Quick Healer

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

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

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

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


[See, the dog is a Blue Heeler.]

Different Cloth

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

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

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

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

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

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

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

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

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

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

The Mendacity of Dumb

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

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

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

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

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

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

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

Man and Machine

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

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

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

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

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

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

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

Revelatory

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

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

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

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

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

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

Over The Top, Under The Skin

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

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

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

Rings and Strings

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

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

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

So I'm of two minds.

Pinning My Hopes...

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

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

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

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

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

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

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

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

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

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

Don't Worry, Heal Happy

On a pass through Kevin MD's website a while ago, I saw a reference to an article which reported a study on anger and healing. The report, at BBC online, said, in part:

"The Brain Behavior and Immunity study indicates stress has a major impact on the body's ability to repair itself. Nearly 100 participants were asked to rate how well they could control their temper, and the speed at which they recovered from a blister was monitored. Hotheads were more than four times likely to take more than four days to heal than mild-mannered counterparts.... The team at Ohio State University gave participants blisters on one of their arms and then monitored how the wound healed over the course of eight days. They were asked to fill in a questionnaire which looked at how anger was expressed - whether externally, by shouting at others, for instance, or internally, when one rages insides but keeps a cool exterior."

At the end of the article, there was this:

"Steve Bloom, professor of metabolic medicine at Imperial College, London, said stress was now increasingly recognized as a factor in recovery rates. "Your body prioritises and sorts one thing out at a time, so if you are stressed - angry in this case - your body works through that before it gets on with the process of healing. We've yet to see a study that categorically proves having an attentive, calming presence by your bedside actually speeds up your recovery, but the evidence is certainly pointing that way." (My emphasis.)"

Studies like these (judging emotion) are a little squishy, and one might well challenge the methodology, not to mention that "prioritises" deduction. But it sorta kinda rings true, off the top of my head. Naturally, I extrapolated. I think there's an important message; or at least there might be.

I often heard from nurses on the surgical floor that my patients were calm and positive when they arrived, and that they seemed to do better than those of other surgeons. (No, I can't say it wasn't just a way to ingratiate -- for all I know, they said it to every surgeon.) Of course, I loved hearing it; it went to a very specific aim and belief of mine. If their assessment was true -- and this is me saying it was -- it validates an overt effort on my part to achieve a sense of comfort and confidence, a positive attitude toward recovery. I've always thought it makes a difference. (I recognize the article in question doesn't draw an outright conclusion. "Pointing that way," is what it says.) (Nor, let it be said, am I talking about "cure." Just recovery from surgery.)

The antithesis is the doctor -- any type, really, but in this context a surgeon -- who makes hospital rounds, perfunctorily pokes and prods and leaves with little or no meaningful communication, ignoring obvious concerns. Having watched such behavior while visiting hospitalized friends and relatives, I can say it leaves the patient and family angry and frustrated, which, this info would suggest, is actually medically counterproductive. Doctors can't, of course, remain a "calming presence by the bedside" for more than a very few minutes at a time; but we can listen, explain, even sit down and look the patient in the eye. Not only is it the human and natural way to behave, if it produces the opposite of anger, it looks like it might actually be medicinal! Even grumpy docs give antibiotics when needed. In the same spirit, maybe they'll work to provide a decent dose of needed nice.

Res Ipsa Loquitur

Having nothing but time on his hands like any law student, esteemed reader Patrick sent me a link to a pdf containing the arbitration brief of a recent and widely publicized case. Far be it from me to beat a dead horse, but it seems a tidy argument for finding a way to provide health care without the need for dozens and scores of insurance companies. (And as an aside, a look at why, to some degree anyway, I've always been sort-of attracted to law as a profession: the orderliness, the linearity, the need for factual and logical thinking. Sometimes.)

The case is that of a woman who, despite having perfectly good health insurance, was approached by a (predatory?) guy wanting to sell her a less-expensive policy. Forms were filled out. She evidently thought it was going to be some sort of automatic transfer, rather than an application. At some point, the number for her weight had been changed on the form; the change was initialed by the agent, not by the woman. The form went forward, the insurance company reviewers noted the change but did not raise questions at the time, at least not to the woman. The old insurance dropped, the new policy established. Then she got breast cancer. Ostensibly because of the weight-change shenanigans, the insurance was canceled. Claims and counter-claims were made, and the case went to arbitration by a retired judge. (My dad was a judge, and when he retired, he was a much sought-after arbitrator.) (There's no real point to that interjection other than the fact that I always enjoyed hearing him discuss the process and the issues.) The result was a decision in favor of the woman, to the tune of several million dollars.

One might see the case as less about bad old insurers than about fine points of insurance law. In the brief, there was much about "due consideration" and "good faith" and various quite particular minutiae, from which one might or might not generalize. But one fact struck me as very important beyond the case at hand: employees of the insurer are paid, in part, based on how many claims they DENY; how much money they save for the company. They get bonuses for that. (Outrage mine.)

