Wednesday, April 30, 2008


Since I was a tyke too tiny to say her name, Mildred was "Moomump" to me, and the appellation stuck for the whole family thenceforward. At every stage in my life, she was the perfect aunt. When my age was in single digits, I could cajole her into giving me the presents my parents refused. I called her a few times at that age when I felt picked on by my parents, and she'd come over, subtly mending fences. In my teen years, it was Moomump who first let me drive; in her big Chrysler 300 we'd blast our way to the Oregon coast, me a fourteen-year-old, being prodded to get it over eighty. "Don't drive like an old lady," she'd say, offering me a cigarette. In my young adulthood and later, I realized how brilliant she was, and what a great source of good advice and amazing stories. Of her famous friends: artists and actors and musicians and politicians.

She and my dad -- he the older by a couple of years -- grew up at the poor end of lower middle class. During the depression, their father, so they told me, would hide in the closet when the doorbell rang, lest it was a bill collector. One of them would answer and say they were alone. But they were both superior students and musicians; her piano gifts were greater than my dad's on the violin. As a young woman she was offered an opportunity to study in New York under one of the great pianists of the time, but turned it down for the need to care for her diabetic mother. (Until I looked him up just now, I thought the potential mentor was Emil Gilels, but clearly it couldn't have been. Rather, I think it was he that she considered the best ever; someone else must have offered the position.)

Unable to afford it, neither she nor my dad went to college. Both eventually enrolled in a night law school; she was one of Oregon's first female attorneys, and also went to a business school. (My dad ended up on the Oregon Supreme Court and was Chief Judge of the Court of Appeals. So they did okay, legally speaking, thin resum├ęs notwithstanding.)

I'm not sure of the order of events, and there's no one left to tell me. There was her law practice, and there was her time working for Ariel Rubstein, a concert pianist and impresario, who brought classical musicians to Portland. Which one led to which, I can't say; but at some point Moomump did legal work for Arthur Rubinstein, having been told by him how he -- along with many other musicians -- was being screwed by RCA, the only record label that handled such classicists. Sketchy are the details, but sales numbers as related to royalties were tightly held by RCA. Never enough, they claimed, to pay their artists very much. When the phone rang from some girl lawyer in Portland Oregon (chain smoking made her voice anything but girlish), the bigwigs in NYC telephonically patted her on the head and told her to buzz off.

When they got a pre-arranged call within minutes, from the largest accounting firm in the country announcing intention to audit the books per fine print in the contract, it wasn't long before they relented, leading to recompense for Rubinstein. And, not long after, for many other artists who heard about Moomump and came to her. My brother the attorney says the contracts she forged remain templates for artist/recording agreements today. RCA, presumably to get her off their backs, offered her a job in their New York legal office, but she demurred.

Moomump and Arthur Rubinstein became friends. She was dining at his home one night when he announced, at around age sixty, that he was to be a father again. "When," she asked, surprised. "Nine months from tonight," he smiled. (Genius musicians don't leer, I assume.) And nine months later, she got a telegram (I've seen it) saying only, "And his name is John." There were friendships with other great pianists, too. In one of my favorite pictures of her (which I can't seem to find at the moment), she is arm in arm with the sweet Vladimir Horowitz. Nor did her acquaintances end with musicians. Paul Newman, Michael Jordan, Hal Holbrook, Robert Joffrey, Yul Brynner. She knew them more than in passing, and had stories. But her friendship with Van Cliburn surpassed them all.

They were polarities: he, much younger, slender and upright, proper and handsome; she, stocky, untidy, and rough. She was quick with a bawdy laugh, he with a gentle smile. Sometimes when he performed on the West Coast, he'd send a plane for her, and she'd fly down, to San Diego or wherever. For his mother's ninetieth birthday, he brought her to his Fort Worth home for a two or three day party. On one occasion, when Van was playing in Portland, I -- a high-schooler -- picked him up at his hotel, stuffed my pockets, at his request, with oranges from his room, and drove him to the concert hall where I unloaded the produce and him.

Leaving an impression that lasts, strong, to this day, Moomump arranged for Van and his mother to have dinner at my in-laws' home in Bellingham, Washington one evening, just them, where he dutifully listened to their pen-youngest play the piano, and rummaged some more food in their pantry after they'd already fed him a couple of steaks.

This unlikely pair talked frequently on the phone; he wanted her critique of every new album, every concert she attended. And she knew her music. When a little girl, she once told me, she'd lie in bed reading piano concerto sheet music before she went to sleep, and could play it fully, from memory, when she awoke. I heard her play only a couple of times -- she hardly ever did, except for herself, when I knew her. (She put on a concert or two, for charity, in her political life, but I wasn't around to hear them.)

Artists, dancers, actors, when they came to Portland, often partied (and sometimes performed spontaneously) at Moomump's house. I was there for some. As full as her social life was, she never married nor, as far as I knew, had any sort of romantic attachments. But was she known and loved! From her position on the Planning Commission, she was appointed by the Mayor of Portland to fill a vacancy on the City Council, to which she was re-elected by huge margins, three times. Both Police and Fire Commissioner, she was adored by those people in blue, and they campaigned hard for her. She'd show up at one fire station or another, usually at dinner time, encourage the captain to volunteer to walk her dog, and talk to the troops about what was going on. My four-year-old son and I partook with her of such an occasion, after which we went along on a fire-boat run on the Willamette River, the kid holding onto the water cannons as they sprayed. If the timing was right, Moomump would show up at fire scenes, having hitched a ride on an engine.

When the Portland Trailblazers played the Chicago Bulls in the NBA finals, we two were there, too, in her season seats -- she'd found another for herself; at half time, people came out of the stands to talk to Moomump as she walked at the edge of the court, her public ignoring Magic Johnson and other stellars who were broadcasting nearby. She introduced me, that time, to Michael Jordan's dad. Hardly an athlete, she loved sports, went to the Blazer games, and to the Timbers' soccer games, sometimes kicking out the ceremonial first ball. Maurice Lucas was a good friend; Clyde the Glide an acquaintance plus.

