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, maybe presented with a holy relic, invited to the temple for a secret ceremony, rooted in ages past. I admit I let myself imagine special things.

He arrived in my office dressed like a Florida retiree. Looking age-appropriately fit, but neither athletic nor powerful, he was of no more than medium stature. Less surprised than embarrassed for my silliness, I immediately discarded my dream and proceeded into my usual doctor/patient partnership, treated him like everyone else, operated in due course, saw to his recovery, and he returned to his homeland.

The letter, which compared my art and skill favorably to his, arrived with a package. Really, the elegance of the letter was more than enough. Once again, I entertained a brief fantasy of what might be in the box.



It was a Mont Blanc fountain pen.

I'm not sure I'd heard of them before that. Very expensive, for a pen. A nice gesture, no doubt, but of not much use to me. A little too showy, it was also impossible to use for writing orders at the hospital, because you need to push hard enough for several copies. Nor was I interested in lugging around a bottle of ink on rounds. I confess to being disappointed. It seemed so impractical, so materialistic, so... unlike a Shaolin priest. Not that I had any information other than a TV show.

In its elegant box, the pen sat on my bedside table for a decade or so, along with its exotic ink bottle. Then I wrote a book, got it published, gave a few readings, did some book signings. Wow, it eventually occurred to me. It's karma, or whatever Shaolin priest kung fu masters believe in. He forsaw it, it was perfect, meaning revealed. I took it to the next signing. With its elegant gold nib, its meaty heft, its characteristic emblem, the soft lines of ink it imparted to the page, perfect for a signature and a few well-chosen words. The mark of a writer of distinction.

After reading from and commenting on the book (I will humbly say my readings were always a hit: I'm enough of a ham to enjoy it and get plenty of laughs -- the first time I did one, it was at a fairly fancy book fair in Portland, called "Wordstock." My reading, in a small room, was at the same time as Gore Vidal's, in a much larger one. "This is my first reading of my first book," I told the audience. "So I'm really looking forward to hearing what I have to say.") I sat at a table and proceeded to sign books for people, bringing out the newly-glorious pen, studiously acting as if it were as normal as breathing.

It leaked all over my hands, and wildly smudged the first book I signed.

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 year olds with advanced cancer and a 5% chance of recovery, instead of ten ten year olds with leukemia, with an 80% chance of recovery? So, like the old joke, we're not really arguing about rationing; we're haggling over details. Not to mention the fact that rationing, so loudly decried by the Foxoid among us as possible under "Obamacare" (whatever that is) is already happening with private insurance: of the dozens of plans offered by each of the twelve hundred insurers, how many cover all things for all people with all conditions under all circumstances? How many people get dropped after an illness, or refused in the first place? Wouldn't it be better to have such decisions made in a system open to public and medical input? (Along those lines, here's a pretty good, and humorous, commentary on the reality we currently face, still defended most arduously by the nay-sayers of the right-wing persuasion.)

End of life care presents us with some of the most difficult decisions we make, as families, as patients, as physicians. Likewise the related situation of "futile care." In neither case are there clear criteria to guide us. The exact same operation -- say, bowel resection for perforation -- would certainly be futile in that ninety year old (let's add some heart and kidney disease to make it easier), and entirely reasonable in a thirty year old, even if that person presented in septic shock. In the latter case I wouldn't hesitate for a second. In the former, I would try (and have, many times) to present for consideration the option of providing comfort care only. I won't psychoanalyze myself, but I hated doing operations wherein I felt there was virtually no hope of survival. (Need I mention that I made more money when I did operate than when I didn't? Yet I tried like hell not to, by presenting as candidly and openly as possible what I thought the situation was.) Not every surgeon would have done so.

I was always scrupulous about cost in my practice, from the little things to the big ones. Saving a few bucks on every case by not demanding different suture for every step when it made no difference: it adds up. So does thinking twice before heading down the road to futility. But it's neither universal, nor easy to know the signposts. Ought there to be some guidelines at the end of life, or should it be up to serendipity? I don't want to take judgment out of the equation; but not everyone has the same capacity for it. Which is part of the problem.

I can't back this up with any data, but when their grandma was dying, it seemed to be those who'd been with her the most who were the most able to let go. It was the out-of-town shirt-tail relative who blew in at the last minute who seemed to demand that "everything" be done. In those circumstances when it was insisted I go for the one/million shot, I've wondered if the same decision would be made were the family responsible for the cost.

So here's my proposal, in the context of the brouhaha over the idea of studying what works, and not paying for what doesn't: let's lay the money on the table. If a family wants to go ahead with an operation or other intervention, for which the odds of success are very long, or which is judged ineffective based on research (let's not get into details for now), here's the deal: if it works, Medicare (or is it Obamacare?) pays. If it fails, the family pays. Cash (credit card?) up front. Takers?

