned in it any hope of changing the political climate (not to mention any chance of a Democrat in the White House). So, great. She can fight like a Republican. Whoop-de-fricking-do. See ya around, America, it was nice knowing you. Show yourself out, if you don't mind. I need to sit here for awhile.

Man and Machine

I don't keep up regularly with what's going on in my former clinic. Since just before I was leaving, they've been making the transition to fully electronic medical records. At the time, my experience with it was nothing but positive. It seems, however, that the process has come to a stage at which I'd have been driven crazy; were I still there but on the fence, it might have been the final straw.

I had lunch recently with some old friends; mainly nurses from our surgery center and a couple of nurse anesthetists, on the occasion of both of the latter recovering from recent surgery. Somehow my corner of the conversation came around to the software recently installed for inputing patient information, and the fact that it's not exactly user-friendly, especially for surgeons. A scenario was described that was like fingernails on a chalkboard.

The subject of electronic medical records has been frequently discussed in the medblogosphere; I think it's fair to say the majority opinion is that, from the point of view of doctors trying to record patient encounters, it sucks. And yet I've frequently commented that I generally thought the good far outweighed the bad. I may have spoken too soon, or, at least, based on a non-representative experience. In its first iteration, the institution of electronic medical records didn't change the way I did business. At that time, I was still able to dictate all my encounters and they were nearly immediately transcribed into the digital record. The only change was that I could get Xray images, consult notes, lab, instantly, from anywhere, without having to screw with finding the frequently-missing folders. But now, with the new format, as others have written, the doctors need to key information into a pretty rigid and unforgiving format, and it's gumming up the works. In terms of what's been described by other bloggers, that's old news. But it gets worse.

The program is so unwieldy, my anesthesia buddy told me, that it's slowing down the OR schedule. Surgeons need way more time to complete operative reports; the OR personnel wait in frustration until it gets done. Lateness, as I've written, burns a hole in my gut. But it gets worse still: because of the way the program is tied to current patient encounters, exacerbated by what sound like draconian penalties for lateness established by my former board (I was on it, once, and quit in frustration), it sounds as if that desirable human touch I was touting recently is getting squeezed into mechanized oblivion. The pressure to attend immediately to the record has gone amok.

In each exam room, I was told, there are now computer modules with sexy flat screens. Taking the history, docs cleave to the keyboard, asking questions while typing away, noses down. Some, I'd hope, might look up once in a while, but patients, they said, are complaining; and well they should. It sounds awful: impersonal, off-putting, humiliating, barrier-building. Some docs are refusing to do it this way, doing their typing back in their office after the visit. But doing so slows the schedule.

I remain convinced that the concept of electronic medical records is a good one: in any case, I'm certain the access issue is so important that there's no going back. Still, it seems there's a long way to go before finding a way to do it that enhances -- or at least doesn't detract from -- doctors' ability to use it efficiently. And willingly! Maybe voice-recognition technology will eventually advance to the point of being able instantly to digitize the sort of rapid-fire dictation that works so well when done immediately after the exam or operation. (I recall hearing old-days stories of surgeons at some big institution or another, dictating the op report from the prior operation to a stenographer while scrubbing for the next one!)

Every time I see my old cohorts I have a tinge -- a surge, really -- of regret that I burned out and bailed when I did. There's much I miss, and I think -- had there been a way to dial it back a bit -- I had more to offer. But on this occasion at least, I found myself thinking there's no way I'd have been happy with the current state of electronic affairs, and would likely either be screaming bloody murder, or producing another of my passive-aggresive (but brilliant) memos.

Revelatory

Comes word of a recent study of the placebo effect: you get what you pay for. In the recent Journal of the American Medical Association, it's reported that when people are given two placebo pills for pain, the more expensive one is the more effective. From a summary in the NY Times:

"The investigators had 82 men and women rate the pain caused by electric shocks applied to their wrist, before and after taking a pill. Half the participants had read that the pill, described as a newly approved prescription pain reliever, was regularly priced at $2.50 per dose. The other half read that it had been discounted to 10 cents. In fact, both were dummy pills. The pills had a strong placebo effect in both groups. But 85 percent of those using the expensive pills reported significant pain relief, compared with 61 percent on the cheaper pills. The investigators corrected for each person’s individual level of pain tolerance.