But it was of her time on the City Council, running a financially tight ship, that she was most proud. That, and her dogs. In her forties, or maybe fifties, she decided for the first time ever that she wanted a dog. There followed in succession several German Shepherds, first Hildy, then Ranger, then Blitz. She doted on them, had an oil painting made of Hildy, the best of them all. Often they came to work with her, sleeping under her desk unless someone came in and got a little heated; at which point it was nose to nose, two paws on the desk, with a clear inference to be drawn that more respectful dialog would be prudent. Among her most-told stories, punctuated as usual with her gleeful cackle, was when Blitz walked down the hall and shat upon the mayor's carpet. (A subsequent mayor, with whom her relationship was a bit prickly.)

No matter how many opponents, she won her elections with seventy or eighty percent of the vote. College kids, downtown business people, liberals and conservatives, all loved her, for her intelligence and straight talk (when the term actually meant "straight talk"), for her lack of artifice, her clunky clothes (she hated gussying up, as in that picture with Van) and her dogs. You showed up at a council meeting hypo-facted at your peril. Shoot off your mouth without engaging your head, she'd help you out on a limb and saw you off, whoever you were. And tell me about it later, ending the story with a sawing motion of her arm, and with that "heh-heh-heh-heh-heh-heh," staccato, like a tommy-gun, and just as lethal. Fiscally conservative, socially left of center, she answered only to herself when it came to staking a position.

When my wife, Judy, ran for our local school board, Moomump gave her plenty of advice, and pulled no punches when criticizing her first drafts of campaign literature. And as she had me, she loved our son. Every time I called her, or visited, she asked about him; would have given him anything he wanted if she could.

Toward the end of her life, she suffered congestive heart failure (ah! it IS a medical post!!) and sank, frustrated, into herself. Her home was dark when we visited, oppressively smoke-stenched. The parties that had filled the place with sound and color were nowhere to be sensed, the room downstairs where they'd been held now fungoid and cluttered. To the end, she smoked, driving her amazingly devoted cardiologist crazy (I met him when he drove her to Seattle, shortly before she died, to attend a Cliburn concert, at the intermission of which we went backstage -- she barely made it down the hall -- and talked with Van, whose assistant took a picture of Moomump, Van, Judy, and me, and promised to send a copy. Never did.)

We went there more frequently as she became more homebound. Closed-down concentric as her world had become, she filled back up when we were there. On the rare occasions she'd agree to go out, people still came up to her, anywhere. And, sitting on her sagging sofa, she still rolled out the stories, with relish. Backstage at the Joffrey Ballet, schmoozing with Kitty Carlisle, at the racetrack with Paul Newman. And Van: always a story, with love, about Van. A little dirt on a politician or two, commentary on family (her appearing at family gatherings, no matter the import, was a rarity. She didn't much like the dynamics, but loved visits on her terms; which included, thankfully, me and my chunk of the family.)

They found her sitting at her kitchen table, ashtray filled with stubbed Tareyton 100s, a couple of days before we'd planned another of our regular trips down there to see her. Van Cliburn sent an armload of red roses; a mayor and a governor attended her memorial, and cops and firefighters, in their dress uniforms; engines with ladders raised were parked, sparkling in the sun, outside the temple. She'd have loved that above all, even if the venue might not have been to her liking. The picture (my favorite by far!) at the top of this post was on the front page of The Oregonian when she died. A nice article from another paper is here, in case you think I might have exaggerated anything. My brother and sister and I spoke at the ceremony, and my dad. Good stories by the former gov'. In my part, I revealed her name to those that never knew it. Moomump.

[Added nine years later: here's that cute pic of Moomump and Vladimir Horowitz.]

Sunday, April 27, 2008

SurgeXperiences, Learingly

So here it is, the TWENTIETH issue of SurgeXperiences. That this carnival of all things surgical has made it to this milestony moment is testimony to the perseverance of Jeffrey Loew, who birthed it quite alone and without benefit of breathing techniques. If this is how he addresses all his goals, he's sure to become the surgeon to which he aspires. It seems a significant passage. I'm honored (so I've convinced myself) that he chose (forced, cajoled, tricked, shamed) me to mark the occasion. So...

There follow the entries received,
In rhymes I have lately conceived.
I offer to you
The best I could do.
It's over, so I am relieved...


In general I'd say I'm inclinedta
Avoid making holes in vaginas.
The trend, though, is clear.
You can read of it here.
To explain, Rico's taken the timeta.


That's not the first time it's been said.
It's possible you may have read
When Buckeye spoke out.
And I've had a shout.
Some surgeons have holes in their head.


A surgeon must do what is right.
But there is some trouble in sight.
The first thing to go
As plastic guys know
Is beauty, when money is tight.


This frightening tale is from Bongi
Who tells us he's doctored a zombie.
I believe every word
'Cause I've never heard
A suggestion that he's ever wrongi.


I'm not sure I know what I thought
When I read what technology wrought.
It might just be true
That no one will rue
The day when I'm dumped for a bot.


Before Annie started her journey
Of sharing her words with attorneys,
She was a young nurse
Who avoided a hearse
In an OR once used by McBurney.


Bob Bernstein has something to share,
Although the hirsute may not care.
He'd just like to reachya
About alopecia,
And move around some of your hair.


We learn quite a lot from a guy
Who lets a doc laser his eye.
He gives us the facts;
If you're worried, relax:
He thinks you should give it a try.


From David who writes on an isle,
A lesson in what sort of style
A doctor will need
If he's to succeed:
You listen and try not to smile.

Another from Dave is right on.
He's singing my favorite song:
For deep in its heart
Our work is an art.
Ignore that and you will go wrong.


When tripping down memory lane,
Rob Oliver hopes to explain
What was going on when
He was two years and ten
In the field in which he's now playin'.


From the Philippines comes a post too serious to rhyme: as in boardrooms, jury rooms, employee and teachers' lounges, in the operating room there are sometimes words spoken and behavior manifested best left out of the public realm. But this clearly went way too far.