I see this health care "debate" as the quintessential test of our democracy. The need for reform is clear; the trajectory is, without doubt, toward disaster if changes aren't made. And yet, here we are, bogged down in disingenuous rhetoric, in overt efforts to stop it for purely political reasons. Trading amendments and concessions to various profiteers like bubble gum cards. Watering down the most serious proposals like potted plants. Media covering it lazily (all of them), sensationally (most of them), or entirely falsely and politically (you know who.) Advertisements and talking points designed to frighten, inflame, misinform. Citizens unwilling to think about it carefully. Faced with a crying need and a failed future that is not seriously in doubt, we seem unable to have serious debate, to argue on the merits, to legislate the sorts of changes that are needed. How can other countries have done it, and not us? And what does it say about our political system?

Can a nation of half-educated people, unable or unwilling critically to evaluate data; a media industry degenerated into selling soap over meaningful reporting -- and, worse, owned, operated, and scripted by people with overt political agendas; legislators elected for their dogmatism above all, the less serious the better; political parties more interested in power games than doing right -- can such a political system meet real and serious and undeniably needed challenges, or not? We'll know pretty soon. In fact, I'd say we already do.

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 distracted, we heard the call to the evening campfire. As we made our way back, I became aware of discomfort. Increasing discomfort. Significant, unfamiliar, impedimentizing discomfort. Double discomfort, throbbing, heated, encompassingly discomfiting uncomfortable discomfort.

The evening ritual involved encircling the fire, all the campers and counselors crossing arms and holding hands, some nice words to end the day, and singing. Henay matovu manayim... a mantra, hypnotizing, over and over, the words guttural, shevet achim gam yachad, soothing, repetitious, chocolaty, warm, pulsing, rising heeNAY... achim... yachad... The ch not like "chop" but kha, no English sound, a throaty sound, the letter X in Russian. Lozengy, physical. Percussive, drummy. Pounding.

Swaying back and forth, all together, the warm night, the song in minor key, repeating, the swaying the throbbing the singing, taking over, obliterating, the pain, rising, the throbbing, spreading to torso, to head, the forehead the cold forehead the singing pounding thrumming pain melding manayim throbbing matovu pounding drumming pain swaying swaying buckling swaying... the vague sense of someone falling, who?, people murmuring.

Looking up at faces looking down. Was it only concern, or was there knowing amusement? I'm okay, I insisted, wondering if there was... evidence. I'm fine, just got dizzy from the heat of the fire, or some other excuse. I didn't -- and don't -- think there was any way for them to have known. Somehow, I managed to convince them I didn't need to go to the infirmary.Walking slowly, I made it back to the bunk. Under observation, even if I knew the cure, there was no opportunity.

The pain was gone in the morning. Wonder if that was the beginning of my journey away from religion...

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.]

Truthteller

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.
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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 operated on was a Russian immigrant from a town in the Ural Mountains where they live half way to forever. He was 102, which was lower than his temperature, caused by a gallstone stuck in his bile duct. His family assured me he was sharp as saber and strong as slivovitz. Two weeks later, he was back working his garden.

It was always my impression that older people were more matter-of-fact about their illnesses, and I found it almost universally true that they were less troubled with post-operative pain. Maybe it was physiological; maybe because they were more sensitive to narcotics. But I always thought it was simply because they'd made it through the better part of a hard life and pain just wasn't that big of a deal any more.

For an older person, the default mode was trust (the "sturdy" lady excepted. Sort of.) They listened when I talked. "Do what you think is best, Doctor," they said, which was like flopping into a comfy chair, after a day of walking on nails. It's impossible to care for the gray-haired and not think of grandparents, not to relax a little, to feel respect.

Okay, in the intensive care unit, not so much. Called there to consult, finding an ancient-looking person, tubes in natural and unnatural orifices, knowing survival odds are in inverse relation to those tubes, one is faced with often impossible questions having unknowable answers. To do what is reasonable; certainly no less, but hopefully no more. And humane. But that's another matter, with not just immediate but global implications (health care costs!). I was talking about the sort of relationship that begins in the office, or maybe a regular hospital bed. Relaxed. Time to get to know each other.

The NYT article points out some ways in which the geriatric population differs from the younger. (It also makes the very good point that whereas all med students do time in pediatrics, obstetrics, etc, there's no requirement for geriatrics. Older folks aren't just wrinkly.) It's certainly true in terms of length of recovery time, healing issues, complications from accompanying disease.

I wish there were objective ways to measure risk, to predict outcomes. Absent that, I always found a couple of reliable -- if unscientific -- predictors: people do like they look. An eighty year old who looks fifty will recover like a fifty year old; a fifty year old who looks eighty will recover like eighty. And, no matter what age, anyone who walks a mile or two every day will do just fine.