From another report on the study, on the WSJ Health Blog:

"The better showing by the more costly pill shows that “how you set up people’s expectation is crucial” to treatment effect, says Gregory Berns, a neuroscientist at Emory University School of Medicine. While he has no proof, Berns tells the Health Blog that he thinks pharmaceutical companies take such expectation into account when they set prices for their medicines."

When the issues are such things as pain or coping with chronic disease, expectation + therapy = outcome. And expectations are heavily weighted by various preconceptions. In the military I happily handed out a big honkin' green and octagonal pill for back pain. I'm sure it was no more effective than aspirin; but when people took a look at those things, they had to figure it was the real deal. It also helped, I think, that I wrote "NO REFILL!!" on the prescription and underlined it a couple of times. As interesting as it is, it's also a little sad to realize how easily manipulable our brains are. (Which, it must be said in these political times, applies way beyond the medical...)

Consciously or not, I think all physicians make use of these para-placebo effects -- maybe, in fact, we should do so more. After all, it's clearly what gives "alternative" and "complementary" mumbo their jumbo. Make a few bucks wherever you can find them. And if it improves response, better still.

Over The Top, Under The Skin

At once very cool, and heading for disaster, this invention impresses me in its brilliance, and scares me in its likely outcome if it gets into the marketplace.

And while we're on the subject, did you hear about the guy who got breast implants for the lady tattooed on his leg? Unsurprisingly, given the lack of sterile technique evident in the pictures, they ultimately became infected and were removed. In fact, the "final" picture looks a little infected already.

Given the size and nearness to the skin of the nerdgasmic and geektastic device referred to in the first paragraph, erosion and/or infection would seem very probable. On the other hand, you wouldn't have to hunt for a phone to dial 911.

Rings and Strings

When I was a med student on my first surgery rotation, I was taken with the coolness of how the surgeons tied all manner of baubles into the drawstrings of their scrub pants. Rings, watches, bracelets. It just screamed "I'm a surgeon, and you're not." So I did the same thing. And carried it on, halfway through my career. It's one of those things surgeons do, like carrying a stethoscope in their pocket rather than around the neck. Pockets populate scrubs like rabbit holes: for one thing, the outfits are generally reversible, with the same pocket pattern inside as outside; for another, many styles of shirts have not only the usual breast pockets, but at least a couple extras at the lower hemline. Storage? We got it everywhere. But you tie stuff into the drawstrings, because that's what you do. Maybe it's to draw attention to one's genitals: shiny things -- in our genes it is written to turn our eyes toward them.

In our fourth year of med school, one of my pals was on his obstetrics rotation. Called to the ER to evaluate a woman with some problem or other, he left her up in those medieval stirrups while waiting for the resident to come and check his findings. Restive and bored, standing there between the lady's knees with time (and lube?) on his hands, he chose that moment to put his ring and watch back on. As he distractedly began untying his drawstrings he happened to cross eyebeams with his patient, and noticed she was recoiling in dread as she witnessed a man apparently untying himself while well within her personal space. "Oh no, no, no," he said, "I'm sorry, it's not...I was just, y'know, putting on my... I'm not..." But there was no recovery.

Without any deep thought (not a huge priority, this), somewhere along the line, a few years ago, I stopped tying up my bling. It's such a cliche´really. Have all those pockets: why not use 'em. Which was fine until, in the wee hours of a long late night, with bleariness aforethought I tossed my scrub shirt -- wedding ring in the pocket -- into the laundry bin after surgery and staggered home. By the time I got there, realized it, and called the OR to request they "hold the bag," it had already been taken away by the housekeeping staff. Calls to every responsible place failed to stop the inevitable: it was never seen again, at least not by me. It wasn't particularly fancy, but I'd designed it and a matching one for my wife; had 'em made...

So I'm of two minds.

Pinning My Hopes...

[Here comes another weekend non-medical rant. This one is purely political.]

Might it really happen that Barack Obama wins the nomination and then loses the election for the lack of a lapel pin? Or a hand not over his heart? If the right wing bloggers and their oily machine (and even the "mainstream") have anything to say about it, he will. Throughout some parts of the political world, people are screaming about his pinless lapel. The horror!

