Sunday, April 23, 2017

Executioner/Doctor

There was a very bad op-ed published in the NY Times Saturday by the writer/cardiologist, Dr. Sandeep Jauhar.  It's called "Why It's OK for Doctors to Participate in Executions" and that pretty much tells you all you need know.  If you were to  read something online entitled "Why It's OK for Rapists to Babysit Your Child" you would feel the same filthy layer of scum descend upon your skin as I felt when I read Dr Jauhar's inexplicable ode to Doctors of Death.

The piece comes on the heels of a recent decision by the good ol' state of Arkansas to execute 8 men on death row over the next 11 days--- not because their crimes were particularly heinous or irrefutable, or just from sheer coincidence, or some other fluke of timing in the sentencing--- but rather because the state's supply of IV drugs used in executions is due to expire by the end of the month.  There's enough in that last batch, apparently, to knock off 8 inmates.  So...while the iron is hot....

Dr Jauhar makes the error of assuming that capital punishment will never go away, that all we can do as a society is to figure out ways of rendering it in a less mendacious, less barbaric, more telegenic fashion.  And who better to assure that a lethal drug cocktail will be administered with elan and efficacy than a practicing physician?  After all, medical errors are the 3rd leading cause of death in our great country! Allegedly.

I need to break Dr Jauhar's piece down paragraph by excruciating paragraph.  It's the only way to do this with any justice.  Here's one paragraph:
The three drugs in Arkansas’s execution protocol — midazolam; vecuronium bromide, a paralytic used during surgery that halts breathing; and potassium chloride, which stops the heart — are administered intravenously. The execution procedure therefore requires the insertion of catheters, controlled injection of lethal drugs and monitoring of a prisoner’s vital signs to confirm death. This makes it important that a doctor be present to assist in some capacity with the killing.
What is it about "insertion of catheters, controlled injection of lethal drugs, and monitoring of a prisoner's vital signs" unequivocally necessitate the presence of a physician?  The next time I witness an actual real live doctor place a peripheral IV in a patient, inject a medication all by himself, and then check a set of vital signs will be the first in at least a decade of practice.  There is nothing about the act of lethal injection that is inseparable from physician presence.  The idea that basic procedures performed every day by nurses and EMT personnel cannot be duly done without a physician watching over their shoulders is both condescending and ill-informed.

Here's another paragraph:
 The American Medical Association, however, strongly opposes physician participation in executions on ethical grounds. Selecting injection sites, starting intravenous lines and supervising administration of lethal drugs, the association says, violate a doctor’s oath to heal or at least to do no harm. Doctors who defy the association’s guidelines face censure and the threat that a state medical board might revoke their license, though it is doubtful such punishment has ever been carried out. I disagree with this view. Though I oppose capital punishment as a matter of principle, as a doctor I believe physician presence at executions is consistent with our mandate to alleviate suffering.
Who edited this piece? Here we have a physician outlining the American Medical Association's firm stance opposing any physician participation in lethal injection executions and then, blithely, distancing himself from that view while still claiming to hold a higher moral ground---- he only wants to alleviate suffering!  That's obnoxious, man.  You want to stick a doctor in a death chamber with vials full of instant death and call yourself a hero because you are allowing for the state to eradicate a human in a way that seems quiet and unobtrusive and clean.  Even the kids can come out to watch.  Watch the bad man go to sleep, Johnny.  See?  See how peaceful he looks?  Is that a smile on his lips?  He's happier now!  His sin has been purified! Christ has smited him!.  Satan has him now!

I have to go to another paragraph before I start writing 3000 words in the voice of a Evangelical Christian from Little Rock talking to his kid at a state sanctioned execution:
A lot can go wrong during lethal injections. In 2014 in Oklahoma, to cite just one gruesome example, a 38-year-old convicted murderer named Clayton Lockett writhed in pain at his execution, clenching his teeth and straining to lift his head off the pillow, according to witnesses, after a botched injection into a vein in his groin.
A lot can go wrong?  Even with lethal injection?  State sanctioned murder for more civilized and  sophisticated tastes?  You don't say!   You mean that when dangerous drugs are given off label for purposes they weren't meant for that sometimes things can "get a little hairy"?  That's some wild and wacky shit.  Short side tangent here: Do you know why vecuronium is always included in lethal injection cocktails?  Because it is a strong paralyzing agent.  My anesthesiologist colleagues often use it to render a patient completely still when I perform abdominal surgery.  The purpose of the drug in a death chamber is pure optics.  The third drug administered, the actual killer, is generally a lethal dose of potassium chloride.  Once injected it causes a massive myocardial infarction--- which is excruciating.  Even the injection of KCL into the veins itself will make it feel like your arm has been lit on fire.  So to spare us the "theatrics" of a condemned man writhing and groaning in agony while strapped to a gurney, we give the paralyzing agent as cloak; to hide the unsavory awfulness of what an execution actually entails.

Here's 2 paragraphs in a row:

Sunday, April 9, 2017

Sunday Poem


Baked In





There is a sadness baked into existence.

Without it there’s no flavor.