Just good business, some would say; and at some level they'd have a point. But that's exactly the problem. Having insurers sitting between providers and patients, taking money from both -- inserting the business of business and creating a whole profit-making/money-sucking ("non-profit" or not) enterprise that has nothing to do with providing actual care -- seems an obvious and unnecessary waste of health care dollars. Particularly when the business thus inserted clearly -- because its business is business, not healthcare -- has the aim of authorizing the least amount of care that is possible.

Most doctors hate the idea of a single-payer health care system, and for many good reasons, most of which have to do with concerns about loss of control. Of care decisions, of pay. I share them. But there can be no doubt that the system as now constructed in the US diverts huge amounts of dollars to companies that have nothing to do with actual care, and even -- as we see here -- to funding their efforts not to pay for it; and the amount is way more than would occur with a single payer and a single set of rules, aimed at paying for care rather than trying not to.

I've made it clear how disastrous I think is the trend, especially in Medicare and Medicaid, to pay providers less and less; how it will lead to huge access problems and changes in the sort of people who choose to become doctors. About that I have no illusions. But I don't think "single payer" and "cutting pay" and "onerous rules" need to be synonymous. For one, there'd be more money to work with. And it simply can't be totally impossible to find an operating model that would include providers in a meaningful way to set up and govern the execution. Improbable, maybe, but not impossible; unless politics as usual remains politics as usual.

You Are So Beautiful

Do you have any idea how beautiful you are? Well, okay; maybe for some it's were. Before you got a little thick in the middle, smoked, or even just breathed city air for enough years, or drank a little, or did a few drugs, there was a time -- and maybe it's still true -- when you were knock-down, take-your-breath-away gorgeous. Many times while operating inside a belly I've stopped working and just looked, and then said to the others in the room, "C'mere everyone, look at this. Look how beautiful it is." Because it's true. Really, you should see yourself.

Operating, as is our aim, on sick people, more often than not things aren't so pretty inside. Diabetic, or old, or overweight, or with concomitant diseases affecting various organs, typical surgical patients rarely retain the born-in beauty and peach-fuzz perfection with which they came into the world. But sometimes bad things happen to the well-kept or the young, and, in another of those paradoxical disconnects of the surgical mind, we are given a moment to find pleasure despite another's pain. Sometimes it's just all look-at-me laid out, not hidden in adipose, undistorted; the logic, the development, the relationships, the purity so bright as to be stupefying. Who gets to witness it, who's allowed at the window? Not many. Me, amazingly enough. Let me try to show you what I mean.

More often than not, when inside a belly what you see is this:

The grayish stuff is intestine. The yellow, of course, is fat, covering blood vessels and other structures you'd like to be able to identify. Here's another view:


If you know what you're looking at, you'd be able to tell what's underneath:

So you dissect, and scrape, and burrow through fat, and you find what you need, and deal with it. But sometimes, wonderfully, amazingly, it looks like this (the picture might not be of a human. The fact that I couldn't find a picture only underscores the rarity. But the point remains):

Imagine the joy! Not only is the operation immeasurably easier, it allows a look at the exquisite elegance of our bodies as they were meant to be. A basic principle of surgical technique is traction and counter-traction: elevating or spreading tissues and applying pressure in opposite directions to stretch things out, making dissection possible. When you pick up a loop of bowel to get that tension, most often there's much more work to do until you find the target vessels. But sometimes, like that picture above, it's all there. You can see right through it. If you like doing surgery, it's impossible not to be ecstatic. Like rounding a bend after a long climb and being able to see forever, you must stop and savor it. You can be precise and gentle; the tissues require no more, and deserve no less. There's something like sadness when the operation is over.

Down the backside of the abdominal cavity runs all the plumbing: the aorta, bigger around than your thumb, carrying blood from the heart; the vena cava, bulging and blue, bringing it back; the ureters, carrying urine from the kidneys to the bladder. More often than not, they're hidden by fat. When you can see them -- the aorta, at least, and its branches -- they're often pocked and corroded, rusted and irregular. But just often enough to be a thrilling surprise, you can see them in all their orderly complexity; shiny and pristine, they ought to sizzle like high-tension wires.

Those big blue veins are both turgid and tender, scarily so. Their thinness speaks loudly of danger. Like a powerful waterfall, they call you closer, even as your knees feel weak. And the aorta, in the young and healthy, is a wonder. Its walls are strong and thick, but they bulge with each heartbeat. Retaining their natural elasticity (before inevitably giving it up to cholesterol) they throb and push against your fingers; simultaneously static and brimming with life. Knowing the power enclosed within (poke a hole and see what happens!), it's like standing at Kilauea and feeling tremors. Smaller branches, curlicued in the mesentery, lift and uncoil, stretching out and falling back, to the music of the heart monitor. It can be mesmerizing.

