Showing posts from 2009

A New Blog!!!

Well, I've done it. I've just created a new blog, which will become the place for my rants. Surgeonsblog, if it ever revives, will revert to what it once was -- a place for insights and information about surgery and surgeons. My new blog is where I'll froth and foam. It's called "Cutting Through The Crap." You can find it here . There (and on this post), readers can comment if they so choose. I hope people will find their way to the new place; and I hope there'll eventually be reasons to return here as well.

Public Option

I know a guy who was in a video...


In a comment on my previous post, a series of slides is recommended. I like the cartoon above even better. In simplicity there can be great truths.


Sooner or later, in any discussion of health care reform (to the extent that screaming and fear-mongering can be gotten past and actual thoughts exchanged), the issue of tort reform is raised. On that subject I'm of two or more minds. Neither a student of the various proposals nor particularly well-versed on the veracity of claims and counter claims about tortophobia adding to costs of medical care, I can only speak based on personal experience. Which is why I'm multi-minded. I've seen good and bad. I don't think I altered my practice style to avoid malpractice suits, but I can see why people would. The central issue is this: there's a difference between malpractice and adverse outcomes . Most certainly, the one leads to the other; but the other does not imply the one. Were that distinction properly made and encoded in the law, the rest of the issue would become moot. If malpractice suits were about bad care -- actual errors, poorly thought-out diagnoses or treatm

Grand Old Times

Nice Grand Rounds up over at the resurrected Dr Charles . His balloon is on the rise again, even as the hot air leaks soundlessly out of mine. Dr Charles has always been one of the most lyrical of medical bloggers, and it's nice that he's rediscovered his muse.


Uuggggghhhhh. Sorry. I feel dirty, I need a shower, I may have to kill myself. Where are the death panels when you need them? So Jon Stewart interviewed Betsy McCaughey last night, on The Daily Show . She's the one credited with raising alarms about the dastardly implications in the health care bill regarding end of life counseling. "Death panels," evidently, wasn't her exact term. "Disgusting," is what she said she wrote in the margins when reading it. There was a point to which she kept returning (in between quite amazing dramatic gestures to the audience -- the kind when a stand-up comedian goes, "Am I right? Am I right? Huh? Huh?"). Medicare reimbursement is increasingly tied to performance standards, and it's an issue about which I've written a bit , and which, in its execution, is potentially problematic for all doctors. Nevertheless, her interpretation regarding end of life counseling was utterly, idiotically, cosmically ass b


Among the many themes of dissent which have gained traction in the health care debate is the canard that we don't wont some government bureaucrat between us and our doctors . Funny thing about that: the only payer entity with which I never had a problem getting authorization for care was Medicare. Here's the sort betweenness I routinely encountered from private insurers: In the fine print of nearly every private plan are exclusions for "pre-existing conditions." Okay. You had breast cancer, now you can't get any insurance to cover issues related to it. Fair enough, right? Guy's gotta make a buck, right? I mean, it wasn't their fault you got it, right? But how about this: more than a couple of times I had patients with colon cancer who were denied coverage because of a previous history of.... hemorrhoids!! Yes. Hemorrhoids . Similarly, people who'd had, say, a rubber band placed for hemorrhoids -- a two minute, hundred buck outpatient procedure -- c

Death Panels

Surprise! It's a Republican idea . .

One Small Step

If anyone here reads Andrew Sullivan's blog, runs across this post , and finds anything familiar in the writing, there could be a reason... Anonymity doesn't do much for blog traffic, but any way to spread the word... The word, of course, is the extent to which health care reform is aimed at doing things that will be helpful. Even -- especially! -- for those very people who yell and weep and carry guns to meetings, spouting verbatim the insane ravings of Glenn Beck and Sarah Palin while having not the slightest idea what they're really talking about. "Keep government out of Medicare," they say. "Socialism." The "socialism" trope may be the most laughable (were it actually funny): all of the proposals on the table fall over themselves to maintain the death-grip insurance companies have on us. (Talk about "death panels!" What is it when insurers deny coverage?) None talks about nationalizing the health care delivery system. Not ev

Local News

Using local anesthesia, I always took care to do it gently, slowly, and thoroughly, and had reason to be proud of the results. Almost routinely, patients expressed their happiness and relief that the process was so... not unpleasant. I've written a bit about it before . So when I couldn't seem to make someone numb, it hurt. As it were. In addition to having a dissatisfied patient, it made me feel like a failure. It has always been my belief that there are some people who, for some unknown biological reason, process the drugs differently; that it's more than just a few 'fraidy cats or me having a bad day. Now, it seems, there's substantiation . It's those darn redheads. It never occurred to me to check. I wish I could play back the scenes in my head, in full color. Were the unhappy ones all rubro-capited? There's much I know now that I wish I'd known a few decades ago (and not all of it is surgery-related.) And there've been a few notable redheads