You’d never know what to savor
Or how to wait for joy’s recrudescence

Your cupboard is a cage
Where it sits in darkness
Next to the cinnamon, pepper and sage.
Take what you need, cook your own catharsis

A pinch here, a dash there
Taste it as you stir the mixture
You always add more as time goes along
There’s no limit, you can’t do it wrong.
Some gets added when you turn your head---
It’s serendipity!
Never was a written recipe
Try to recall what mother once said

Put it in the oven and let it bake.
There’s no timer, it’s imprecise.
No way to know when the swirl of sadness coalesces
With the rest and then rises.
A taste you can only imagine will have to suffice

Look outside in the early pre-dawn, dark as sable,
Rows of homes with kitchen lights on.
All of us awake, anxiously waiting at tables
For our cakes to get done


4/9/17

Listening

From Erich Fromm's The Art of Listening:

  1. The basic rule for practicing this art is the complete concentration of the listener.
  2. Nothing of importance must be on his mind, he must be optimally free from anxiety as well as from greed.
  3. He must possess a freely-working imagination which is sufficiently concrete to be expressed in words.
  4. He must be endowed with a capacity for empathy with another person and strong enough to feel the experience of the other as if it were his own.
  5. The condition for such empathy is a crucial facet of the capacity for love. To understand another means to love him — not in the erotic sense but in the sense of reaching out to him and of overcoming the fear of losing oneself.
  6. Understanding and loving are inseparable. If they are separate, it is a cerebral process and the door to essential understanding remains closed.
 Some useful advice in there for the working physician.  It may not improve your patient satisfaction scores.  Press-Ganey is unlikely to have a metric that measures one's adherence to the above.  But a concentrated effort to focus on your patient's narrative with open mindedness, imagination, empathy and love sure seems like a good way to be a better doctor.

It's the best part of the job, really.  Once the OR lights go off, the post op orders are written, you finally sign out of the EMR for the night, what you will remember most are all those moments in time when you sat in a room alone with other human beings and listened to them tell you not only what hurt but what things were like before the pain started. Past and current lives and loves.  What the future might hold.  Expressions of gratitude and disappointment.  You will hear special and unique kinds of humor and anger and fear.  In a minute of side wise glances between spouses you will see the theretofore hidden dynamics of an entire relationship.  In short, you will experience the transformation of the human into the Human.  Real known people will emerge from the great mass of anonymity that we mindlessly push through every day like prairie grasses.  And all you have to do is sit there with patience and an open heart, ask a few questions, and just.... listen.


Sunday, April 2, 2017

A Nation in Pain

This past week, Governor John Kasich of Ohio issued an executive order limiting the amount of opioids doctors and dentists can prescribe to no more than a 7 day supply.  Failure to comply could result in disciplinary action, including loss of license.  Exceptions exist only for patients with cancer or those enrolled in hospice programs.  For all the rest, it represents a hard full stop.  No longer will the chronic pain sufferer, the woman status post lumbar back fusion x 3, be able to get a prescription for a month's supply of oxycodone with 3 refills.

On the surface this appears to be a reasonable initiative.  We are undoubtedly in the midst of a true crisis in terms of opiate/opioid abuse in this country.  It is a crisis that disproportionately affects the poor, the downtrodden, across large swaths of flyover rural America.  Something must be done, any reasonable elected official would say.  Over 50,000 Americans died last year as a result of an overdose.  Overall life expectancy declined last year for the first time in nearly 30 years, a decline mainly attributable to middle aged males and females from lower economic and educational attainment strata dying sooner.  Suicide and overdose have been targeted as culprits in this real "American carnage".

But what I am uncomfortable with is the evolving narrative that the entire crisis was fomented by evil "pill mill" doctors lining their pockets with cash as their patients spiraled into despair and degradation .  Certainly, bad apples are out there.  But anecdotal stories about physician malfeasance fail to adequately explain the opioid epidemic.  Why does it exist?  Why are so many Americans turning to escapist options to dull their pain?  What is this constant throbbing ache, this intermittent sharp twinge, that afflicts so many?  Why are so many from very specific geographic areas, from very specific socioeconomic stations seeking relief from a great contagion of pain?

It's easy to say: those damn doctors.  Bad doctors can be fixed.  They can be demonized as scourges upon society.  All stories flow easier with an identifiable villain.  But it's much harder to say: the structural/cultural/economic foundations of our country have been slowly eroding over the past 35 years and as the ramparts come tumbling down, those left exposed, vulnerable to the ravages of life's uncertainties will then turn to something, anything to assuage pain, numb anxiety.  A life lived in a state of constant uncertainty and despair breeds hopelessness.  And for many, escape becomes the only reasonable solution.

Since we embarked upon a path of free market globalization, our nation has seen a rise in income inequality that puts the Gilded Age to shame.  As the following graphs show:

Source: Emmanuel Saez, Center for Equitable Growth, June 2015
Source: Striking it Richer: The Evolution of Top Incomes in the United States, Emmanuel Saez, June 2015
Source: Institute for Policy Studies and AFL-CIO analysis of Bureau of Labor Statistics average hourly earnings data and corporate proxy statements, 2016

And how did this occur?  How is it that, in the richest, most wealthy nation in recorded history, so much of the fruits have gone to so few of its citizens? The answers of course, reside outside of what this blog post can elucidate, but the common theme revolves around wealth concentration and restricted distribution.  We have all driven by the shuttered factories in the heartland.  Those jobs shipped off to third world countries in the 80's and 90's will never return.  No longer can a male of mediocre intellectual talents just sign up for a job out of high school at the local Ford plant or the rubber tire factory and plan to settle in for 25-30 years of solid pay with good benefits and be able to raise a family, send his kids to college, retire at 65 with a 7 figure pension.  Those days experienced by the baby boomer generation, are almost mythically unattainable by the bulk of Americans in the heartland today.