Dave Gorski calls surgeons to task.
Before jumping in you should ask
If the new ways are best
Or might still need a test
Before you slip into your mask.


This article sends out the love
To surgeons who don double gloves.
It's not that it's dumb
But my hands feel numb;
I say "no" 'less there's cameras above.

Ramona is one of a kind.
If ever you're caught in a bind,
The shirt off her back
You never would lack.
She'd give it and not even mind.

(The preceding has nothing to do with her post; it just happens to be true. In her essay she eyes, in fascinating detail, a little-discussed syndrome. )


Since the days of our heroes of old
Surgeons have thought themselves bold.
But sometimes it's best
If we give it a rest
And helpfully do what we're told.

(Especially if it helps prevent sterility in cancer patients.)


In thinking of losing her bits
She's come to the end of her wits.
Less parts in the nether?
She does wonder whether.
At least her new blog will get hits.

(Originally, the last line was "Of course she will still have her... sense of humor." But I decided against it.) And part two of her post is here.


Another post from bongi. The subject seems unsuited to lighthearted verse. We make difficult decisions every day; the hardest are often when it's time to do nothing more.


A dentist requests that I act
On this informational tract.
It's less like a post
Than many or most,
But there's data for you to extract.


Readers might say it's uncool
To hype oneself, but there's no rule
Preventing me from
Referring to some
Faves from my memory pool.


Now Bongi once more raised his hand
From his home in a far away land.
Midst branches of nerves
I guess he deserves
To brag how he handled a gland.


Our carnival ends on this note:
I thank you for all that you wrote.
Were I more a poet
I'd happily show it.
On the other hand, it's admittedly a questionable way to showcase your work, forcing, as I did, a thumbnail into an unyielding format; and if anyone feels their essay got short shrift, I'm sorry.
And I hope that you know it.

The next issue of SurgeXperiences will be hosted at The Sterile Eye and will appear on May 11. I assume there'll be word of it at that site; and if past is prologue, posts ought to be submittable here.

Saturday, April 26, 2008

There's No Hope. Seriously. None.

[Yeah, it's another weekend rant. Don't know why I bother anymore.]

Maybe it's just me. Maybe things aren't as bad as I think they are. Perhaps a nine-trillion dollar debt isn't a threat to our country; maybe the rising cost and self-limited supply of oil doesn't bode ill. It could be that environmental degradation and global warming are just a bunch of hype; and, I suppose, our country is not facing the possibility of governmental gridlock and economic meltdown. Nor, it could be, is the war in Iraq leading us to self-destruction. I hope so. Because from where I sit, it's now or never.

I really thought people would get it. To me, it seemed tautological: eighty-plus percent of the people think the US is on the wrong track. Therefore, whatever direction they think it ought to take, the one thing everyone might agree on is that the politics of the last several decades isn't working. QED. If there's one kind of change behind which everyone could get, it's the way we elect people. Attack. Destroy. Make shit up. Focus on irrelevancies; distract from the important issues. Fear the impossible, ignore the actual. But no, it's clear I was wrong. Whomever we elect as our next president -- and likely the same is true for most of our congressional folk -- the decision will not turn on energy policy, the war, the unsustainability of our deficit spending. It will be about convincing the electorate (easily, it turns out) that one candidate is a closet terrorist; and/or that realigning our military priorities will amount to "waving the white flag" to al Queda, that someone wants to raise taxes (as opposed to what? Moneh from heaven?)

Barack Obama began his campaign by saying, among other important things, that he'd tell people what they need to hear, not what they want to hear. And, to a certain extent at least, he did. For a while. But he's finding out, big time, that that's not a winning strategy. People want to hear what they believe. Which, of course, fits perfectly with the fact that more than any other developed country, we are a nation of believers.

In comments on my rantings, people tell me to cool it. Why, they ask, do I get so upset about religion? Well, it seems pretty clear: the instinct for religious belief has slopped over into politics to the extent that it's made it impossible for us to face facts without magical thinking. Honestly, if people could keep their religious beliefs and their attendant make-believe separate from their ability to confront earthly truths, I'd have no problem with it. But to me, it's of a piece: magical thinking in the face of overwhelmingly difficult problems is the easy way out. It's the equivalent of the brain going into "tilt" mode. Fear of death, meaning of life? Sure. Do what it takes. Energy policy, economics, Iraq? Sorry. We need to look at them clear-eyed. If the magnitude of these problems isn't enough for people to stand up to the muck-meisters and say, NO, not now, not ever again, then it's over. Really. It's over. It's become apparent that the only way people might wise up and say it's time to elect people willing actually to confront problems is when those problems are so unignorable there's no longer any hope of fixing them.

The reason I've been so enamored of Barack Obama is that he seemed to be getting people to understand: what needs changing is not any particular policy (although they all need changing). What needs changing is the way we do politics. Young and old, left and right, people of all colors: if they could agree on anything, they ought to agree on that. Solutions, he seemed to be saying, will come from a gathering together of people of good intent from all points of view. The answers that we find will not be the verbatim policies of any candidate; those will only be a starting point, a set of priorities. It matters less what a candidate outlines in policy papers, than it does how he or she proposes to get there. But after the last few primaries, it's clear that voters haven't bought it. It's too complicated an idea; it doesn't fit on a bumper sticker. Even when the problems are so scary, old politics still works. The middle majority of voters really don't want to hear reality. They want politicians who give permission to look away. Scare and distract. Bait and switch. And if there's one thing we know about successful politicians -- McCain, Clinton, Gingrich, and their enablers, Limbaugh, O'Reilly, et al -- they're master baiters.