Much more than simple tubes, the ureters produce sensuous muscular waves, more subtle than gut peristalsis and less frequent, and therefore more pleasing. When unsure what you're looking at, rather than wait you can pinch with a forceps or give a flick with your finger: it'll respond with a lazy roll. Sometimes, just for the pleasure, I've done it more than once.

Funnyman

[Another weekend non-medical rant. Warning: may be offensive to some, but not all, believers, in that it is generally anti-religious. It does represent how I feel; questions I've asked myself and answered over the years. In the same way that my religious views never affected my practice, or devotion to my patients (except in those rare instances when people said they thought God was working through me and I responded, "I'll do my very best" or something similar) I hope readers will be able to separate this sort of post from my writings about surgery and medicine. Or will bail now before going further.]

I offer a comment on a TV show I didn't watch: having seen a preview is quite enough. The show "In God's Name" presents interviews with several heavy-hitting religious leaders, including the Pope, The Dali Lama (maybe it's unfair to lump him in, since Buddhism is about spirituality and not about deity), the Chief Rabbi of Somewhere, an Ayatollah, and a few others who aimed to address the problem of god and violence, and murder, and hatred. All were men, of course, and they spoke with the confident certitude that comes from being in direct contact with God, while likely ignoring the fact that the others were just as confident of their connection. In the preview I heard a quote from one of them which exploded inside my head and made my ears bleed.

"God must have a wonderful sense of humor," the guy said, grinning beatifically. It was in the context of someone becoming a religious spokesperson who'd formerly been a nay-sayer, or a bad person, or something. That a cleric -- or anyone, for that matter -- could look at the world and conclude that god is a jokester is what fried my brain. On the other hand, much religious thought -- especially the brands that we see becoming more and more a part of the political process -- is about seeing the world as it is not.

The mind reels. It's like walking into a crime scene, wading through body parts, and, because the perpetrator wrote "Hah hah" in blood on the wall, saying he must have a humorous streak.

God talked to George Bush and told him to invade Iraq, which has, among other hilarious things, led to the murder or displacement of most of the Christians there. Good one! He (God, not George) grants some prayers, which by definition means he chooses not to grant others. Because of him -- in his omnipotence he surely could have chosen otherwise -- children starve, or are maimed, or orphaned, by the thousands, every day, all over the world. (Stop me if you've heard this one.) 

He pits people against one another; he makes floods and tsunamis and earthquakes and wipes out innocents by the tens of thousands. Or, if they're not innocents, as we hear from the likes of Pat Robertson and Jerry Falwell (may peace be upon him), it can only be god the omni-powerful that made them that way, only to wipe them out. Then, we are told with certainty, he burns them in hell for a trillion billion gazillion years. Because, in addition to being a laugh-riot, nothing happen but that he wishes it so. (There is no logical middle ground: he chooses everything, or nothing.) Oh: but he loves us. That's the good news.

What a comedian! He makes mankind imperfect, sets up some rules to follow, knowing (by definition) that billions of people will be unable to follow them, and then sees to it that in their failure they suffer eternal punishment. Eternal. To infinity and beyond, hallelujah. (Although according to those who build the churches and collect the cash, you can live a life of sin and crime and have a deathbed conversion; or drop a dollar in a dish; or, like Jimmy Swaggart, weep and declaim, and be fine, poof, it goes away.

On planet Earth some killers get off after a couple of decades. But god's "vengeance is mine" jones doesn't get satisfied after a million years or two? Pretty harsh.) And for what? Well, murder, I suppose, except when it's in his name; whacking off, I'm pretty sure; but for most, just not accepting him as their savior. Even if you live an exemplary life by all other measures, if you don't kiss his... ring, you boil and blister forever. FOREVER. 

Life is short, eternity is quite a bit longer. It's like giving a first-grader the SAT and jailing her for the rest of her life if she fails. This particular picture of god, which seems to place many beside themselves with self-satisfied delight -- by any reasonable criteria is one of a child abuser. If you heard of a guy who had a bunch of kids, starved them, and then threw them in a hole when they reached for food (god made rules he knows we'll break, gave us hungers he knows most can't resist), you'd call the cops for sure. Good for you, by the way. And even if you found cartoons on his hard drive, I'm thinking you wouldn't say with a chuckle (did I mention the chuckle in the preview?) what a funny guy he is.

Remember this post about a beautiful girl dying of cancer? Many honest and heartfelt and absolutely sincere comments indicated how god-loved and humbled people felt in her presence. But consider this scenario: A man tells his youngest child, "In your pain, the others will know my love. In your suffering, they will feel enriched. This honor I give to you." And then he breaks her leg. She screams in pain, but says "I know you love me, Daddy, and I know you'll stop." Then he breaks another. "I love you, Daddy," the girl shouts. "Your love is boundless, I must try to understand." And he cracks her arm. "Daddy," the girl cries, "I'll be better, your love is great, I'll always love you." The other arm goes. 