And so what happens?  What happens when a man or a woman cannot honorably earn a living?  When the costs of higher education go up 400% over 25 years?  When health care expenses skyrocket beyond affordability and, in the absence of employer based insurance, become the driving etiology of bankruptcy and financial catastrophe?  What happens?  Is it simply of case of legions of evil doctors descending upon these wracked plains of a nation and unleashing their addictive and destructive medicines?  Is that the narrative we ought to go with, in the face of so much contrary evidence of systematic instability?

Governor Kasich and Senator Portman in my home state, have made the opioid epidemic a priority in terms of legislation and executive orders.  I am not so cynical as to doubt their motivations.  They see the pain and suffering in so many of their constituents and want to alleviate it, to the extent they are able.  But these measures are akin to the crackdown during the War of Drugs.  We ended up incarcerating millions of Americans (mostly minorities, mind you) without having any impact on drug use, especially in the areas where the crackdown was most targeted, i.e. the inner cities.  Prohibitionary measures simply don't work.  The evidence from the 1920's and then from the 1970-2015 War on Drugs era is irrefutable.  You cannot simply criminalize or police your way to complete abstinence.  The black market will always step in to fill the gaps in supply.  And the greater you restrict access, the more the black market will place its foot upon the throats of those clamoring for a fix.  The vicious cycle will continue.  The drugs will be less regulated, stronger, more dangerous.  More will die.  More will go to jail and be forever stained with a felony tag.  It would be a tragedy to repeat the same mistakes we've made in the past for this new scourge.

The real issue, the potentially fixable issue, is one of demand.  Why are all these Americans turning to the escapism offered in the form of heroin or prescription opioids?  And how can that demand be addressed?

We know that 20% of Vietnam veterans were addicted to heroin during the war.  But only a small percentage continued to use heroin once they returned home to America, back to jobs and wives and existential stability.  We know that in Portugal and Switzerland, opiate addicts can go to "clinics" for heroin injections early in the morning on their way to work.  That many of them eventually simply stop using the drugs as they become more and more integrated back into stable and meaningful life routines.  In America opt to do things differently.  Marijuana is categorized as a  Schedule I substance (no accepted medical use).  Addicts are treated as derelicts, scum of the earth.  We continue to incarcerate more people for drug related offenses than the rest of the world combined.  And nothing has changed, nothing has improved, despite the trillions of dollars spent on this ill-advised "war" over the past 35 years.

A nation writhes in pain.  No one can avert their eyes from it.  Our ER's fill up nightly with overdoses.  The young and middle aged are dying in unprecedented numbers.  A plague is upon us.  You can regulate doctors a little more, I guess.  You can repudiate the idea that "pain is the fifth vital sign", as the American Medical Association has done.  But you can not simply tell people that they are not hurting.  You cannot erase the pain of dislocation, uncertainty, economic catastrophe.  You cannot tell a man with three kids, a drug habit, trapped in rural middle America, that the pain he feels every morning in his back, his joints, his heart and soul is somehow not real.  That he ought to feel shame.  That it is somehow all his fault.  

You can threaten doctors.  You can cut off the legal flow of a few bottles of prescriptions drugs.  But it won't stop the pain of the millions with no prospects and no hope.  Kasich's order is a band-aid applied to a gaping hemorrhaging wound.  It's something, I guess.  But it isn't nearly enough.





Sunday Poem

The Pattern of this World

Romans 12: 1-2  Therefore, I urge you, brothers and sisters, in view of God’s mercy, to offer your bodies as a living sacrifice, holy and pleasing to God—this is your true and proper worship. 2 Do not conform to the pattern of this world, but be transformed by the renewing of your mind. Then you will be able to test and approve what God’s will is—his good, pleasing and perfect will.


She lie wasted and hollow eyed and thin
A skeleton hung with threadbare robes of skin
The CT scan showed free air, extravasation
I rushed in, found her swallowed by sheets and blankets
Alone, shivering, at the last way station


She showed me the spot where it hurt
And I found the other places, here, and over there.
She grimaced as her abdomen stiffened
And then smiled, as if to apologize, a soul imprisoned---
Anorexia, drug abuse, years of imperfect will


Later on she lie splayed on the OR table arms extended
As if an offering on a cross, a life expended.
The hard lights shined truth on her naked flesh
The tattooed verse etched in Olde English across her pale chest


Her bowels were limp and gray and lifeless
Like the newspaper left out in a rainstorm
The words smeared and meaningless.
Handle gently, all falls apart; words, world, body---
The patterns lose form

4/2/17

Saturday, March 25, 2017

21st Century Scourge

The CDC recently put out a paper in their Morbidity and Mortality Weekly Report (MMWR) that studied the likelihood of long term opiate use after initial treatment with an opioid medication for acute pain.  The results, for me as a regular prescriber of opioid medications, were fairly shocking.  The study randomly reviewed 10% of patient records from the Lifelink database over the time period of 2006-2015.  If a patient was given a prescription for an opioid for longer than 10 days, there was a 1 in 5 chance that patient would be a regular opiate user one year later.  That's just staggering.