Patriotism is no more about a lapel pin than love is about a charm bracelet. Or than support of our troops is about slapping a magnet on your car. In fact, when I think about the destruction to America's future and its ideals and laws that has been wreaked by the lapel-pin-wearing occupants of the West Wing of late, I'd propose the opposite relationship may well be true. There seems a smugness, a sense that as long as one wears the pin, any behavior is exempt from criticism: look at me, I'm a patriot. So sit the hell down and shut the hell up.

In choosing not to wear a lapel flag, I think Senator Obama is saying, "I'm not about short cuts and symbolism, which are so easy and so deceptive. I'm about saying what I mean and doing what I say, and letting that speak for me." Anyone can wear a pin and hope to hide behind it. Lapel pins are inexpensive, and not just in dollars. In the current climate, I find them a lot tainted and a little suspicious. And, mind you, I've gone to veterans' political rallies wearing my Purple Heart pin. Proudly.

Sometimes I've wished that he'd just poked one through that little hole and moved on. Why give the screamers a screed? But then I think how principled and brave it is to eschew a symbol that has been perverted and diluted and which, in its ubiquity among the slimiest of politicians, has become meaningless at best, and a perversion of patriotism at worst. Who'd want to accessorize like Tom Delay and Dick Cheney and Karl Rove? Or this guy. I think how utterly cynical, given the challenges that face the US, is the outrage of those who spread the smear, and how credulous in those who buy it. But on it rages. For a lot of voters -- maybe most -- it's easier to latch onto a spurious and simple-minded meme than to sink one's teeth into the meat of our problems. Rove knew that, and played it like a harp from hell.

What, in fact, is patriotism? Surely it's not as simple as what you wear. Is it love of country? I suppose it is; but what does that mean? What does it require, and how do you show it? Much as I admired JFK, when he said "Ask not what your country can do for you, ask what you can do for your country," I had questions. For whom is the government established, itself or us? Is it enough to work hard, follow the rules, educate yourself before you vote (and vote!), pay taxes, give to charities if you can afford it? Does the average person owe more? Obedience, acquiescence? Conversely, can you be considered a patriot if you render prisoners to other countries to be tortured? Is it patriotic to put the country trillions of dollars in debt and walk away, leaving it for others to fix? Wearing a lapel pin, it seems, absolves one of many sins. "Patriotism" has become just a concept with which to bludgeon one's rivals. Lightly it is that we use the word; empty it is of meaning. Like Yoda am I writing.

Barack Obama has been criticized for having too hopeful a vision of what's possible. But when he argues for a new kind of politics that brings people together over old divisions, when he says that the changes we need to restore viability require support from the bottom up (as opposed to the current top down, we're-in-charge-and-you're-not approach), it simply cannot be seen as the words of someone who doesn't love and want something good for his country, head in the clouds or not. Lapel pin or not.

To me, this is what's most attractive about Barack Obama: when he talks about "change" he's referring to exactly this kind of bullshit. He's asking (and, I'd aver, not just for his own sake) that people resoundingly reject politics that is all about fear and smear. The kind that, rather than discussing and trying to resolve the challenges we face, resorts to lies and innuendo to destroy a candidate. There is, I'd like to hope (and sometimes actually allow myself to believe-- oops, well, there it went again -- that was fast!) a huge portion of the country that's sick and tired of it. But the only (slim, very slim) chance that it could disappear is if the electorate stands up and demands it. By electing someone who specifically decries and overtly eschews it, and by unelecting those who don't. On both sides of the aisle. A pox on 'em all.

What if patriotism is redefined? What if we had a president who implored people to stay involved by letting their elected representatives know what they think, clearly and often? What if he said to the nation, "Now we need to address healthcare (or the deficit, or energy policy, or....) This is where I think we start, but we need legislators to come together. Whether you agree with my ideas or not, let your congressperson and senators know, demand they get to work. Email them; keep the pressure on them. They will respond to numbers, or risk losing their jobs." It's pretty simple, tapping out an email. But in that context, what could be more patriotic? What if people actually did it? Isn't that what Barack Obama is asking of us?

And as to the hand-over-heart thing: next time you're at a baseball game, look around during the Anthem. You'll see guys with hats on, beer in hand (bet they have "United We Stand" bumper stickers.) You'll also see people standing attentively, singing along with hats in hand and arms at their sides (that'd be me, doing the bass harmony). Bet those folks are all glad to be there and not in another country. Bet their devotion to country is a lot less than one running for President, risking it all.