Surgeonsblog

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

[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 thin

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 cal

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 lik

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

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

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 di

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

[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

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

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-refere

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 w

[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 g

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 ma

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

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.

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 m

[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