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!

Insult

This morning in my email was the following message:

Hello,

Your blog at: http://surgeonsblog.blogspot.com/ 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 dedicate more storage, bandwidth, and engineering resources to bloggers like you instead of to spammers. For more information, please see Blogger Help: http://help.blogger.com/bin/answer.py?answer=42577

Thank you for your understanding and for your help with our spam-fighting efforts.

Sincerely,

The Blogger Team

P.S. Just one more reminder: Unless you request a review, your blog will be deleted in 20 days.

But the real insult was in following the link to explanations, finding this (emphasis mine):

As with many powerful tools, blogging services can be both used and abused. The ease of creating and updating webpages with Blogger has made it particularly prone to a form of behavior known as link spamming. Blogs engaged in this behavior are called spam blogs, and can be recognized by their irrelevant, repetitive, or nonsensical text, along with a large number of links, usually all pointing to a single site

So much for my assertions that this blog has been of value, or, at least, once was.

I should add that in order to perform any action in posting, I now have to do a word verification. The distortion of the letters is so extreme that I can barely read them. So you might not actually be seeing this. I await the judgment of the blogger overlords. Meanwhile, I'll have the words in my brain: irrelevant, repetitive, nonsensical. Alas, it is I.

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/or chest injuries, and I'd guess that is universally true.

During training, trauma care was the center of the world, the cauldron in which the steel of the surgeon was annealed. At every level of training, and especially as Chief Resident, my involvement in trauma care taught me more about surgery and surgical patients than any other time I spent in hospitals. I'm grateful and lucky to have put in several years, literally living there much of the time, at one of the (at the time, probably still) preëminent trauma centers in the country. Brilliant and tough, my teachers at SFGH (actually, when I was there, the emergency wing looked like this) gave me my sense of duty and commitment to my patients, the ability to make difficult decisions and to take responsibility for them, an understanding of the sort of "digital" thinking that a surgeon needs in the operating room. From them I learned a lot of technique, too; but the frosting on that cake I really owe to another, a decidedly non-trauma surgeon, Vic Richards, a legendary innovator, surgeon of singular intelligence (M.D. at age twenty, give or take), and a significant figure in my book.

But in real life, trauma was a pain in the ass. Unlike training, when we waited hungrily for the next case to roll in, in practice it was by definition a disruption. Destroying an operative schedule, crashing a full office, or robbing a night of sleep before a fully scheduled next day -- those were the least of the problems created by a call to the ER. It was the circus of managing a complicated and unexpected case in a hospital not primarily devoted to such things. It was dragging in a bunch of reluctant other surgeons (depending on the problem) -- orthopods, neurosurgeons. And the worst were the MVAs, for that very reason: multiple organs, multiple docs. If I had to come in to see a trauma case, give me a tidy gunshot or stab wound every time.

And I DID see a few injuries to femoral arteries from those causes. And to much bigger and bleedier vessels than that.

Once I got over the frustration at having been called (I'm an orderly sort of guy), it was never hard to be swept into the torrent. There is unequaled immediacy to trauma care, a series of "yes-no" decisions, absent "maybes." Real time, instinctive, urgent in the extreme, it's invigorating. There's nothing like the intrusion of certain death, turned around and sent away by the coming together of everything you know, to give a sense of purpose. There's nothing like slashing into a dead man's chest, sticking a finger into his heart, and watching him awaken even as your hand is beyond the wrist into him.

And I can do without it just fine.

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 across America are going through decisions like that all the time, and you're absolutely right that if it's my family member, my wife, if it's my children, if it's my grandmother, I always want them to get the very best care.

Predictably, this has been jumped on by detractors and touted in pretty much the way the commenter did: Obama's plan is good for your family but not for his, says Obama. Since we all love our country and don't wish our President to fail, I'm sure it was just an honest misunderstanding. Like my snippet above, most of the criticism leaves out the President's next sentence:

...but here's the problem that we have in our current health care system. Is that there is a whole bunch of care that's being provided that every study, every bit of evidence that we have indicates may not be making us healthier.

Which, of course, is the most important thing he said.

First of all, the wording of the question was, well, questionable. It's a false premise. It implies there are "plan physicians." It implies that treatments recommended by "medical leaders in major centers" wouldn't be part of "the plan." There's simply no reason to think either is true. There isn't, as far as I know, a proposal to separate "plan physicians" from others. And there most certainly is NOT an implication that therapies that carry the weight of "leaders" in "major centers" would be off the list. The opposite is true.