I'm convinced it ain't gonna happen. For this election, and so many more that it'll become impossible to reverse course, enough people will be influenced by the usual crap that they'll take us all down with them. Of that, I'm now sure. You see it in the polls, in what people say is important, the filthy ads and the reaction to them. The only thing I can't figure out is this: those purveyors of political porn; do they believe the shit they say and do, or are they the ultimate cynics? Tell people what they want to hear, because it still works. Take what they can get; rake it in while the getting's good; protect the status quo to make their pile and screw 'em all. And if that's who they are, could it be because they're convinced they'll still get raptured up, or is their religiosity just another gimmick, too: the megachurch of manipulation.

Friday, April 25, 2008


It'd be darn hard -- probably impossible -- for a one-handed person to be a surgeon. Virtually all technique we use is predicated on the use of two hands: traction, and counter-traction. Hold the scissors with one hand, use forceps in the other. (Or fingers. I love the way the fingers of my left hand seem to know exactly how to noodle the tissues around as I'm scissoring or otherwise instrumenting with my right.) It's nice to be able to switch hands, and I'd say most surgeons do, myself included. But I admit it: I'm better with my right than my left when it comes to the finer stuff.

There's nothing I do with my right hand in surgery that I haven't done with my left: place a stitch, cut, grab; and, of course, we all throw knots happily with either paw. Still, if I really want to be precise, where there's no wiggle room, I use my right hand. A completely ambidextrous surgeon, though not likely to rise above the pack on that alone, has an advantage; at least in terms of annoyances.

The reason I bring it up is that in response to a comment on a recent post, I mentioned the idea of centers of excellence, and a skeptical post I'd written on the subject. In my comment I suggested the time might come when you take your breast to Omaha and your gallbladder to Newark. It could even happen, I said, that you'd take your left breast to Omaha, and your right one to Cleveland. There's the tiniest kernel of truth. Very, very, very tiny, but enough to have produced this here post. As a right-handed person, it's actually a little bit easier to do a right mastectomy than a left.

It's an uncommon situation in which one holds dissecting scissors, which are curved at the tip, in such a way that the curve does not follow the natural arc of one's hand and fingers. (See how awkward it looks?) Without trying to describe the whole operative technique, suffice it to say that the classic approach to mastectomy is the removal of the breast and the lymph nodes under the arm en bloc, meaning in one continuous section. From the "axillary tail" (the upper outer portion) of the breast the dissection is carried into the axilla (underarm) along the axillary vein. With the patient lying on her (sometimes his) back, arm extended, the surgeon is standing to her right. The sweep of the dissection is very natural, holding scissors as they were meant to be held, moving forward in the natural direction for such things. On the left side, there's that awkwardness (even holding the scissors properly); the flow of the operation is against form, like water running uphill.

It's not a big deal, of course. We learn what we need to learn. There's no compromise in quality, no threat to doing the operation properly. It's just that it feels a little better, the one over the other. As a lover of the motion of surgery, the beauty that it can encompass, I simply take note of such things. And move on.

Thursday, April 24, 2008

Last Call

I'll be wrapping up my presentation of SurgeXperiences soon. It'll appear this Sunday. I'll take submissions till midnite Friday, Vulcan Standard Time. Removing one expectation unit (referring to hosting, not the quality of the essays) per hour from now until then ought to end up about right.

Tuesday, April 22, 2008

Sinking Fast

An article in today's paper incites a post, where none had been forthcoming. It's not news, really, in the sense that it's been well-known to many: us general surgeons are a dying breed. But it threatens to become very serious. There are many reasons, the mentioning of some of which could cause ire. The usual: doctors complaining about money and work. Sex, too.

It was just before I started training that California adopted a system for comparing one operation to another, payment-wise. Called the California Relative Value System (CRVS), and used or copied nationally, it purported to consider degree of difficulty, post-operative care, and, as I recall, a few other factors, in order to compare, say, a colon resection to a hernia repair; and, more interestingly, to a prostatectomy or hip replacement. Rumor had it that the general surgeon on the panel that came up with the scale was so busy he missed a lot of meetings. As a consequence, general surgery got screwed. The work of a colon resection was very unfavorably compared to that prostatectomy and pretty much everything else. The CRVS assigned "units:" if a hernia got, say, 11 units, (making that up; I don't recall the specifics and don't feel like looking it up), a colon resection got, say, 24. It was up to insurers, and medicaid, and medicare to assign dollars to units. Depending on who was paying, a unit might differ from institution to institution by many dollars; but the relative values were the same. The lowness (which translates to lowliness) of general surgical operations always annoyed me. The systems are different now, but the comparison remains: there are some quick outpatient eye operations, for example, that pay more than a Whipple procedure, which takes several hours, a boatload more skill, and requires many days of inpatient, and weeks of outpatient, care. Alas, poor me.

Add to the above the fact that emergency call for general surgeons can actually involve emergencies. This is, of course, true for other surgical specialties -- particularly orthopedics -- but in most communities there are fewer general surgeons than orthopods, so the frequency of call is greater. And the orthopedist fixes the bone and bolts (as it were); the general surgeon is left holding the bags. It's disruptive, it's hard, it's onerous. So it's not surprising that surgeons looking ahead, while looking back at the debt that trails them out of training, see options that are more remunerative and less demanding, and find the choice pretty clear. General surgery has its special attractions. No other field is as broad and deep. The variety of what we do is both rewarding and challenging; and the opportunity to have on-going relations with patients and families -- to be their "family surgeon" -- is something I cherished in my own practice. But there are limits... So, as we see in the initially-referenced article, the relative and actual numbers of general surgeons is heading down, dramatically. And there's another factor, not mentioned in the paper: girls.

I wrote recently about a trip I took back to UCSF, my training grounds, for a dinner honoring an old prof. Among the speakers was the chairperson of the surgery department, a very impressive and very talented woman. (Also, it was clear, a hell-raiser, in the best sense of the term.) With pride, she mentioned that for the first time the entire incoming group of surgery interns was female. The guest of honor, Senator Feinstein, seemed pleased. "Uh oh," was what I thought.