If you were to witness such a thing, what else would you call it but despicable and inexcusable? Wouldn't the girl's professed love pain you to your soul; make your heart break? Would you not rush in to rescue the her? Dial 911? Shoot the guy, lodge an axe in the back of his head? Surely you'd not feel privileged to have stumbled upon it; or blessed. You'd have nightmares for years. But isn't the situation exactly the same as with Gloria? Yet in the one, people are filled with love of God, and in the other -- quite properly -- they'd be enraged and sickened. Now there's a punchline!

No, whatever is true about the god of those men of god, a kidder he ain't, contumelious he is, if his hands are on the levers. Either that, or he's incompetent. Intelligent designer? Gimme a break! Cancer, diabetes, Crohn's disease, asthma. The heartbreak of psoriasis, cold sores. My mom's Alzheimer's. It would seem we're under the thumb of a pretty nasty and capricious guy, and I hope I'd have the moral fortitude to tell him so if I ever saw him. But if he's not calling those shots, then either he's disengaged, or a blunderer; in which case what are we doing worshiping him? 

"God works in mysterious ways," those scions say. But wait: wouldn't they agree he gave us brains? When some things are plainly nonsensical, ought we not feel empowered to say so? To find meaning and joy based on concepts that aren't contradictory and impossible on their face?

As I've said in other posts, I've witnessed as a physician the ability of belief to give comfort. (For the reasons above, it's hard to understand how the prevalent -- or at least most publicly preached -- view of god provides comfort, but belief is rarely about consistency.) In the privacy of one's thoughts, when religion assuages that "sickness unto death," I don't doubt it's a good thing. But for too many, in order to protect those impossible beliefs from being shaken, there's a need to demonize -- not to mention murder and maim -- those who don't share them. Sadly, it's the religious of that sort who are on the world stage, here and abroad.

If religion has value, I'd think it ought to be central that it maintains some connection to reality. Allows one to deal with life as it is, to give flight to our spirituality without the need simply to make stuff up and ignore the contradictions. If it gets you to look at the world and chortle at what a wiseacre god is, it's leading you too far into unreality. Religion requires one to believe in things that are disbelieved by billions of other-believers (and not to find that fact at all disquieting.) But why must it also require one to reject that which is known to be true? Like, oh, the age of the earth. Carbon dating. Science, evolution. Stuff like that.

Did It Again

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

Ripoffs or Reticence?

Couple of months ago I read an article about a guy who did a three or four simple un-fixes to his Subaru, took it to a bunch of repair places, and reported the results. Bottom line: only about twenty percent found the problems and provided the appropriate and easy repairs. The others suggested all manner of unneeded and very expensive work, and missed some things. Not a surprise.

The article analogized to medical care: experts who have a stake in providing the care and charging for it may not always be trusted to give the best advice. It's not an entirely specious proposition. I was reminded of it recently.

I get ongoing comments on posts from long ago; most particularly the gallbladder series. "I'm so glad to have found your blog," they say, and then proceed to tell me their saga of problematic diagnoses and/or recommendations, and they ask my advice. At some level it's flattering, until I realize they're probably pretty desperate to trust some guy on the other side of their computer whom they don't know from a bag of groceries.

Anyhow, I try to help when I can, within the parameters of my disclaimer over there on the right. Recently there was a description of a symptom complex that was quite typical of gallbladder pain, with confirmatory ultrasound which even showed some thickening of the organ's walls -- pretty much diagnostic of active problems. Her gastroenterologist had her scheduled to have upper endoscopy to "rule out ulcer," and then she'd be sent to a surgeon. Her question was less about the need for the scoping than about how to approach the upcoming surgical consult. (The preceding link is worth checking out, by the way, because the doc appears to be using an invisible scope and looking at a lampshade.)

So here's where it gets complicated. Unlike a Subaru, the human body doesn't have a shop manual. Doctors sort through incomplete, conflicting, and inadequate data (because all of our tests are fallible) in order to come up with a diagnosis and recommendations. On the one hand, I can't judge from afar the need, in this case, for endoscopy; on the other, from the little info I had, it seemed a waste of time and money, with at least a small amount of risk.

I didn't say anything.