And it's exactly the point Obama was making. But it's neither sound-bite worthy nor easily explained; and, as we've seen, it's very much selectivequotable and outofcontextable. (Incidentally, that he got tough questions like that sort of shows the right wing fury (ie, Fox News) over the "unprecedented access" ABC was granted was so much hot air...)

Among the many ways to control health care costs is to establish what works and what doesn't. As I've written, severally. Patients and families, as President Obama said, face such dilemmas all the time. "The very best care," he said. Exactly. Would that it were always as easy as the example that the questioner (a doctor) gave, in which there would be general agreement from the creme de la medical creme. (It'd have been better if Obama had pointed that out: again, showing the session was hardly planned and canned.) On the contrary. It's often a decision involving futile care: the operation with a one in a million chance of helping; prolonging life in the ICU; trying dangerous drugs with virtually no chance of helping. Or -- and one assumes this would not be covered, since it currently isn't -- heading to Mexico (or, like Farrah Fawcett, to Germany) for entirely bogus treatments.

These sorts of things are, in my opinion, way too difficult for our political system, as currently manifested, to handle. Rather, at best (if that's what to call it), we'll get a plan to pay for insurance for those who can't afford it, leaving the excess costs of insurance untouched and not tackling effectiveness in any meaningful way at all.

But, perhaps, we could at least do it or not, without deliberately taking out of context what the President said.

Yeah.

Right.

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.

Progress

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 a half-inch incision. Maybe. What they stick in is this baby, which, according to what I've read, requires a 3.5 cm incision, or about an inch and a half. In total, that's at least half again the total length of incisions made in standard laparoscopy, for removing the gallbladder, anyway. No less painful, one would assume; although the pain isn't that great, usually, in either case.

Now I must admit I've neither seen nor done it. As I've said about laparoscopy and robotics, it's fun to do, and I have no doubt this wrinkle is fun, too. So far the operative times are longer than "regular" laparoscopy, which equates to more expensive. In that article, the recovery is no different from standard stuff. Without knowing for certain, I'd say there are also issues with exposure and perspective, since the camera and tools are all coming in at the same angle. That, one might predict, adds up to higher risk. Time will tell.

The other day I read an article about a kid who had his spleen removed this way. Nice scar in the belly button. Humbly, the surgeon says it's not about fame, or being first. It's about preventing the trauma of a scar. The cynic in me says it's about referrals. But what do I know?

Here's my point, about which time might well prove me wrong. In my opinion, NOTES, robotics, and single-incision laparoscopy, so far, have one thing in common: dubious value compared to other options, more expense, and possibly more risk. For what? In the case of robotics, marketing. In the other two, marketing and cosmetics. These are examples, it seems to me, of therapies which, if effectiveness research becomes pervasive and meaningful, may well be taken off the list of covered procedures. And then what? Well, for one thing, the disconnect between reform and having it all will be illuminated. Maybe, rather than disallowed (which, realistically, is unlikely) the extra costs of these operations will need to be paid by the patient. Surgery which is purely cosmetic, after all, is never covered by any payers.

In any case, this is the sort of thing that doctors and patients alike will need to face if and when real cost control is effected. It won't be pretty, even if the data are there. Because when have data had anything to do with anything?

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 evident that the "we" is the populace, but not its elected officials), it ought to be the case that any citizen who gets sick can receive care, regardless of the timing of their illness or where it falls in the fine print. Period. And, of course, the same ought to apply to well-care (assuming we know what interventions actually add to health. As opposed to prophylactic spine manipulations, homeopathy, and other forms of woo.) The criterion for coverage: you exist. Other countries do it; why not us?

This is the central idea, the raison d'etre, of a single payer plan. Same rules for everyone. Guaranteed coverage. No wondering, no legions of people spending dollars intended for health care trying to find ways out of spending dollars intended for health care.

And, taking it all the way, what if this care were not only guaranteed but free (or nearly free) of premiums? So what if certain taxes were raised to pay for it? Wouldn't that be more than offset (or at least evenly offset) by freedom from those premiums? And by the fact that there'd no longer be an unnecessary and very expensive intermediary between people and the care they get?

To me it's obvious. Inevitable, even. Although watching Congress I conclude it won't happen for a few more decades, assuming we still exist by then; and only after a complete failure of the current system. The opposition continues to parade their hand-crafted talking points, designed to scare and distract. There simply are no salient arguments I've heard that make a case for maintaining the intermediary of hundreds of insurance companies, other than what amounts to "we need them because we have them." What good are they adding? What particular and essential need do they fill? For the billions and billions of dollars, intended for health care, that insurance companies make, take, and keep, what do consumers get that justifies their existence? The "public option," they tell us, "is just a way to get rid of insurance companies." And that would be bad, how?

Seriously. Somebody tell me. I can't think of a thing.