It's reality: women doctors are more likely to shorten careers for raising a family; or to seek opportunities for job-sharing; or to choose specialties which allow more flexibilty. One of my partners was a woman, and she quit entirely, and young, to be with her kids. The one hired after I left took several lengthy times off for maternity excursions. It's not that I object. I don't see any qualitative differences between boy surgeons and girl surgeons. It's just that it represents another -- and not-much-talked-about -- hole in the sinking ship of surgery. It will add to the shortage. Is all I'm saying.

You can't force people to become general surgeons (oh, I suppose you can, but I doubt it'd work out.) Solutions, if there are any, will be multi-faceted. Reimbursement inequities will need addressing. So will work hours. As I've said recently, the trend toward hospitalists might be a major boon; in fact, I don't see a solution that doesn't involve it. Meanwhile, look both ways when crossing the street, eat plenty of fiber, exercise, and don't swallow cherry pits.

Sunday, April 20, 2008

Hell No!!

[The recently usual warning: there follows a weekend rant, non-medical, and, in this case, against some manifestations of religion. Coming upon the included literary quote is what re-occasioned the thought.]

Among the things that most disturb me about the way some Christians view their god is the concept of eternal punishment. That a "just" (or any other adjectival attribute considered worship-worthy) god would consign, for all of forever, some people (his creations!) to such a fate is bad enough. That it could be for as meager a failing as rejecting him as one's savior despite living an otherwise exemplary life, is even worse. But worst of all is the absolute delight with which some people of that flavor of faith (including the ungrammatical zealot who made the above "artwork") contemplate the levying of their god's retribution on all those with whom they disagree. Sticking someone in the celestial slammer for an eon or two isn't enough for these lovers of their neighbors. It's forever, for infinity, for more time than anyone can possibly imagine. This, from a loving god, the arbiter of morality, the one single guide to right and wrong, without whom -- say the fantastically faithful -- non-believers surely wallow in an amoral morass.

So, to give the slightest inkling of what this really means; to provide a tiny basis on which to judge this judging god and those who judge him favorably; to give some context to the magnitude of the monstrosity in which these people love to believe, I present (soon, I promise) the words of James Joyce, in "A Portrait of the Artist as a Young Man," describing eternity. When reading it, consider whether eternal punishment, with no second chance, meted after but the briefest of sojourns on this planet (far less, in cosmic time, than the single vibration of an electron), no matter the grievance, bespeaks a just god (forget "loving!"); think about whether believing in this outcome makes one a party to malignancy. And my point, if it needs to be stated, is NOT that you better watch out and fall in line with God; it's that THIS view of god is one of someone whose justice is so horrible that the very acceptance of it makes one unworthy, whether the concept be true or not. Such punishment demands outrage from all thinking people. Silence is immorality. Think about it!

To me, this doctrine of eternal punishment is the worst kind of biblical literalism; even worse than the pensive pretzelling required to claim the earth is six thousand years old. To believe in it and not to call god out on it, not to march into the streets and shout on every corner at the injustice, is to be complicit in egregious behavior. Neither to reject the teaching nor to speak against it is far worse than keeping silent about Abu Ghraib, or slavery, or child abuse, or genocide. What does it say about those who accept it; or worse, who actually savor contemplating it? More tellingly: how, if it were actually true, could any decent person justify lounging around heaven knowing what was going on down below? In what kind of monster could the conscience lie at peace, or consider itself deserving the favor of such inequity, such iniquity? The smugness, the self-regard, the complicity seems so, oh I don't know, unChristian. Put down your damn harp, circulate petititons!

So here's Mr. Joyce, on how long is eternity in hell:

"For ever! For all eternity! Not for a year or for an age but for ever. Try to imagine the awful meaning of this. You have often seen the sand on the seashore. How fine are its tiny grains! And how many of those tiny little grains go to make up the small handful which a child grasps in its play. Now imagine a mountain of that sand, a million miles high, reaching from the earth to the farthest heavens, and a million miles broad, extending to remotest space, and a million miles in thickness; and imagine such an enormous mass of countless particles of sand multiplied as often as there are leaves in the forest, drops of water in the mighty ocean, feathers on birds, scales on fish, hairs on animals, atoms in the vast expanse of the air: and imagine that at the end of every million years a little bird came to that mountain and carried away in its beak a tiny grain of that sand. How many millions upon millions of centuries would pass before that bird had carried away even a square foot of that mountain, how many eons upon eons of ages before it had carried away all? Yet at the end of that immense stretch of time not even one instant of eternity could be said to have ended. At the end of all those billions and trillions of years eternity would have scarcely begun. And if that mountain rose again after it had been all carried away, and if the bird came again and carried it all away again grain by grain, and if it so rose and sank as many times as there are stars in the sky, atoms in the air, drops of water in the sea, leaves on the trees, feathers upon birds, scales upon fish, hairs upon animals, at the end of all those innumerable risings and sinkings of that immeasurably vast mountain not one single instant of eternity could be said to have ended; even then, at the end of such a period, after that eon of time the mere thought of which makes our very brain reel dizzily, eternity would scarcely have begun." [Wow! Whole comprehensible sentences in a row!! By James fricking Joyce!!!]

That's how long the Dalai Lama and Mahatma Gandhi (and maybe, for her doubts, Mother Teresa) will be in hell, according to the self-righteous. And only half as long as I will, despite having paid all my taxes and made rounds three or four times a day and having lain awake at night worrying about my patients, taking a shower and brushing my teeth when I got up. Flossing. And, lately, feeding a stray cat. To anyone who believes that's justice and who delights in it: you should be ashamed of yourself. And so should God.

This might be my last post for a while (other than the promised issue of SurgeXperiences), and although I'd hate to end on a rant, I figured I should let you know where I might be... eventually.

Thursday, April 17, 2008

Yugoslavs, Urine, and Me

As the summer of my second year in med school approached, an announcement was posted (on a bulletin board I had previously made infamous, but that's another story) advertising need for a student who spoke Serbo-Croatian, to spend a summer in Yugoslavia helping on a research project. Since it was a requirement of graduation that we engage in some form of research, and since my fluency (at the time) in Russian was as close as they could come, I got the job, and off to Yugoslavia I went.