In my series on the appendix, I told the story of a call I got from a family doc, asking me to see a young man he suspected of having appendicitis. A twenty year old with a day and a half of abdominal pain, starting near his belly-button, moving to his right lower quadrant, he now had point tenderness, associated with loss of appetite, nausea, fever, and an elevated white blood count. Which did I want ordered, I was asked: ultrasound, or CT scan? If ever there was an appendicitisoid duck ("if it walks like a duck, quacks like a duck, has feathers and feet like a duck, it's a duck"), this was it. But here's the point: in this case, the doc had no financial stake at all in the imaging studies he'd have ordered. (I operated with no further tests, removed a hot appendix, and the guy lived happily ever after.) So yeah, it's complicated: it's not just about self-interest, at least in the purely financial sense.

I've been referred many patients over the years, all teed up by their docs and expecting an operation. For a variety of reasons, it wasn't an intergalactic rarity for me to tell them it wasn't needed or advisable. I can say with near certainty that I never did an operation where I let monetary considerations tip the scale. But I'm sure nearly all docs would say the same thing about any procedure, even the ones that did. Is it conceivable that an ulcer could cause severe colicky right, upper abdominal pain, intermittent, radiating to the shoulder blade, and not be related to the proven gallstones and gallbladder wall-thickening? I guess it is, although she might also have been struck by lightning on her way to the test.

If the patient were seeing his/her family doc instead of a gastroenterologist, would s/he have been referred first for endoscopy before an appointment to a surgeon? I'm guessing not. If the patient were seeing a surgeon who did endoscopy, would that procedure more likely be done, pre-operatively, than if it was a surgeon who referred such patients to a gastroenterologist? And if not, would there be any back-scratching involved? I'll defend my profession vigorously, and I'll argue as hard as possible that caring for humans will never be subject to binary decision making. But in this I can't claim we, as a group, are pure as a virgin's smile.

I am.

Were it possible, liability-wise, and avoiding-being-burned-at-the-stake-wise, it'd be interesting to consider an on-line business wherein one provided prospective (as opposed to working for lawyers) second opinions or general guidance through a problem. Obvious preclusive limitations and dangers and presumptions aside, I bet it'd be eye-opening.

Where You Find It

Enlarging on a footnote in my book, I share the story of a magical picnic:

Toward the end of my year in Vietnam, as the North Vietnamese Army marched ever more successfully downhill toward Danang, we had to bug out to Thailand. We shuttled to a barely re-opened base at which our "hospital" consisted at first of cots and bare walls, and where my office was furnished with boxes. My arrival was met with delight by a fully-trained surgeon who had not been allowed to leave until I (having had only a surgical internship's worth of training) got there. When he left, the portable OR and the anesthetist went with him: such was the logic of the military.

There was a small town nearby, which grew rapidly, putting up bars and other establishments more quickly than we fixed up our facilities. One of my fellow docs found himself a Thai girlfriend, with whom he moved in, part-time at least, downtown and in short order. My friend thought her an amazing young woman, and wanted me to meet her. The first visit was to her (their) little hut near town, where she made us a memorable meal. On a little cookstove, while telling us the story of her life (another time, maybe) she whipped up some stir-fry, leaving out the hot sauce which she reserved for herself, saying the stuff she made us was so mild she could barely taste it. My lips and tongue burned for a week.

Several days later, she took us on a picnic. Riding in the back of a tiny pickup truck she'd hired, we bounced our way through the countryside, eventually pulling up to a marble stairway which led partway up an abruptly rising mountainette. Yes, a marble stairway in the middle of nowhere, up which we lugged the bounty she'd brought: a hibachi, bags of fruits and meats and breads. And other material of a horticultural nature.

At the top of the stairs was a monastery. Shaved-head men in citrus robes took no note as we followed Banjit down a path and into a cave, at the back of which was a dark wooden platform with airily carved sides, supporting several statues of the Buddha, incense, and a monk in prayer. Behind it was a handmade ladder, rungs tied with rough cords, up which we climbed through a hole at the top of the cave, handing our bags up to one another, coming out to find another path, seemingly leading to a different planet. On the truck we'd traveled through flatlands, rice paddies, all horizon and open space. Now we were in a green grotto, rocky and steep, softened by banana trees, huge ferns and palms. The air was hot and humid, smelled like a prom corsage. We sat on chunky rocks, looking down on the monastery and up at cliffs, while Banjit fired up the hibachi and handed out the previously-referenced, subtly-mentioned, vegetable-based, mood-enhancers. Not that the mood needed enhancing.

There was papaya, banana, and the most honey-succulent pineapple I've ever tasted. She cooked satay, passed around mango juice, and we lay back on the rocks and took it all in. As much as we could. Then, Banjit climbed a tree and began shaking its limbs and chanting.

"What you do?" I asked her.

"I call monkey."

"How you know monkey come?"

"Monkey come."

"You be here before?"

"No, not be here."

They came. Small, grayish, timid, a group of maybe ten or twelve monkeys appeared out of the undergrowth, looking wary, as if worried why they'd been summoned. We tossed pieces of fruit their way. Never taking their nervous eyes off us, they reached suspiciously, clearly not tame like park-squirrels, grabbing morsels and retreating to eat them, entirely, with care, licking their fingers when finished. Ants, I was thinking. I've been on picnics with ants, but this... Banjit stayed in the tree, laughing. It was beyond ecstasy.