Advance Directive

On those few occasions when a patient had an advance directive, it was terrifically helpful. To me as their surgeon, to other caregivers, to the family, and, of course, to the patient. Which is why the outrage over a plan to assist people in making them (and cover the cost of counseling) is as cynical as it is ill-founded. Cynical, because people are turning it into "they're coming to kill grandma." Unfounded, because it actually puts people in control , not caregivers or government. My parents serve as two examples. Like most people (or so I assume), my dad had always said he'd never want to be kept alive by machines, and had a directive that put it in writing. Yet when he entered the hospital for what turned out to be the final time, after months of physical decline that had made his life only about the rudiments of existence, when the chips were down he opted for the ventilator. Which is an important point: nothing in his directive prevented him from changing hi

Scam Alert

For months I've been getting spam comments linking to a website called "Findrxonline." I finally took the time to look at it, and find that it requires a monthly subscription which supposedly pays them to find you low-price meds from other websites. As if you couldn't do it yourself. What a joke. I assume none of my readers is so dumb as to fall for it, but I thought I'd mention it anyway. An outfit that thinks leaving spam on blogs is a good business plan is surely one to avoid. There was another, recently, that responded to my complaint by apologizing. This one not only doesn't do that, but at least one of its email addresses bounces back. Sigh. For all the beauty of the internet, there must be, it seems, a little ugly too.


I simply don't get it. Quite aside from the fact that the plan to disrupt health-care town-meetings is overtly to stifle honest debate on a very difficult subject, and despite the fact that there isn't even a bill yet (only a House version and several Senate versions that need reconciling), and even imagining that the anger is real and not ginned up by the distortions and outright lies of the right wing media or fomented by interest groups with a long history of ripping off the health care system for legal profit -- not to mention being fined one point seven billion dollars for fraud -- overlooking all of that: what the hell are these people so mad about? As far as I can tell, the proposals out there -- the ones that are actually in writing as opposed to the absolutely insane claims of the Rush O'Beckly axis of a$$holery -- are fairly weak-kneed attempts at maintaining the status of most of the quo. Are people really that upset about a bill which aims to prevent their



Think Slow

Not too long after setting up shop in this town, I shared a tough case with one of my favorite intensivists. (By way of diversion, I'll add there were only two of them at the time, and they were both my favorites. Practical and canny, surgical-patient-wise, they were a pleasure to work with. Over the years we developed great mutual respect and affection; to the extent that caring for critically ill and deeply challenging patients can be fun, it was. It's unique to private practice, I think, that such relationships can be so positive and mutually supportive and satisfying. I know I have said that in the academic centers, there's too much turf war and defensiveness. Was, back in the day, anyway. The discovery of such collegiality was one of the pleasures of my entry into private practice.) To make a long and dimming story short and bright, the patient was an older woman, admitted in extremis to the intensive care unit. Dying, evidently, of infection of indeterminat

Kung Fu Surgeon

Somewhere in my home is a letter I received from a Shaolin priest, one of five (so I was told) grand masters of the martial art of kung fu on the planet. The letter is embossed with the gold seal of the temple of which he was the head honcho. With its beautiful calligraphy and that timeless seal, I've thought of having it framed. The temple is in another country. The master came to me, that I -- and only I -- might operate upon him. (To put it a little more dramatically than circumstances might warrant.) According to the man who sent him, he taught only a select few, and demonstrated his skills only in private. The referring person, who had been a student of kung fu (but not of the master), described to me the man's ability to toss a group of attackers like fish , and other unearthly wonders. The priest was in his seventies. I'm not sure what I expected. An aura? Rays of light? Surely, were I to give satisfactory care, I'd be granted some sort of special status, m

Rationing. There. I Said It.

Thirty percent of Medicare money, it's said, is spent in the last month (or is it six months?) of recipients' life. It shouldn't be surprising: people who die are generally sick. Sick people -- especially ones that die -- require more care than healthy people, or people who survive an illness. But it gets to the most thorny of issues when tackling health care costs. And it's a perfect example of why real reform is next to impossible: our politicians are too venal and stupid, special interests are too powerful, media are too superficial, the issue it too freighted with grayness, and the public is too easily distracted for there to be a meaningful discussion. Notwithstanding the truths just enunciated, I have a few things to say. A proposal, too. Absent having all the money in the world to spend on health care, I think it's fair to say that everyone is in favor of rationing. If all we had was a million bucks, would anyone choose to spend it on ten demented ninety