There's a mysterious illness over there. In very specific spots in several Balkan countries are pockets of a devastating kidney disease, known as the Balkan Nephropathy, or the Balkan Endemic Nephropathy, BEN. In many villages lots of people have died of it, young. Because of his expertise in streptococcal kidney disease, a professor at my med school had been asked to look into that possibility, and although he'd long since disproved any connection with strep, a lab remained in a small Bosnian town and a couple of our docs continued the school's involvement. So there I was.

Bijelina (pronounced "bYELL eenuh") is in the northeastern corner of Bosnia, near the junction of the Sava and Drina rivers. Of very mixed ethnicity, with churches and mosques cohabiting the place in peace (years later the city was "ethically cleansed," a scene of many crimes during the implosion of the country), in the late sixties Bijelina seemed to have a foot in each century. Horses and carts outnumbered cars, the central park was full of people at night, with smells of grilled meats and sounds of bands mixing magically in the muggy night air. The park was very near the little hospital in which I lived in a tiny room near the lab. Every night I walked the park, eating raznjici (razNEEchee, with a trill of the "r") and cevapcici (chuhVAHPcheechee) and drinking rich strawberry or cherry juices, or chewy dark beer, talking to folks in my mixture of Russian and local phrases. Dobr dahn. Lahku noch. Preeyatnuh. In the morning I'd go to the lab where a pretty young tech made Turkish coffee thick as paste, sweet, and strong enough to grate away any remnant of sleep.

With a Yugoslav medical student, I drove an old Land Rover every day to a tiny farm village, Velina Selo, where many people had contracted the disease. There, all the farming was done by horse-drawn wooden plow; the homes were huts of sun-dried mud bricks, most with a well, one or two with a single light-bulb, all with a grape-arbor for shade and a fence keeping the chickens in. And, always, a barrel of fermenting plums, for making the ubiquitous and painfully raw slivovic. In the village was a beautiful brass still, on a wooden cart, pulled from home to home by an elderly man who, in return for a piece of the action, distilled the festering and fly-fed mash into the brandy. I had more than one round, still warm, fresh from the still, aged in the time it took to bend my elbow. And no, it doesn't cause the disease. Not that one, anyway.

Our job was to gather information from each villager: where they farmed, from what source did they get their water. What did they eat in the fields, how often did they get food or water from outside the village. Other questions I don't remember. While my fellow student asked the questions in Serbo-Croatian, I wrote down the answers -- I could understand enough to do so without the need for translation. Then we collected urine samples from everyone, later to be analyzed for protein content and distribution of albumin and globulins: electrophorectic patterns had been correlated to early signs of the disease. And we made maps of drinking water as related to protein patterns.

I had an additional project. Because it had been noted that many children in the endemic areas had an unusual pattern of albumin in their urine, the question had been raised whether this was just a form of exercise proteinuria (heavy exertion is known to cause spillage of albumin into urine) or whether it was a marker for this (or some other) disease. So I put together a bicycle race. Gathering urine samples before and after the event, I organized a couple dozen young kids to race a few kilometers on their bikes, with the winner to get a few dinars (a hundred, I think. Or was it a thousand?), with everyone else to get some, too. Exercise, it turns out, produces the same pattern in them as it does in you and me, which answered -- to my satisfaction, anyway -- the question. (A paper was published that included my results, but not my name. PW Hall, whose name is included, was my supervisor, back in the USA most of the time.) Forty years later, the meaning, the cause, the solution remain elusive (although there's recent suggestion of connection with a chemical from local vegetation.)

The villagers were extremely grateful that we were there trying to help. They vied with each other for the privilege of feeding us. Every noon we'd find ourselves sitting under another arbor while chickens pecked our shoelaces, kids came from the fields bearing fresh vegetables and watermelons, and the mom produced an invariably amazing meal from within her meager home. Spicy chicken, stews, bread from heaven, salads, and pastries that belied their simple source. It was embarrassing, really, the effort that was made to please us. I doubt it was every-day fare we were being offered.

Each day we visited several homes, covering the entire village over the summer. Knowing our expected schedule for the next day, farmers would interrupt their work to be there. They were particularly excited that I was an American. Sleeves were pulled back, tattoos from the German prisoner-of-war camps were shown to me, with the words, quietly, looking into my eyes, many times, "It was Americans soldiers who freed me."

Tuesday, April 15, 2008

Fading Memories

As Alzheimer's disease relentlessly robs my mother of her memories, and me of her, I think of opportunity lost. Youth, rightfully, is centered on itself. It's a rare young person (and I wasn't one of them) who recognizes the wellspring of history and of connection that resides in the minds of one's elders; by the time we do, it's often too late. I wasn't entirely tardy with my parents; I pried some stories loose before they were gone forever. But about my grandparents I have many questions, and, now, no way to find the answers. It's hard to flesh out the details in family lore. But there are some good stories.

I only knew one grandfather beyond my childhood. Born in Russia around 1890, he went to Moscow as a teenager, where he got some sort of degree from an agricultural school (he kept it, must have brought it on the boat, and I saw it once.) While there, so the story goes, he caught wind of the revolutionary whispers and brought them back to his village. Down with the tyranny of the Tsars! Fortunately for him, his father -- the village Rabbi -- was friends with the chief of police who came to him one evening saying he had orders to arrest my grandfather the next day. Get him out of town tonight. So -- and this is the part I'd love to know more about, including the truth of it -- he up and left, in haste, around sixteen years old, somehow finding his way to a port. Somewhere. With money from whom? Getting a ticket how? Still in his teens, he shipped to America (in steerage? In a cabin?), checking in through Ellis Island, spending a while (how long? In what sort of place? A tenement? With whom?) in New York City. He made a friend (Polish? Jewish? Met how?) and (somehow) the two of them got a job on a farm in Pennsylvania, owned by former US Senator Flynn.