And yet, if you listen to our Congresscrowd -- practically all of 'em -- you'd think it's the insurance companies that are responsible for everything that's good about American health care. "The best health care the world has ever known," as one of them recently said, ignoring the price we're paying compared to the rest of the world, the millions with limited access to it, and the fact that we are at the bottom end of most measurable health criteria.

This might be a good time to insert a cartoon that Ellen sent me:

I think it is the essence of the contrary argument. Although, as I've said, were we to go all the way to provide universal coverage under a single payer, taxes would be offset. For those who love insurance companies, there ought to be a way to provide them the option.

Or, if they want the same result without all the paper work, whenever they get sick they could run into their bathrooms and do this.

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. Attempts at controlling costs have included, for instance, both restricting and increasing the number of doctors produced in medical schools. Neither worked. To date, disguised and dressed in many pretty outfits, the main tool for cutting costs has been reducing payments to physicians and to hospitals. At best, results are mixed: forced to work harder and harder to maintain income, many doctors (speaking) have burned out and quit in their prime. Turned into bean-counters, those that stay have adopted methods that frustrate patients: cramming more visits into an hour, charging for phone calls, etc... Ancillary charges are outrageous: a friend recently wrote me about a $3,500 CAT scan, a charge of $850 for a simple automated blood test. (Not that anyone but the uninsured actually pays them: in some sort of dance macabre, insurers reimburse ten or twenty percent of those fees and the rest is smoke.)

(In a related note, I read that President Obama's doctor isn't happy with Obama's health reform proposals. In the article the good doctor says neurosurgeons get $20,000 for "cutting into the neck" of his patients. Now, I have no idea what goes on in Chicago, but I'd propose that, if twenty grand is an actual fee, like the $3,500 CAT scan, the reimbursement is a small fraction. In this post I don't want to get, yet again, into the frictions between surgeons and real doctors; but such a claim suggests a certain amount of hyperbole in the discussion. On the other hand, he implies he's for a single-payer plan; on that, we agree!)

Pay for doing stuff is the wrong incentive, so we are told. It leads to over-ordering of tests, over-doing of procedures. Can't entirely disagree. Read Atul Gawande in The New Yorker, or Buckeye Surgeon in Buckeye Surgeon. But if it's a problem, what is the solution? Salaries, says Atul. Better docs, says Buck. And me. With the right incentives.

I've said before -- to hoots and snark -- that I don't think many physicians are in it primarily for the money. But I do believe that, as in most other professional pursuits, people willing to work hard and who produce superior results have an expectation of some sort of recognition. Which includes income. And that's precisely why I said above that what we have now is the worst of all possibilities; fee for service with no incentives for quality, no differentiation among bad, mediocre, and excellent providers. For doing a colon resection in half the operative time (saving thousands in OR costs), sending a happy patient home two or three days (or more) sooner than average (saving thousands in hospital costs), with a lower rate of complications, I got exactly the same reimbursement -- from Medicare, from any insurance company -- as the surgeon who did none of those things. If, to a payor, a colon resection is a widget, the only criterion for payment for which is agreement to accept the latest slice in compensation, why bother to do those things? (Getting patients home quickly requires, among other things, making rounds two or three times a day, which most docs no longer do -- but which I always did. Faster operative times result from many things, among which are attention to detail, making sure in advance that what you need is in the room, keeping the team informed of what's coming next. Even helping move the patient and clean the room. Not seen frequently. Since I retired.)

A high percentage of doctors are human beings. That means they often respond like other people. Incentives and disincentives have an effect on behavior. Which is among the reasons "effectiveness research," or whatever the proper name for the effort (the blocking of which is desired by several legislators on the rive droit) to identify best treatments, makes nothing but sense.

I suppose it gets tiresome to read such treati. The bottom line is I think a system works best when there are incentives -- positive and negative -- to do the right thing. Some will, no matter what. (Of those, some have hung it up...) Salaries (at least those with no opportunity for adjustment based on performance) encourage laziness; capitation encourages the withholding of care. Fee for service which makes no allowance for differences in quality encourages abuse. And burnout.

Based on the snippets coming from the halls of Congress, I'm pretty well convinced that whatever so-called reform we get will fail substantively to address the real problems in our system: insurers, excessive or inappropriate "care," reasonable reimbursement across all fields of medicine, costs. And, for the life of me, I can't understand why.

Well, of course, I can.

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 talking about a national health service, ie, a plan whereby everyone goes to government-run hospital, staffed by government employees. (Well, that's not entirely true: several in Congress are comparing the so-called "public option" to the Department of Motor Vehicles. But that's completely disingenuous. The comparison, as I've said, is to Medicare.)