Campfire Blues

As I once understood it, it's the pampiniform plexus , the veins around the testis, the prolonged congestion of which during unrequited (as it were) sexual stimulation, that is responsible for an unpleasant pain syndrome particularly prominent in adolescent males. This is a medical blog. Blogs are, by definition, personal. So, here's a post about something vaguely medical, and highly personal. Suffering from topic deficit, I've sunk to this. But it's a good story. In short, I may be the only person known to have passed out from a case of, well, you know... It was at summer camp, a co-ed religious camp, which makes it even better. A high school freshman, by any standards, even in those innocent times, I was inexperienced. And there was a girl, a California girl , wiser than me by light years. One cool night found us together, in the woods, for quite a while. I will say no more; but you can easily infer how it didn't end. Despite being what might be called

Note To "Andrew"

You, sir, are the scummiest of the scum that is blog spammers I've ever seen. You discredit yourself and the "business" you "represent." Meanwhile, to anyone who might be thinking of satellite TV: I'd strongly advise against an outfit that calls itself "directstarTV." If its advertising methods mean anything, it's a total scam. [ Update, 7/22 : I emailed the business, and today I received a reply which included the following: Thank you for informing us of this issue. We’d like to offer our apologies for these incessant and unnecessary blog posts you received from a former affiliate of our company. Please know that DirectStarTV does not support such marketing tactics. As of July 22, 2009, this affiliate has been terminated and ordered to cease and desist immediately. So I feel a little better about them.]


If I can't write, there's no reason not to post things that write themselves. The interviewee is Wendell Potter, former head of corporate communication for CIGNA, one of the largest health insurers. He left after twenty years, in order to work for health care reform.

False Start

I've tried, but I don't seem to have it. Much as I'd like to return to the sort of writing I was doing earlier in Surgeonsblog , it's not happening. It's as if I'm in a darkened house with many rooms, but all the doors are locked. In a deja vu sort of way, I know there is stuff behind the doors, but it's inaccessible. Familiar, yet out of reach. Re-reading old posts, I feel envious of the person who was able to write them, and of the good I feel it did, not to mention the wider world it created for me. But now I'm an interloper in my own life. It feels unnatural. Or, at least, unavailable. So we'll see. I'm rummaging around in my brain, but so far it's like showing up for an Easter Egg Hunt . A day late . To anyone who may have wandered here for the first time, I invite you to check out the " Sampler " post, for a sense of direction. Meanwhile, I'll keep trying. .

Oldies But Goodies

An article in today's NY Times got me reminiscing about operating on old folks. While it's true there is inherently increased surgical risk in their care, my list of favorite patients is heavily populated with the elderly. Like the ninety-six year old who lived with a very cumbersome hernia because he'd been told repairing it would be too risky. He had some friends over for a truss -burning party after I fixed it under local anesthesia. Or the WWII vet, rejected by other surgeons for his age and (only slightly) less than perfect heart, who told me I'd replaced Douglas MacArthur as his hero after I cured his debilitating reflux esophagitis. The many many older women who took their breast cancer in stride; the sturdy lady who fought tooth and nail, literally walked out on me, when I first told her she needed a colostomy but who finally acceded and insisted on seeing me bi-annually forever afterwards, bringing treats from her garden every time. The oldest I ever ope

Not Guilty

I haven't heard directly from Blogger yet, but I note the red-flag warning is removed from my dashboard . Guess the human reviewer was convinced this isn't a spam blog . Ironically, I've just deleted a spam comment from the previous post: it's one I get sort of frequently which links to an online drug seller . Annoying. I've contacted them and they deny doing it . Now they don't return my emails. Excessive links, indeed!


This morning in my email was the following message: Hello, Your blog at: has been identified as a potential spam blog. To correct this, please request a review by filling out the form at [link deleted by me.] Your blog will be deleted in 20 days if it isn't reviewed, and your readers will see a warning page during this time. After we receive your request, we'll review your blog and unlock it within two business days. Once we have reviewed and determined your blog is not spam, the blog will be unlocked and the message in your Blogger dashboard will no longer be displayed. If this blog doesn't belong to you, you don't have to do anything, and any other blogs you may have won't be affected. We find spam by using an automated classifier. Automatic spam detection is inherently fuzzy, and occasionally a blog like yours is flagged incorrectly. We sincerely apologize for this error. By using this kind of system, however, we can dedica

Trauma Call

In response to a call for ideas, Mike asked about trauma. Specifically, he mentioned hearing that the most common cause of death in motor vehicle accidents (MVA) is injury to (and, presumably, exsanguination from) the femoral artery . He didn't hear it from me. (In fact, he admitted he heard it on an episode of "ER." That surprises me a little, because that show -- despite a completely inauthentic and distorted portrayal of emergency care -- didn't often give out-and-out false medical information. Or maybe they did. I stopped watching a few years ago.) I'll admit I didn't look it up. But I can say that in several years working at one of the busiest trauma hospitals in the US, during training, and having cared for many MVA victims including fatalities then, and subsequently in my private practice, I don't recall seeing a femoral artery injury resulting from a car crash; certainly not a fatal one. By far the greatest number of deaths were from head and/o

Gotcha. Not.