After a period of time, he and his friend, the westering spirit filling them, saw an ad in a newspaper for help wanted on a ranch in California, and hopped a train (hoboes? Scraped together the money? Confirmed the job before they left?) to Valley of the Moon. The ad was placed by, and Grandpa was hired on by, none other than Jack London.

Some stories I recall hearing from Grandpa himself: he became a trusted hand -- livestock foreman -- of Jack London, and rode the range with him, chasing and shooting coyotes. Many times he showed me the pistol given him by Mr. London: a five-shooter Smith and Wesson (or was it a Colt?), kept in a leather box and clean, oiled, beautiful. He'd let me break it open, an umbrella-like contraption lifting up from the center of the cylinder to pop out the spent shells (never saw any bullets.) The gun has disappeared, as have letters to Grandpa from Jack London when in Alaska.

The story goes that while away, London entrusted Grandpa with looking after his wife, a young beauty, his former secretary, named Charmain (after whom he named his yacht, on which my grandfather sailed a few times.) Staying as he did in the bunkhouse, he got a call one night from the main house, from Charmain, asking Grandpa to come there. The knocked-on the door was answered by the lady, fully unclothed. I believed Grandpa (because he was an impeccably honorable man) when he said (or was the story told to me by my mom?) that he repaired immediately back to the bunkhouse and never mentioned it to Jack.

After Jack London's premature death, my grandfather made his way to Portland, Oregon, where he got a job (how, exactly?) with Metropolitan Life. Trustworthy from the first knowing, he became a successful salesman, eventually ending up manager of the office there, after having been sent first to Montana, and then San Francisco. He met my grandmother in Portland, where she'd been born; that's a whole other story, with many gaps. She, among other things, was (so it's said) the first president of the Oregon League of Women Voters, and somewhere there's a picture of her with FDR.

Impeccable he was, and immaculate. I never saw him in an unpressed shirt, almost never absent a necktie. Rarely without a hat. Even after his first stroke, he walked perfectly erect. My mother says he could sit a penny on a saddle and ride at full gallop, returning with the coin still in place. He lived a few blocks from us and when he came to visit, he'd first head to our garage, where he'd oil the doors on my dad's car and attend to my brother's and my bikes, with one of those old-fashion oil cans. Thumbing the bottom, clickaglug, clickaglug.

Grandpa remembered very little Russian, but sang Russian folk songs with relish, boomingly. The love of hearing them is what led me to study Russian in high school and college. There was almost no phrase you could utter that wouldn't spring him into song; he had one for every occasion, mostly in English.

His English was perfect, florid, and just enough accented to be mysterious and charming. When I was about ten, I think, he had me memorize something that I'm quite sure he wrote himself (I've searched and have found it nowhere else.) There was some sort of reward involved: a dollar? I did as ordered, and still remember it. Overwrought, too wordy, but a connection to him that remains. It's how he talked, because he loved his adopted language. And here it is:

"Whatever we dwell upon most, mentally, we bring ourselves in closest contact with. That is why it so often occurs that we get most of what we most dislike, because our aversions and fears occupy so large a part of our secret meditations, even when we keep them out of our general conversation. 

Concentration on that which we most desire is the surest way to bring it to us; but there must be no excitement or agitation in connection with our anticipation."

The power of positive (and calm) thinking, is what it is. He seems to have lived it.

Monday, April 14, 2008

Still Trying, Rantwise

For anyone interested in taking the time, here's a lengthy post by a person actually present when Obama spoke his scurrilous San Francisan words. In context, as I said in my rant, they are the thoughtful words of a person interested in the big picture, and uninterested in politics as usual. But given the effort (and willingness) required to see it (William "the war will be easy" Kristol concludes he's a Marxist), no minds are likely to be changed. Can't hurt to try.


By appealing to my baser instincts, namely susceptibility to flattery, Jeffrey Leow has cajoled or tricked me into agreeing to host the next SurgeXperiences. So consider this a call for submissions (in the other sense, as opposed to how I submitted to Jeffrey's third or fourth entreaty.) Here is an official announcement (ripped off and slightly modified from Suture for a Living):

"SurgeXperiences is a blog carnival about surgically-related blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit. The next edition will be on April 27th. The deadline for submissions will be April 25th. Please submit your posts here."

Having complained previously about themed blog carnivals (while acknowledging that people have a perfect right to do it however they choose), I'm making no suggestions other than getting your entries in on time. Unless an unprecedented deluge leads to more than I can handle, I plan to link 'em all up. So feel free, and freed. And please: lower your expectations.

Saturday, April 12, 2008

The Truth Will Set Us... Upon Ourselves

[Another weekend political rant. Stay away. It's all downhill from here.]

How many people would agree that the Republicans have been brilliant at getting the average person to vote against his or her own interests? (Hint: I would.) Knowing that their actual agenda of giveaways to the wealthy wouldn't fly on its own, they've managed to get people to think that this country will live or die over gay marriage and gun laws. So along comes a politician who points this out, and it becomes 24-hour news, drowning out the fact that the president admits, finally, that he authorized torture; wiping off the public consciousness the deficits, the war, the health care problems. Barack Obama said something that takes more than two seconds to explain, and the media and his opposing politicians go crazy.

I'm not sure about John McCain, but I do think Hillary Clinton is smart enough to understand what he said. The talking heads on radio and TV? Part stupidity and part cynicism. But Hillary knows, and plows ahead anyway. And what was it that Senator Obama actually said?

Government has failed to deliver to the average person, he said. It makes people frustrated and angry. By exploiting those feelings, politicians manage to get people to look away from their leaders' failings or their plutocratic agenda and to vote for them anyway, by sleight of hand. When people feel bad about their situation, they tend to look for issues to make them feel better. Immigrations, guns, gays. Is this untrue?

Okay, I admit he said it awkwardly. He's admitted it, too. But his words were "elitist" or "out of touch" only to those who willfully or stupidly misconstrued them. In the case of Hillary and her supporters, it's willful. Nor did he make stuff up out of whole cloth, like, say, bullets in Bosnia. He made a sophisticated point about how people think and how the political system exploits it. If anything shows how much change is needed, it's his words and the bullshit-filled reactions to them.