I'm not saying there are no arguments to be made against that "public option," or to a single payer system that enrolls everyone. Many doctors worry about losing control over reimbursement, having to accept ever-decreasing payment for service; they fear the monolithic. It's not without reason, or precedent. Funny thing is, as I've said, Medicare is already pretty much calling the shots: insurers largely take their reimbursement cues from them. Moreover, I've seen several situations in which an insurance company plays docs against one another: fearing losing their patients who are covered by a particular company, they cave to the demands to accept lower fees. It works particularly well in towns that have several competing physician groups.

It's also been a repeated theme of mine that endlessly cutting reimbursement to "providers" is a policy doomed to failure. We're about as low as it can go, if there's an expectation that smart and dedicated people will take up the caduceus. Rather -- and President Obama at least speaks the words -- the real savings will be in identifying those treatments that are the most cost-effective; and, even more importantly, finding those docs that provide the best care at the lowest cost and spreading the word.

The concept is ripe for demagogurery. "Do you want the government to get between you and your doctors?" they ask. As opposed to, what, a high-school grad in an insurers cubicle, telling the docs what they can and can't do? Like it is now? (In the linked article, it would also appear some want to prevent -- by law!! -- research into what treatments work best. To me, that's pretty hard to explain. How awful could it be to be told you can't have one operation that has been shown to be inferior to another?) (Okay, I recognize the potential problems. But if an idea is a good one, surely there's a way to implement it with safeguards.)

Reforming health care, it seems to me, is a perfect metaphor for everything that's wrong with our political system. While faintly acknowledging that for tens of millions it's not working, some in Congress nevertheless want only to maintain the status quo. Their efforts, unashamedly, are mainly limited to coming up with loaded (and disingenuous) phrases calculated to obfuscate. Given the complexities, it would be daunting even for legislators committed to comprehensive and effective reform. Would that we had some.

I'd bet very few people feel loyal to their insurers, per se. They may be loyal to their "providers" and to their preferred hospital. (Sort of. I read a study a few years ago that put the price of loyalty at, as I recall, about twenty bucks: ie, if switching docs meant saving more than that per month, it was hasta la vista, dockie.) What is the argument, from the consumers' point of view, of having insurance companies in the middle of the system? Where, specifically, is the value-added?

I fault the whole gang: Republicans, Democrats, and those in the White House. I can think of no reason why single-payer isn't on the table, except for the fact that it has so little support in Congress. But why? Whose goose is being greased? (If that's the term...) If a plan were to provide the same care we're now getting (or, hopefully, better), using the current infrastructure of doctors, nurses, clinics, and hospitals, while costing less by keeping more money in the system, why would that be bad? Because some call it.... SOCIALISM? Might not the result be more important than the name?

Some who've traveled these parts before will know I've made some suggestions. Funny thing: President Obama seems to have read them and bought everything but the single-payer part. He talks about identifying best practices; he talks about a larger role for the Medical Payment Advisory Commission. The latter, of course, is a double-sided axe; how acceptable it might be to physicians and hospitals would depend on its makeup and its responsiveness to reality. But it's the idea that is a good step. Cautiously endorsed.



[Acknowledgment: I know I said recently I didn't want my return to this blog be by way of the politics of health care. But I find myself unable to cast it out. I think I may have to get a little rubble off the desktop before I can find my way back into the mind of a surgeon.]

I Dream

I dream of surgery. It's in my mind, if not always on it. The fact is, I miss it. A lot. The good parts, anyway. The doing.

Even though the dreams aren't always pleasant, it's frequently disappointing to awaken to the realization that I'm no longer a surgeon. Last night, I was showing some sort of student how to repair a hernia, showing the anatomy (not exactly accurately rendered), explaining why I was doing what I was doing. The fact that it turned complicated, and that the student seemed annoyed that I was asking him to participate didn't diminish the sense of pleasure. (I think it's possible to sort of meta-dream: when I'm a dream-surgeon I feel like I contemporaneously know it's just a dream but also take pleasure in the pleasure of it. Like watching a movie, I'm simultaneously enjoying the story, the unreality, and the art of the making of it.)

There are many possible directions from the above: a plea to my fellow surgeon-bloggers not to do what I did, to find ways to prevent early burnout, so you might keep your craft active longer than I did; a discourse on the difficulties of leaving behind such an all-consuming profession; the wonderment at having achieved a measure of competence in such a thing; the extent to which leaving it behind confirms something I always said -- that surgeons in particular, and doctors in general, aren't really special. We're just people who learned some stuff. And now I'm back to that unspecial tabula, heading toward rasa.

I does convince me of one thing. I do want to resume this blog, if only to retain or regain a connection to that former self. Consider this another step, after the previous post. A stretching before the ride, a calesthenic. I'll see if I don't pull a muscle, flabby from disuse.