Suddenly the monkeys scattered in fear, as if a shot had been fired, eyes directed up the mountain. Down strode who could only have been the king monkey, half again as tall, walking on hind legs intently, commandingly, boom, boom, boom, hands fisted. His testes looked as big as the other monkey's heads. Drilling us in our eyes with his, he grabbed up a slice of papaya, chomped off a bite or two, and tossed it away. Then another, the same way. No nibbler; not this primal padrone. He glared at us as if to say, "That's all you got?" then spun around and marched back whence he came, and, as his remarkable presence ebbed, slow, like a setting sun, returning the place to us, the monkey-flock reappeared, gingerly taking up his leftovers, picking them clean.

Banjit spoke from the tree.

"I think, before, man, monkey, same-same."

"You mean," I asked, "Man, monkey, live same-same?"

"No. Man. Monkey. Same-same."

There. Evolution. Obvious to anyone with eyes open, in the jungle, sitting in a tree.

* * * * * * *

Oh, and what of the place where this magic occurs? As happens in Southeast Asia, the sky darkened before we knew it, and when we did, we saw a monsoon on its way. Grabbing what we could while Banjit called, "Go now, go now," we couldn't get everything together even though there was now less of it.

"Time go now, big rain come."

"No, no, have to get stove."

"Come now," Banjit cried. "Leave stove. We come back, it be here. Not be here, be in temple, wait for us."

Pleasin' Squeezin'

From my prior comments about my love for bowel surgery and for the old-fashion method of hooking the ends together, one might draw the erroneous conclusion that I eschew all forms of operative shortcuts. Untrue. While not the top priority, speed is an issue, and I've written about that, too. My reasons for preferring hand-sewing over staples -- aesthetics, cost savings, connection to the history of surgery -- don't apply when it comes to clamping and tying blood vessels. Surgical clips, particularly the old-style individually loaded ones (as opposed to the fancy disposable multi-fire guns) are cheap as dirt, simple as hell, and save lots of time.

For the first thousand years or so, surgical clips were made of stainless steel. More recently, and mainly because of concerns about clips being pulled off by MRI machines, they come in titanium or, most lately, are made of absorbable material. Whatever the composition, the idea is straightforward: shaped like the marriage-bed issue of a V and a U and grasped in the jaws of whatever instrument, the open part is slid across a vessel or duct, the holder-handles are squeezed, and the clip flattens into two legs tightly pressing the tubular structure in question and rendering it closed. Depending on size, pressure, and tightness of one's own sphincter, more than one clip might be closed onto the business end before cutting. Either way, it saves several seconds over clamping and tying; over a long operation with need for many ligatures, it adds up.

Blessedly uncommon, one teensy problem can occur: if the jaws of the applier are out of alignment, instead of bringing the "legs" of the clip properly together, they may overlap in such a way as to turn it into a scissor, cutting when the intent had been the opposite. Depending on where and what, it can fall anywhere along that line which connects "nuisance" with "disaster."

Practically every patient who's had his/her gallbladder out in recent years will have had two little clips placed, one on the artery to the gallbladder, and one on the duct that drains from it into the main bile duct. By the pattern and location, you can tell a person has had the operation just looking at a plain belly Xray. Consequently, I've had many patients return to me upset because their chiropracter took one of their infamous whole-body Xrays and told them that those clips near their spine are causing all sorts of problems, likely requiring monthly manipulations for the rest of their life. I'm guessing the regular reader will not have to wonder what I think of that. It did, however, lead me to be sure to inform everyone in advance, pointing out that we leave chunks of steel the size of doorknobs in hip sockets, and pacemakers aplenty, big as a pocket watch and housed happily.

Mother of all general surgical operations, the Whipple procedure (about which I've written here and in my book) affords many opportunities for applying clips, and I've always done so liberally. One such patient brought me an amazing story, which I'd never heard before and haven't since.

Other than being the color of a daffodil, when I met him he was a very healthy and vigorous man, in his sixties and in need of a Whipple, which I did promptly, slick and quick. His recovery was rapid (much more so than indicated in the preceding link) and he returned in short order to his major pleasure, golf. One day, several weeks after the operation, golfing as usual and on a dog-leg left, long par four, he explained, he felt a strange tickling sensation on his belly. Lifting his shirt and looking down, he noticed some activity at the small and previously healed scar from where I'd placed, and left for a few days, a drainage tube. He got his hand to the area in time to catch a whole series -- fourteen, to be exact -- of steel clips exiting out the former hole in single file like little tin soldiers, blip, blip, plop, plop. He brought them to me in a baggie.