The spectacle of CNN and its ilk making 24 hour shrieking punditry out if it, finding it more important than all the problems facing us, is dispiriting beyond my ability to tell it. Between the cynicism of our politicians and the mendacity of our media, the American political system has become incapable of self-correction. We have, ultimately, no one to blame but ourselves. We elect the idiots, we watch the networks. Comes a person who actually thinks it's possible to change how we do our national business, and he's set upon by those for whom the status quo is their life-blood, while the people who have most to gain or lose are too complacent, or too burnt out, or too disappointed to make the effort to push back. They buy the crap because they've stopped believing there's anything else. More's the pity. The audacity of hope meets the beat-down of burnout.

Tuesday, April 08, 2008

Numbers Game

In the military they graded you on everything, and you graded those of rank below yours. Drafted out of training at the end of my internship, before flying off to Vietnam I headed to San Antonio to learn what makes a Flight Surgeon (after a brief stop in Bellingham Washington to get married; the timing, one could argue, was poor, if optimistic, but it seems to have worked out.) During the sojourn at Brooks AFB, in addition to sinus blocks, decompression chambers, water-survival, altitude sickness, G-suits, and the self-injection of antidotes to toxic gas, we were taught the way the evaluation game was played. Specifically, we were instructed what not to do.

Careers can be unmade by those forms. Listing all manner of attributes, to be rated in numbers running from 'one' (for performance worse than would be done by a cold corpse) to 'ten' (ostensibly for attributes seen only in the divinely touched, but in practice doled out like drinks at the Officers' Club), the forms needed filling annually. For officers, there were OERs, for "Officer Efficiency Report (or was it "Rating?")" For enlisted personnel, it was A-something-something, for Airman something something. As draftee docs, none planning on a military career, we were made to understand it was not our place to screw up anyone's future; most especially that of a lifer. The default grade, in other words, was 10. Or, in extreme circumstances, 9.

I had no problem with it. In fact, I had more difficulty with the idea that I was about to be someone's boss. (In reality, of course, I wasn't. Anyone who's been in the military knows a good NCO runs the show in any given shop. I found mine, and hung on for dear life.) The ultimate example of the "shit runs downhill" phenomenon, internship hardly qualifies as ego-supportive. I'd never been in the position of judging anyone in any impactful way (plenty of experience in being judged), and I had no desire to start at that lowly point in my career. Tens it was. On the other hand, I got a nine once, and the hospital commander was concerned enough to call me in to tell me about it.

With a look of fatherly disappointment on his face, the Colonel told me that on my OER (this was while still in Vietnam) I'd gotten -- having otherwise run the table with tens -- a nine in the matter of "military deportment." Which translates into saluting a little less crisply than the manual describes, and maybe having a little more hair touching my ears than specified. No matter that by all measures medical I was in the perfect category, and no matter that a nine was, theoretically, equivalent to walking on water but maybe getting your ankles a little wet. Damn near perfect, so you'd think. But the concern was that, were I to choose a career in military medicine, such a blight could besmirch it, and I should deign to develop my demeanor, amplify my attitude. Shine my jungle combat boots, presumably. Kiss me some colonel ass; administer a high colonelic.

Other than the telling of an amusing story, my point here is that measurement of performance is difficult and distorted; perverse, even. This, it turns out, applies not only to those charged with protecting the life of our nation, but to those protecting the lives of patients. In the military we had hospital inspections regularly, by several inspectors general from several command levels. Every month or so, it seemed, there were people wandering around the facility with clipboards. Our preparation? Buffing the books, polishing the paperwork. It's not that much different in civilian medical life. What's looked at, because it's easiest, are protocols and procedures, bound in binders. Are the boxes checked: at what time was the antibiotic noted as given in relation to the surgical incision? What forms were filled before the patient went to sleep?

I think there's not the same pressure in civilian life, as there was in the military, to bend toward favorable reviews. The opposite, in fact, is becoming the way: guilt is presumed over innocence; punishment preferred over finding and correcting the process that led to an error. Accreditators want to see a few scalps hanging on a few hooks.

Near the end of my military service, having been sent to Vietnam after being told I'd not be; having found, at first, that I wasn't needed when I got there (not for a while, anyway); having endured the broken promise of first choice assignment on returning home, and having witnessed the randomness with which doctors were matched to their skills, I got a call from a high-ranking officer who tried to convince me to stay in. "Yer thuh kahnda ofzer whur lookn fer, See-id." Really? With a nine on my record? But I wonder: given the difference between their kind of evaluation and the ones crawling up our legs in the civilian world: might I have ended up happier had I stayed?

Monday, April 07, 2008

The Death of Health Care

In today's New York Times there's an article that addresses something I've argued for a long time: the way to control costs of health care is to look at how and why costs and practices differ, and to adopt the best practices.

Now this article in particular is about the costs of end-of-life care, which is tricky. Even better, though, as a point of discussion, because it's been shown that a huge amount of the health care dollar is spent in the last months of life. Were this area looked at -- really looked at -- we'd have a paradigm in which to figure out what we really want from our health care money. About 30% of Medicare money is spent in the last year of life. Of that, 40% is spent in the last month. It's not surprising, of course: you tend to be sick before you die. So one would hope. Still, it would seem that in the variations described in the NYT article, there's much to be learned. Is it the same care being delivered more efficiently? Is it philosophical?

I don't know the answer, and I've already posted once today, so I'll wax waningly. I'm just saying that it's about time to turn our attention to where the real money is and have a little candid politicking. Candidates propose ways to fund insurance. Scheduled to go into effect this year and next are major cuts in physician payments by Medicare. Politically popular. Easy. And looking exactly 180 degrees away from the heart of the matter.

The Truth; Students, Be Warned


Moving this post to the head of the list, I present a recently expanded sampling of what this blog has been about. Occasional rant aside, i...