Few are unaware of the opioid epidemic sweeping through America.  In 2015, 52,000 Americans died from opioid overdoses.  That's more than the number of Americans who died during the peak of the AIDS epidemic.  And this scourge has been particularly problematic in predominantly rural, working class areas.  The mortality rate for white, middle aged Americans without a college degree has gone up a half a percent every year from 1999-2015.  This precipitous drop in life expectancy amongst a demographic cohort is unprecedented in an advanced western democracy--- the only comparable decline was seen in Russian males in the immediate aftermath of the fall of the Soviet Union.   Many epidemiologists attribute much of the startling rise in death rates of white middle aged Americans to opiate overdoses.  But it's far more complex than a simple x=y formulation.

The MMWR paper identified several risk factors for long term dependency: female sex, older ages, prior pain diagnosis before opioid initiation, and patients who were either publicly insured or had no health insurance.  In addition, the risk of long term opioid addiction in patients who receive short acting narcotics like Percocet or Vicodin (the ones I usually prescribe for post operative pain) is actually fairly low.  There seems to be a cumulative dose threshold of 700 mg morphine equivalents, after which the risk of long term use rises exponentially.  More powerful narcotics, especially dilaudid and fentanyl, will narrow that safety profile window.

One of the best books I've read in the last 10 years is Johann Hari's harrowing Chasing the Scream, a historical review of the "War on Drugs".   Substance abuse has long been understood by most Americans as either a manifestation of personal weakness or of illegal drugs getting their "chemical hooks" into your brain and never letting go.  This is a faulty and wrong and harmful way of thinking about substance abuse.  This blog post is not the place to dutifully review the complexities of Hari's book but I will give one example.  In the Vietnam War, over 20% of American troops-- marooned in a chaotic, sweltering jungle for opaque reasons, facing the threat of their own mortality day after day--- were using heroin on a regular basis.  But then when returned to the United States, over 85% of those users simply stopped using the drug.  Environment matters.  A sense of purpose matters.  Personal security matters.

The theme of Hari's opus is that addiction is a function of isolation and despair.  Whether it's Vietnam or a hard scrabble existence in a broken down rural Ohio town hollowed out by factory closures and shuttered businesses, when a man or woman faces uncertainty and existential dread, some will turn to alternative forms of escape.  Some regrettably will turn to drugs in order to cloud the mind.

In America, we turned our backs on the blue collar backbone of our nation.  We weakened unions and shipped jobs overseas and embraced all the ideals of a " new globalist century".  But we never thought about what would replace the old models.  We never constructed an adequate social safety net.  We let college tuition costs skyrocket to such an extent that even state schools are out of the range for the average American.  The exponential rise in health care costs was increasingly passed on to individual Americans in the form of high deductible plans and rising premiums.  Wages stagnated.  The imbalance in wealth distribution in this, the wealthiest nation in world history, reached banana republic proportions.  We stole the opportunity to make a good living, the ability to raise a family, from the millions of "slightly above average" Americans and passed on the proceeds to a tiny sliver of the super wealthy.  We asked too much of our Heartland to forego their own dignity in order to drive the inexorable upward rise in the Dow Jones.

And so no, as a surgeon, I take no responsibility for the opiate epidemic.  I will continue to prescribe Motrin 600 and 10-15 percocets for my post operative patients to ensure they have adequate pain management after elective surgery.  The cause of the opiate epidemic is not doctors or "pain as the fifth vital sign".  The cause of the opiate epidemic is economic stagnation, collective despair and the inability (or outright disinterest) of our government to do anything about it.

To paraphrase Hari:  The treatment for addiction is not criminalization.  The treatment for addiction is love, solidarity, expanding the idea of community.  To give back to the people the notion that life is not hopeless. To re-assert that the American Dream is not just a bygone myth.....


Thursday, March 23, 2017

GOP Grasp of How Health Insurance Works is Dumb and Also Very Dumb

Between cases today I watched a little of Sean Spicer bloviating at his daily press conference. He seemed vastly uninformed on the nature of Essential Health Benefits (EHB) and how health insurance works, in general.  As per Spicer (start watching around 13:45):




Mr Spicer seems to think that health insurance premiums are going up because people are being forced to buy health insurance packages that they don't need.  Old men buying maternity leave "packages" and young healthy Americans being forced to buy "Cadillac all-inclusive prescription plans" when they are perfectly healthy and fine.

This is very dumb.  It betrays ignorance.  It is embarrassing.  It befuddles.

First off, insurance premiums have not "skyrocketed" under Obamacare.  Americans who obtain their health insurance through employer based plans, which represents the majority of Americans, have indeed seen their premiums rise, but at a much lower rate than they had been rising prior to the passage of the ACA.  Let me say that again.  Health insurance premiums had been skyrocketing for years prior to 2008, contributing to wage stagnation, higher deductible plans, and an overall sense of panicked consensus that "something needed to be done".  This is a fact.  