Good One!

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

Sad Times

[This post is another of my forewarned weekend rants, written in part a while ago, during my outage.]


The New York Times recently ran an article that hits home. For a variety of reasons, I've been feeling pretty depressed; if you put my mood on a pie-chart, the state of our nation and world occupies a large part of the dark areas. The rest, well, it's just who I am, and not worth sharing.

If anything, the article doesn't plumb deeply enough. The world IS depressing; and to the extent that some people don't see it that way, well, that's depressing, too. Where to start? OK, how about the war in Iraq?

I accept that some don't see it as the worst mistake ever made by a US president since the beginning of the Republic. It most certainly was, but that not everyone agrees isn't what disturbs me. What does, is that the argument for ending the war is characterized by all the Republican candidates as "surrender," as a great victory for al Queda. But it seems so obvious: our being there in the first place is an enormous victory for AQ. If you were a bunch of guys living in a cave, who had no army, no means on their own to take down this country, wouldn't it be perfect to sucker us into an endless war, depleting our military, our treasure, and our standing in the world, while providing them with a steady stream of recruits? In order to avoid "waving the white flag," as McCain et al like to put it, we must keep doing exactly what those cave-dwellers want: stay there forever, bleeding ourselves to death, and blatantly disregarding everything we've always stood for; not to mention ignoring the things that really might make us safer. On their own, terrorists could hurt but have no means to destroy us, yet it seems they inveigled us very possibly to have done it to ourselves. I'm not arguing that we have no obligation to the Iraqis whose country we so carelessly invaded, nor that leaving wouldn't potentially lead to big trouble within Iraq and beyond. I'm just saying that Bush's war is a win-win for al Queda, and a lose-lose for us. To frame the argument as "white flag" versus "love America" is depressing political bullshit. And stupidity. In his culminating project, ending his string of flip-flops du jour, Romney said, in effect, that voting for a Democrat is "surrendering to terror." How venal is that? How completely despicable!

"Stay on offense." "Strong on terror." What the hell does that mean? Invade another few countries? Of course we need to be intensely vigilant and to intervene when it makes sense. That requires the gathering intelligence; doing so, among other things, depends on having friends around the world who'll help provide it. Which is why it's so important to be respected and admired, rather than hated. Or laughed at. Mitt wanted to "double Guantanamo." If we are so insecure about the ability of democracy and our Constitution to deal with such an enemy, then what the hell are we doing trying to export such a system to the rest of the world?

It's depressing to hear the Republican candidates promise to be like George Bush only more so. McCain: more war, lower taxes. Giuliani wanted even bigger tax cuts. At their debates, they elbowed each other out of the way to exhume the corpse of Ronald Reagan. How many examples do we need before we agree that Reaganomics doesn't work? Reagan instituted tax cuts, everyone felt great, while the deficits mushroomed. It doomed George's dad, who followed him. Clinton raised taxes, Tom Delay and Newt Gingrich screamed, but it brought the budget into balance, the economy roared back; then Bush cut taxes, the Republicans felt great, the deficit once again skyrocketed, and the economy is crashing like the house of cards that it obviously was. And yet... all we hear from the right is a return to Reagan (who also, by the way, reversed all of Carter's initiatives to reduce oil consumption -- and look where that's gotten us.)

"George Bush has kept us safe." Reminds me of the guy falling off the Empire State Building who says, as he passes the thirtieth floor, "So far, so good." The things that HAVE kept us safe, any president would have done: airport security (anyone remember what a fiasco it was at first, because of Bush's insistence -- or was it Cheney's? -- that it be privatized); surveillance (any reason why it couldn't have been done legally; change the law if needed?) The centerpiece, the central front -- ie, Iraq -- has by no reality-based measure made us safer. The opposite is undeniably true. And the list of remaining needs is long.

Some things seem so obvious that they ought to transcend politics. Why is it only Republicans who deny global warming? Why do the people who believe Earth is six thousand years old (or is it twelve?), who want evolution out of school curricula and creationism in, come from the right wing? As the current government overtly tries to redact and ignore science, why isn't everyone screaming bloody murder?!!

How can anyone argue that the institution of marriage is threatened if people of the same sex who love each other have access to it? If your religion doesn't allow it, fine. No church ought to perform marriages of which it doesn't approve. But why prevent another from doing it? Why amend the Constitution? Where's the harm? I've been married thirty-six years. I feel not the slightest threat to my marriage if gays join together in love. Moreover, it's clear that sexual preference is for the most part genetically determined. Like claiming the age of the Earth is a few thousand years, arguing that homosexuality is some sort of abomination in the eyes of God is to ignore fact; at the very least, he has seen to it that there are gays in every culture, in every religion, in every age of man. If it's a perversion, who's the pervert? Clearly the fear-based need to cleave to certain beliefs trumps common sense and common decency.