By the way and for the record, it's hard as hell to remain silent about the insanity of the real world. Surgery blogging is a weak set of arms, paddling toward the surface, trying not to drown in the sea of stupid which laps ever more insistently at our shores. Pretend I didn't say that.

Rumbling

I feel a disturbance in the force, a stirring. Desire precedes delivery; but just this side of the edge of possibility I see resumption of Surgeonsblog, if only for a while.

There's no doubt I've always wanted to; it's been a combination of running low on ideas, and the taking over of my mind by the disignorable realities of politics, of our nation, our world. And it was easy: every day there are outrages aplenty, no end of blogfodder, as the evidence of devolution of our politics is everywhere. I suppose I got a few things out, decongested my hepatobiliary system. But really, it was the ever-truth that nothing I said on my other blog mattered. I always knew it. I don't know what led to the final recogniton that there was no point. Partly, I think, it was re-reading some posts over here, and the comments they engendered. It's not cold fusion, but I think it was useful, once in a while adding something to the common good, if only a tiny blip.

Here's the problem, though: now fully retired, I have only my diminishing memories on which to draw. My estimable surgical colleagues in the blogosphere are out there every day, doing good things and storing them up for good writing. I might have to steal ideas from them. I may have to repeat myself on a topic or two; spiff it up, add to it, make it better.

And I'd happily receive suggestions from any reader any time; comments here, or later. Barge in anytime. Meanwhile, I need a little more fermentation. But I think it's brewing.
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Alternate Universe

Careful readers of this blog, those attuned to subtlety, may have sensed an occasional tendency to dip a toe, if ever so carefully, into political waters. My opinions, shrouded as they have been in gentle deference, may not have even been recognizable as such. Generally shy, and of the belief that I have no right to impose my thoughts on others, it will surely be agreed that I've never said anything unkind or provocative about politicians with whom I disagree.

I may have to speak up.

I begin with a question, a simple request for factual input: WHAT PLANET IS JOHN MCCAIN LIVING ON? HOW MUCH EFFLUVIUM OF BULLSHIT CAN ONE MAN SPEW BEFORE CHOKING ON IT? DOES HE REALLY THINK EVERYONE IS STUPID, OR IS IT JUST HIM???

Long have I admired politicians across the political spectrum for their ability to say one thing and do another, evidently free of embarrassment. It matters only which party is in power: complain about the other party's tactics until the power is reversed, then do exactly what it is you've been decrying. Without shame, without a second thought, without the need even to mumble something like, well, I realize I used to say "A" and now I'm saying "Z," but...

A pox on both parties. I'm partisan, but not above realizing that at the national level they're all a bunch of bullshitters. Still. It seems there must be some sort of line beyond which people couldn't cross without a grain of self-awareness pulling them back. Y'know: a point where it's so obvious they'd be unable to keep going, throat constricting involuntarily, words so ridiculous they'd be unutterable. Not so, evidently, with John McPOW.

So we have the spectacle, this week, of the economic meltdown. (Let's ignore the previously most obvious fact that everything he's been saying about Sarah Bush-in-Lipstick Palin has been proven false while he and she continue to say them). In response to the crisis, Barack Obama got together with several real heavyweight people -- past chairman of the Fed, previous Treasury Secretary, most successful investor on the planet, several others -- and calmly (okay not entirely without a political jab or two) presented a summary of reasons behind the crisis, and an approach to dealing with it. Called for bipartisan cooperation. John McNuts, on the other hand, got up and.... blamed the whole thing on Obama!!! He -- mister point man of the Keating Five -- claimed it was Obama who somehow represented everything that was wrong in Congress. His entire response was political attack, and at that, one entirely ungrounded in fact. Repeating, umpteenth, that Harold Raines is Obama's main economic advisor, among other demonstrably false notions. Disproven. No matter. John McCain, who's been in Congress since before the Constitution was written, whose actual economic advisor personally dismantled the regulations that were there to prevent such things as have happened, whose most visible (until a couple of days ago) surrogate on the economy was the CEO of HP who was fired after killing its market value but who nevertheless got a thirty million dollar severance package -- this guy actually stood up and said everything that has happened is entirely the fault of Barack Obama.

I mean, come ON!!!!

He didn't, of course, stop there. While choosing, rather than proposing anything serious, to spend the entire time blaming Obama, his campaign denounced Obama for "politicizing" the crisis. Complained about fundraising emails while sending out fundraising emails.

I know some conservatives. Even like some of them. Many are educated and thoughtful people: honest, generous (up to a point). So I'm quite sure that when the lights are off, bathed only in the holy light from their shrine to Ronald Reagan, some of them are cringing. He's lost it, they must think (in fact, before he was nominated, most of them thought he never had it.) Politicians distort, obfuscate, ignore facts. But really. McBush and Palin have crossed that line by so much that they're entirely untethered to Earth. Don't they even care? Evidently not. Nor, it seems, do their supporters, waving lipsticks in the air like lighters at a Dead concert.