Secondly, health insurance doesn't work like this.  You can't just go to the "insurance store" and peruse the shelves, looking for a product that "fits your needs".  Illness and disease are unpredictable events.  You can't reasonably say, oh I'm a healthy 29 year old male.  I don't need insurance.  I'll just a get a bare bones plan like I have on my car.  It's possible that you may remain healthy and avoid lymphoma or perforated appendicitis or a car accident that results in a 3 week ICU stay and 6 weeks of rehab in a brain injury facility.  Odds are, you'll get away with it.  But if everyone in reasonably good health opted to either not buy insurance at all or just buy a cheapo plan to cover catastrophes, you leave large swaths of Americans, the ones with chronic disease, serious illnesses, expensive health care needs, who are left to purchase the more encompassing plans.  What would a reasonable person conclude if this were to play out?  What would happen to the premiums on those plans covering sick, high cost Americans in a market run by private, for profit insurance companies?  Well the premiums would have to go up, stratopherically, in order to maintain that thin profit margin.  The death spirals would ensue.  The market would collapse.  It's just common sense.  Freshman year economics.

Health insurance is not a "product" like other tangible goods.  It isn't something you run down to Target and purchase.  You can never predict how much health care you will consume at any given time, either now or in the future.  (Actually that's not true.  You can be assured that you will need more health care the older you get.  Thank goodness for Medicare!)  But the fact remains, health care costs are abstruse and opaque.  You cannot make an "informed decision" on what you need.  Not now and certainly not ten years from now.

The only way it can all hang together, absent a move to a single payer system (like Medicare), is to mandate universal participation in health insurance markets, regardless of actual, in the moment health care needs, and to remove the profit making incentive from health insurance companies, i.e. they must re-invest any surplus premiums back into patient health care needs.  This is how it is done in Germany and France (where universal coverage is achieved, without resorting to single payer, at half the cost).

So no, Senator Roberts, you aren't being asked to "give up your mammogram benefits".  If a nation decides to ensure that all its citizens are to have medical coverage, then, to paraphrase Dostoevsky, we all must become responsible for one another.  My premium will fund your mastectomy and reconstruction and hopefully, some day, your premium will help fund my 2 week stay in the ICU after a rocky post op course following a prostatectomy.  A nation that stands together in illness, will heal together.  .

Unfortunately, the United States has yet to make that leap of moral imagination.  We remain the last advanced western democracy without universal health care coverage. If only the shame of this  might suddenly alight in the consciousness of folks like Sean Spicer and Paul Ryan and Pat Roberts....

Sunday, March 12, 2017

Paul Ryan and the Triumph of a Cynical Barren Idealism

My son watches a lot of old hockey highlights in YouTube.  One day he came across a grainy video about the "Miracle on Ice", that time way back in 1980 when a ragtag bunch of college kids shepherded by Herb Brooks went toe to toe with the mighty Soviet hockey machine and somehow pulled a monumental upset out of their asses.  It was a time when America was "going through a bad time".  There was the hostage crisis in Iran, the Soviet Afghan invasion, stagflation, the Carter doldrums, the post Vietnam hangover.  The Red Army was on the move across the globe.  Things seemed dire.  And then this plucky band of young kids looked the lion in the eye and achieved unexpected glory one cold February in Lake Placid, New York.  I remember watching that game.  I was almost 7 years old.  Mike Eruzione.  Jim Craig.  Al Michaels.  Something seemed to shift afterwards,  a renewed sense of purpose and pride that diffused through the whole country.  Not trying to aver that it represented some sort of geopolitical turning point.  But something shifted.  The national mindset changed.  It was the last time I ever remember the United States as an underdog.  This is a difficult concept to convey to a five year old who just wants to watch Patrick Kane put another puck top corner.

A lot has changed since February 1980.  We are different country.  We have not been the underdog in a long long time.  Ronald Reagan swept into power with his vision of the shining city on the hill.  The Soviet Union collapsed from within leaving the the United States as the unparalleled, unquestioned world hegemon.  Exponential economic growth has positioned America as the wealthiest nation in recorded human civilization. To what extent we have squandered our unprecedented bounty will be debated by historians decades hence.  But we are certainly no longer the underdogs.  Our military bases range across the globe.  We have been in a near-permanent state of war, both formally declared and otherwise, since the end of WWII.  We are the only nation to have dropped a nuclear bomb.  We have invaded and occupied lands far away, under pretenses both misguided and outright false.  During the post-9/11 era, we even embraced torture, indefinite detention, and the surveillance of domestic communications as reasonable uses of state power.  We became bullies, asserting our will in ways our Founders never would have imagined.

In meantime, much fell by the wayside on our own shores.  The wealth and prosperity boasted about in our increasingly financialized and unregulated economy failed to materialize at the local level.  Wages stagnated.  Incomes tailed off.  Jobs disappeared.  Factories shuttered.  Small towns in Ohio and Kansas and Illinois went into a long irreversible decline.  Supply side trickle down theories of the Reagan years were empirically repudiated.  Neo-liberal centrist policies focused on globalization  during the Clinton era resulted in off-shoring and free trade deals that hurt the vast heartlands of America.  Income and wealth skyrocketed for the tiny select few while, for the mass of average, blue collar Americans, real living wages and income did not keep pace with the costs of living.  A gap developed which soon widened into a vast canyon between the haves and have-nots. The wider the gap, the easier it is to fill with resentment, tribalism, nativism and anger.  The talented demagogue knows this quite well.  Take a man's job, his means of providing for his family and you take his dignity.  Compound the error by lecturing to him about how he needs to stop being so racist and misogynistic and trans-phobic and he will turn as fast as you can say "Danton" to a Strong Man who promises to make everything "great again".  The very personification of the bullying nature the country has cultivated since Lake Placid, the Great Leader will come to punish those namby-pamby language police in academia and all those corrupt pigs at the trough politicians in Washington DC who made careers out of betraying their own constituents for personal enrichment.  And here we are.