From a commenter: I think as long as Obama admits that he wouldn't subject his own family to the limitations he proposes for everyone else, his plan will fail. Regards, A Better Angel I assume he/she refers to comments by Obama during the recent ABC News "town hall" held at the White House, in which there was this exchange, edited selectively in many "news" sites: "Q: If your wife or your daughter became seriously ill, and things were not going well, and the plan physicians told you they were doing everything that could be done, and you sought out opinions from some medical leaders in major centers and they said there's another option you should pursue, but it was not covered in the plan, would you potentially sacrifice the health of your family for the greater good of insuring millions or would you do everything you possibly could as a father and husband to get the best health care and outcome for your family? OBAMA: [....] I think families all a

Why It Won't Happen

An eye-opening (for those with closed eyes) interview with a former executive in the health insurance industry. As long as there is an enormous industry whose aim it is to make money from insurance premiums, and as long as that industry is able to influence politicians and credulous reporters, and as long as that industry remains between money spent and money received to deliver health care, we'll always have care that is too expensive and which fails to serve those who need it most. Simple as that.


Kodak announces it will stop making Kodachrome, and I don't care. I'm down with digital. I mention this so as not to sound like a Luddite in the following paragraphs. I don't know if we'll get health care reform or not; nor, if we do, whether it'll be in any way significant. Unlikely. Meanwhile, there are examples in surgery which illuminate one aspect of the problem of skyrocketing costs. Technology, in a word. Technology as selling point; technology as sexy; technology for its own sake. Unlike my digital camera, medical technology includes much about which it can be asked: "Huh?" Previously I've expressed an opinion on "NOTES" surgery. More recently, I opined about robotics . I've also described the way I did gallbladder surgery through a single small incision, as an outpatient, with recovery times the same as laparoscopy, at significantly less cost. The latest hotness is single incision laparoscopy . The linked article describes

The Nubbin

 One need think about the implications of this video only for a moment to understand the essential issue: a system that depends on private insurance is potentially no system at all. That insurers routinely deny coverage for any number of reasons means that, in addition to the forty-seven million who have no insurance, there are potentially millions more who only think they do, despite paying premiums. Insurance companies do not provide medical care. They collect money, invest it, dole it out when they have no way not to. Even for the so-called "non-profits," it's a money-making business, the basis of which is taking money intended for health care, keeping as much of it as possible for as long as possible, returning to the system as little as possible. If it can also be said of physicians and hospitals that they profit from the ill health of others, at least those entities are providing actual care. If we're serious about real health care reform (and it's evi

Fee For Service

Not too many years ago, as the many-layered onion that is physiciandom brought tears more and more constantly to my eyes, I said, "What the hell, I give up. If this is all just a way to break us down and put us on salary, bring it on. Just tell me how much I'll get, and I'll decide if I want to keep doing it." Paperwork propagating like potatoes; rules compounding themselves like viruses; payments receding like ice-caps. There's no doubt it affected my enjoyment of my work, steadily plunging the pleasure, the honor, the gift, and the psychic rewards of being a surgeon deeper into the bulb of the allium , harder to find without crying. And yet such thoughts find little if any resonance with the public. Fee for service, it's said, is the root of the economic evils of our health care system. I don't entirely disagree: what we have now is the worst of all possibilities. There are many ways in which health care doesn't follow other capitalistic models. A

Reform School

What if every American of a certain age knew they had medical coverage; what if all they had to do was register? What if, in this program, they could choose their doctors, who would be privately or self-employed, not government workers? What if the hospitals they went to were the very ones they go to now? What might you call such a program? Medicare . And what if this coverage were extended to all Americans? What might you call that? Single-payer . For those who have insurance, the only thing different would be the paperwork: it would become far less, or cease to exist. Neither the care nor the people and places providing it would change. From the point of view of the consumer, I simply see no advantage to having multitudes of companies standing between them and care, sucking money out of the system which goes into the pockets of executives, investors, and into the paychecks of tens of thousands of workers filling out forms at both ends of the transactions. No one -- NO ONE -- is