I read a couple of articles recently that have helped me to understand. Here's one. It's touching. The other, if it's repeatable and accurate, really gets to the nub of the matter. Read it, and decide for yourself.

The Bed In Which They Lie

Might there actually be justice? Could it be that McCain and his lipsticked liar have overplayed their hand to the point that even voters will notice? Is it possible that the dual deceivers have devolved in desperation, doubling down on duplicity? Might a campaign based on lies be rejected? Well, it's never happened, of course. But could it, finally? Would unsustainable deficits, lack of energy plans, an unfocused response to the threat of terrorism, health care failures, education devolution be enough to make a majority of voters think seriously enough to demand straight talk from their politicians? Not to mention their free press! Nope, nope. Probably not. But a guy can dream...

I've never bought the media-enabled persona of McCain as a man of integrity; but let's give him the benefit until now. Now. Finally, it's being asked: is there anything he and his campaign have been saying of late that's remotely true? Isn't it obvious that, whoever he might have been, he's happily and without any remorse lying about pretty much everything? Pigs, pork, sex-ed. Taxes. Travels, tallies.

And here's the thing: whereas it's clear that Sarah Palin and her fight against "earmarks" is a complete fabrication, even if it weren't, WTF??? I mean we're facing outrageous deficits and our debt is intolerable, with consequences so dire that practically no one is talking about them. (Want scary? Watch this.) So even if Slippery Sarah rides in on a white horse and eliminates all the earmarks that she ever asked for (lots), turns back all the money she kept from bridge to nowhere and other porcine programs (millions), and even if she wipes out all the acoustical aims of every other politician in Congress, it'd have virtually no effect on the budgetary problems we face. So it's a diversion, and a very cynical one at that. Talk all you want about Sarah Palin, says Juggling John. The more you do, the less time there'll be to look behind the curtain. 

What got me going this time? This. McCain's senior economic advisor, in a book to be released after the election, acknowledges that any president will have to raise taxes, that we simply can't sustain the current policies. And whereas McCain insists not only that he'll not raise taxes but lower them, and while he declaims against Obama for suggesting the need to raise them, the reality is that no one can or will speak about the fatuous folly. From the article, there's this:

"So why does tax-cutting mania persist among Republicans, I asked Holtz-Eakin, the McCain adviser--given...that, as Holtz-Eakin himself explain to me, taxes soon have to go up substantially in any event?

"It's the brand," he said, "and you don't dilute the brand." "

We are so screwed! I'm not so silly as to think that Obama and the Democrats will be lots better; but at least they're acknowledging the problem and saying unequivocally that the Bush tax cuts (which McCain has promised to make worse) can't be maintained. 

Patriotism. Love of country. Sacrifice. Country first. What empty words; how meaningless, as enunciated by John McCain and his apologists. In these dire times, what are called for are things no one wants to face: tighten our belts; use less oil; be willing to pay more taxes to save the country; address entitlements; stop useless military programs. Talk straight about oil, debt, terrorism. But that's the sort of straight talking that if McCain was ever for, he no longer is. Run on lies and innuendo and obfuscation; pick a veep willing to do the same, willing to say anything. Tabula rasa, like George was. Prestidigitation. It's obscene. At least they admit it:

“Every day not talking about the economy, the war and how to fix a broken system is a victory for McCain,” said John Weaver, a former top strategist to the nominee who left the campaign last year. “They’re going to ride it as long as they can and as long as the mainstream media puts up every ridiculous charge.”

The only way politicians would actually stand up on their hind legs and say and do what needs saying and doing, is if the electorate were to demand it; if they'd make it clear that the kind of sleaze, distractions, and phoniness that we're now seeing, mainly coming from the McCain side, will no longer cut it. Not now. Enough. Not in these times!

Might such a rejection actually happen? Well, so far it doesn't look like it. Fed a line of b.s. for the last eight years, told not to worry, everything's fine (well, not exactly not to worry: not to worry about anything but terrorism), voters expect not to be asked to think, nor to make demands. Prefer it, no doubt. So whereas it seems our pathetic media are finally waking up and seeing McCain and his campaign for the lies and sleaze that they are, I'm far from convinced -- the opposite, really -- that it'll make much difference. We're not about solutions in this country. We're about ignoring the facts, wishful thinking, scapegoating, and referring to anyone who points it out as part of the "hate America first crowd." Until that changes, nothing else will. And if it doesn't change in this election cycle, it'll be moot. The future will have slipped away irretrievably. Party on, dudes. Why not? They're playing the tune, and we're dancing. Party like there's no tomorrow.