I try not to dwell too much on these themes.  I have a busy life and I have to stay focused, not get too bogged down with patriotic despair.  But then I see a tweet from the current Speaker of the House like the one below and my blood just goes into full boil mode.





Former President Barack Obama presided over the passage of the Patient Protection and Affordable Care Act (PPACA) 7 years ago.  Known as Obamacare, even before it was actually passed, the act was met with unprecedented opposition from the GOP.  Which would have been fine, as far as that goes in politics, if the opposition party had only put forth their version of how health care needed to be reformed and, accordingly, the two sides could have hammered out some sort of Obamacare-weighted compromise bill .  But there was no alternative bill.  Beyond a few tired and worn out bromides about "health savings accounts" and "opening up intra-state markets" and, of course, "decreasing regulations", PPACA was countered with nothing but vitriolic rhetoric and opposition.  This, for a bill that, to a large extent, was a direct descendant of ideas hatched in conservative think tanks and tried out with some success as a pilot project in the state of Massachusetts under the governorship of Mitt freaking Romney.

And let us be very frank: health care reform was inevitable.  Nearly 50 million Americans were without health insurance in 2008.  Insurance companies run by CEO's earning 8 figure salaries could deny insurance to people with pre-existing conditions, could cap yearly and lifetime benefits, and could cancel your policy at any time.  Health care costs were exploding; the United States was spending 17% of its GDP on health care sector alone.  Employer-based insurance, long the backbone of the American health care system, was feeling the pressure of an aging population and higher costs and so transitioned to offering more high deductible plans, shifting those cost burdens on those who could least afford it.  Health insurance with a $5-15k deductible is not insurance.  Change was needed.  It was almost a matter of national emergency.

And so for 7 years we have heard over and over, ad nauseum, about the "disaster" that is Obamacare. How it is a job killing, innovation and entrepreneurial stifling government take-over of the health care sector of the economy.  For years, it was the one constant theme in elections from the local level on up; Republicans would fight to repeal Obamacare.  From day one.

Now, I personally have some major issues with Obamacare.  There still remain some 20-25 million Americans without health care.  The cost control mechanisms are just a hodgepodge of pilot projects, the overwhelming majority of which won't work.  It mandated electronic health records without ensuring inter-operability between competing EMR's in different health care systems.  Too much of it hinges on the expected good will of governors of red states for the Medicaid expansion.  The mandate is too weak.  The exchanges were poorly conceived.  There are better ways.  The Germans and French and Japanese have figured out better ways, without resorting to single payer goverment-run health care.  (Hint: you need universal citizenship participation to ensure better risk pools and you need to mandate that if your sickness funds or insurance carriers are to be privately run, then they must, by law, be non profit entities)  But it was a needed first step.  Something to build upon.  To be tinkered with, added to, improved.

But Paul Ryan wants none of that.  Yes, with his AHCA bill, he declares he will keep most of the regulations banning the denial of coverage and rescission and benefit caps.  But he's just cherry picking the universally loved components of  PPACA for political gain.  There's no actual replacement plan in the bill--- just a series of measures that will weaken or outright eliminate over time most of the structure of Obamacare without supplying the necessary scaffolding to prop up what's left.  It's terrible and cynical and hollow-minded.

For so many years Paul Ryan has represented the "intellect" of the Republican party.  He has always been the "smart as a whip" policy wonk lending a thin patina of intellectual legitimacy to Tea Party angry hollering.  But he's revealed himself to be a fraud.  This bill, this AHCA is a fraud.  It cuts the legs out of Medicaid expansion.  It is a gargantuan tax cut for the wealthy.  It will lead to death spirals for the non-Medicaid, non-employer based health insurance exchanges.  For too long, we have heard nothing but platitudes about "free choice"  and "getting government out of the business of healthcare" and that plays well as a series of sound bytes on the Sunday shows.  But where is the nuts and bolts of actual governance?  Where is the framework for a system that will work?  If for too long, you spend all your time just articulating talking points and ideologies without having to worry about the practicalities of implementation, at some point the words just become...words, drained of any meaningful context, devoid of pragmatic utility.  Less a mode of communicating concrete policy meant to assuage human suffering, and more just a means of signifying where one stands on the continuum of socialism vs capitalism, collectivism vs individualism.  And so words became barren.

In the above tweet, Paul Ryan reveals this idea, to an almost embarrassing degree.  The Emperor without his clothes, on social media.  Freedom?  Freedom to do what, exactly?  Not buy insurance?  As if health insurance is some sort of tangible elective product one can either choose to buy or not buy at Target or Wallmart?  To paraphrase Dr Gawande from his most recent New Yorker article, we all have a pre-existent condition.  It's called mortality.  It's the one thing where we can say, with unvarnished truth, that we are all in it together.  For all of us, it's a matter of time.  Paul Ryan's bill represents a complete disconnect from the actual lives of actual Americans, their struggles and worries.  As if what keeps the average 52 year old man in Iowa up at night is disquietude over whether or not he will be able to forego health insurance for the coming year since his only health problem is "a little bit of the gout".