Democrats, the hollerers spew, "blame America first." What crap!! There are those of us who know the transformative power this country can and has shown, who have seen its greatness, and who long for its return. To lament the last seven years is not to hate America, but to pine for lost love. I was in college when JFK was president; only two weeks before his assassination he spoke at my college, and I was there. His vision and his rhetoric, his wit and intelligence -- even his good looks -- were, to a young person like me (idealist, maybe, but not naive), inspiring and energizing. I hear echoes. But not from the right. From them (from their candidates and radio and TV hosts at least), I hear the peddling of fear, of divisiveness, of exclusion. To the extent that there's hope of harnessing the power of the diverse opinions and skills in this country and bringing it again to greatness of the positive kind, that hope resides not Rovian divide-and-conquer politics, but in imagining much more. From another website: "The reason Obama is winning and will win is so simple. Americans want to believe in themselves again." I think it's true for more than Democrats. But is it possible?

As a veteran, I find it depressing that for most Americans, "support our troops" seems to mean sticking a magnet on the back of their vehicle (well, I admit I have one: but it's this); that patriotism is defined only by loving the war in Iraq. When I was in Vietnam, my wife was working for George McGovern, and I felt supported as hell. How many nowadays would park their yellow-ribboned gas-guzzling SUV and agree to a tax surcharge to pay for the war and its long-lingering needs for our vets? Show of hands?

Ever since Ronald Reagan declared the US was once again "walking tall" after we (wow, successfully!!) invaded that super-power known as Grenada, keeping the world safe for people who couldn't get into American medical schools, there are some that are only proud of this country when it's "kicking ass." That form of patriotism is good for selling flags and ribbons and bumper stickers, but for not much else.

The people who would label me an America-hater and an infidel want to believe in fantasy, to live on borrowed money, to let another generation deal with the mess our politicians (and those who elected them) have made. Unfortunately, they may well have been successful to the point of no return. I'd like to think Barack Obama is right, that there is hope. In the thirst to be proud of this county again, and to be inspired one more time before senescence, I'm willing to risk disappointment. But I think it's too late. We're screwed, and we've done it to ourselves; by succumbing to fear and superstition, by twice electing a president who clearly does not believe in what has, until recently, made our country great. Respect: given and received. Laws: made and followed. Discourse: valued and encouraged. Reason: sought and produced. Power: respected and reserved.

Other than that, I'm feeling pretty good. And believe it or not, I edited a lot of stuff out before I posted this.

Doing God's Work

In response to outbreaks of MRSA and c.difficile, hospitals in England have instituted various hygiene policies, including the need for medical staff to have bare arms, which they must wash to the elbows. Muslim female medical students are refusing, on grounds of immodesty inconsistent with Muslim law. When mentioned on the website Pharyngula, among the comments thereon was this:

Many moons ago I lived with a Bedouin hill tribe near Petra in Jordan. One winter I got terribly sick with pneumonia and had to receive treatment by a Muslim doctor in Petra. Whilst he was a lovely man and their training is first rate he still had to adhere to the silly requirements of his religion. As such, sick as a dog, I could only be examined from the other side of a sheet held up by his two giggling nurses. I explained that it didn't worry me to be examined and to go ahead, lift up my top and listen to my lungs, but no, still had to have that damn sheet. I was in that clinic for a week and all I remember in my delerium is that...sheet.

Some time ago, in another context I wrote about the very regal and imposing matriarch of an immigrant Muslim family on whom I operated. Seeing her in my office, I was forbidden, in no uncertain terms, from exposing her in any way when I examined her; I thumped, prodded and auscultated through her black coverings. When she came for surgery we brought her fully clothed in her religious garb into the OR, and I left it on during the whole operation, sliding it up (while keeping her lower body covered) only after she was asleep. Both the office exam and the OR proceedings broke a few rules of thoroughness, but I really didn't have a problem with it. I made some non-critical compromises to accommodate her beliefs; I assume (but don't know) that under other circumstances -- like evaluating her in critical shape after a car wreck -- her family would have allowed whatever uncovering was necessary.

In refusing for religious reasons to allow a full exam, my patient was the one taking the risk, however small, of forcing me to be incomplete: her religion, her problem. Had I thought it dangerous, I'd either have insisted otherwise, or if unsuccessful, I suppose, refused to provide care (since it was elective.) But the situation in England (and in Petra, for that matter) is different: in following their covenants the medics are putting others at risk. People have right to practice their religion freely (in most Western countries, anyway.) But isn't a line being crossed here? If your religion prohibits you from doing certain things, professionally, that are in the interest of others, ought you not opt out of that particular profession?

Well, of course. And in the US, there are pharmacists who refuse to dispense "morning after" pills for similar reasons. What's next? Young-earth firefighters not rescuing a married gay couple?