Our country seems split at the seams right now.  We've been in this boat before.  We even turned our guns on one another, cousin against cousin over the right to own other humans as property.  We have become two countries again, speaking over and around one another like blinded prophets wandering in the same forest.  Tribal partisanship and mutual suspicions have poisoned the arena of productive discourse.  I fear the chasm this time may be too broad to bridge.

But alas we all will face decline and sickness, pain and suffering.  Like Falstaff, we all "owest God a death".  It pauses for no mortal.  That we cannot alter.  But we can take care of one another.  We can do that for God's sake.  We can ensure that, at least within these borders, no man or woman will face financial catastrophe or be forced to choose between health and some other base necessity.  We can ease the downward fall.  We can choose to do this.  We have the means.  We have the principles embedded in our culture, our manifold religions, our shared history.

I remember that night in Lake Placid, watching Herb Brooks' boys take down the Soviets.  I watched it by myself but I remember exactly how I felt.  Pride, solidarity.  Hopefulness.  I felt that I was not alone.













Saturday, March 4, 2017

Ten Years In

My first day as an attending general surgeon in Cleveland, Ohio was August 7th, 2006.  I saw one patient with a hernia in the office that day and then, around 430 pm, the call came in from the pediatric ER about a kid with abdominal pain.  Some healthy 17 year old boy with obvious early appendicitis.  I booked the case, tip-toed my way through the laparoscopic appendectomy uneventfully and went home feeling awful proud of myself.  It was exactly how I envisioned a life as a general surgeon.  I had been a confident 5th year resident.  I hadn't done a fellowship.  I had felt ready.  I was ready to take on the world.

A whole hell of a lot has happened since then.  Ten years have elapsed in the blink of an eye.  Thousands of cases.  Thousands of patients.  I have two beautiful kids now, 5 and 8.  I was married, then divorced, and now married again.  Life rolls on--- you don't realize how it slips away in the accumulative moments, the episodic nature of consciousness, the way we compartmentalize chunks of time. As Auden said:
‘In headaches and in worry
   Vaguely life leaks away,
And Time will have his fancy
   To-morrow or to-day.
Nowadays I'm busy as all hell.  My clinics are jammed.  My OR block times are filled far in advance.  I did 900+ cases last year.  I'm on ER call pretty much 180 times a year.  I've built a career and a reputation in a pretty competitive market.  I drain abscesses and hemorrhoids in the office.  I whack out lipomas and epidermoid cysts.  I do bread and butter laparoscopy (gallbladders, hernias).  I use the robot.  I get to do enough of the more complex stuff (colons, Nissens, etc) to stay sharp.

And I love it still.  I can't imagine doing anything else to fill the hours of my days on Earth.  I was made to do this job.  Certain personality quirks come in handy: obsessive compulsiveness, work ethic bordering on the pathological, single mindedness, a baseline anxiety only partially quelled by work and more work, an innate desire to please, to prove one's worth to strangers. It isn't a life for everyone.  It can be brutal and exhausting and self defeating.  But I was born for this.  The idea of a community general surgeon with a wide armamentarium of skills may be a dying paradigm in this era of super specialization, but the life I am living now was always my vision.

Older surgeons, as a way of passing on sage advice to residents, used to resort to tired cliches like: "Know the 3 A's of a successful practice--- Ability, Affability, and Availability".  Those things are still in play.  You can't be a dick to everyone.  You have to be nice all the time, now---not just when you see referring docs at medical staff meetings.  You can't throw scalpels around the OR.  You can't tell a PCP "no" when they call you about a hemorrhoid on Friday at 445pm  And you can't be a hack.  You can't be the guy everyone talks negatively about in the PACU or SICU when you're not around.  The most truthful component to your reputation is the way the staff at the OR where you work  feels about your talents.   The 3 A's still hold sway.  But there's more to it than that.  A truly satisfying life as a general surgeon is not so easily distilled by just three letters.  I'm a grizzled, gray bearded old vet now.  I think I've earned the right to weigh in with a few of my own thoughts.

1)  Humility, and being humble, is universally lauded as a personality characteristic of the "well adjusted".  No one really likes a pompous dick (well, except for the 40 million Americans who somehow voted for the current POTUS).  Nothing will turn off a patient, a nurse, a physician colleague, a hospital administrator, any goddam regular-ass human faster than behavior that is perceived to be "arrogant" or "lacking in humility".  This is tangentially related to the Affability component in the 3 A's but it's deeper, more complex.  You can't just decide one day that you are going to be a swell humble guy.  It cannot be a persona one dons.  False humility, humble-bragging, lightly cloaked self-effacement is all too transparent to people who have experienced actual loss and trauma and despair.   At least that's the way I have always felt.  You can't fake it.  It's not that easy.  True humility can only arise out of something real and true and lasting.

 And in my mind, the provenance of authentic  humility is humiliation.  The life of a general surgeon, especially in the nascent years is a series of humiliations.  I mean this in the best sense, the most edifying sense of the word.  It has always been humiliating to fail in front of others.  Forgetting your lines in a grade school play.  Showing up for a first date with your zipper down.  Missing a penalty kick to tie the game with seconds left.  Humiliation is painful and demoralizing; for the first time you begin to honestly doubt all your preconceived notions of who you are.  Am I worthy, do I even belong on this stage?  A general surgeon experiences humiliation on a near daily basis early in his/her career. The 2.5 hour laparoscopic cholecystectomy, the moment during an anorectal case when you inexplicably aren't exactly sure of the anatomy and you make the circulating nurse call your senior partner in for help, the cut ureter and the sheepish call to a urologist, the anastomotic dehiscence, the Lushka leak, the recurrent hernia 6 months later, the flubbed lines of an inexperienced doctor trying to offer final parting words to a dying patient's family, the poor judgments, the complications, the sleepless nights replaying surgeries and decisions over and over in your mind.  The alarm goes off early.  Your eyes flash open.  Another day to face.  Another chance to make it better.  To get better.

Three things can happen at this point.  You can ignore the humiliations and become a false person, a shitty surgeon, a sell out.  (More opt for this  than we'd care to admit.)  You can quit.  I mean, sometimes it's just not worth it.  Get out when it becomes clear you've lost the will.  But you can also just accept it, the humiliations.  You can own them.  You can accept that you have failed both yourself and all those previous patients who trusted you with their lives.  You can accept it.  And then you can show up for work the next day and when you walk into that next patient's room, something seems different.  You feel relaxed.  You smile before you have spoken.  It just happens.  You feel blessed and calm and grateful. You experience for the first time true humility.  And the patient who meets your gaze knows it instantaneously.  It's what they've all been been expecting all along.  Finally you can get to work.  You can do what you were meant to do.

2)  I wrote a piece 7 years ago about what the recently deceased JD Salinger could pass on to new doctors.  I'm a different man now than what I was back then.  But the sentiments I expressed in 2010 still hold up after all these years.  There are two components to making the best of this gig.  One, you have to do everything patient-related with all of your damn heart.  You have to check those labs every day and follow up on x-rays.  You make your rounds and you sit down in that pleather chair bedside and listen to them even when they bore you.  You have to sit in that chair long enough until it stops being boring or annoying and then, inexplicably, before long, you won't want to leave, you'll want to order a bottle of fucking Beaujolais and listen to them all morning long.  You have to call the ones you're a little worried about on their cell phones with your own cell phone without doing the "star 67" thing.  You change your own dressings. You put an NG tube in when the nurses can't get it.  You prep your own patient on the table.  Put a damn Foley in when the young new PA can't seem to get it to go.  Call your referring doctors.  Text them.  Send emails.  They know and love these patients more than you will ever know.  God I hope they do.  I barely know these people and I'm always sad when they walk out satisfied, healed, never to return.

The other part is more difficult to explain.  It resides in the realm of the poets and painters and artists.  It's a little more abstract that just work ethic and dedication.  You have to make sure that, every time you walk into a patient room or glove up in the OR, no matter how tired you are, how much stress you're feeling, no matter how much work you have left to do that night, you have to strive to make sure that most of your stars are out.  Stay above the fray.  Keep that bird's eye view.  Find that sliver of darkness between the silvered clouds where your stars are always shining.  They will guide you through the toughest of moments.  When your stars are out it's never really all that dark.  It will sustain you.  Remember always, this is what you worked so hard to attain.  You are doing the very thing you hoped would happen when you were young.  Rise above the desultory drudgery of EMR charting and high maintenance patients and 3am ER calls about nursing home patients with fecal impaction.  You won't always find all of them.  Some will hide behind clouds.  But most will be there.  Just make sure you look up every day and every night.  You will find them by looking.

3)  Once as a fourth year resident I was making rounds with Ted Saclarides, MD on the colorectal service.  We were talking about how demanding and all-encompassing our chosen field could be.  The residents were grumbling and whining about how we never saw the sun that month.  Sac just sort of smiled and shook his massive head.  He told us he worked harder as an attending than he ever did as a resident.  That he spent so much time in the hospital he had missed a few of his kid's birthdays.  It didn't seem to bother him.  He said that he was a surgeon.  That this was what he had always wanted to do.  He liked being busy.  He liked being in the hospital, taking care of patients.  He was a surgeon, first and foremost.  It was his identity.

At the time I just sort of felt sorry for him.  It seemed ghastly.  Missing your kid's birthday?  Defining yourself by what sort of work you did during the day?  How sad and provincial--- a life abridged, it seemed.  Instead, I saw a future that was broad and more diverse.  I had so many other interests and goals and dreams.  To be a good husband.  To be the sort of father I wish I had.  To travel the world.  To write stories, maybe even the next Great American Novel.  To learn about all the millions of non-medical things I didn't yet know.  To read and think and grow as a simmering human soul.  This poor middle aged sap, I thought.  He has no idea what he missed.

But of course, life happens to us all.  We get bogged down, thrown off course.  Time has its fancy.  Books we meant to read collect dust on shelves.  Marriages break down.  You find out that being a father is harder than you ever imagined.  A few short stories get written but you realize they're all for shit.  The novel hibernates in notebooks for years, stashed in a desk drawer.  But one thing doesn't change.  Every day the alarm will go off at 430am.  Every day you find yourself at the hospital, making rounds, meeting patients for surgery, writing notes, dictating, rushing off to see someone in pain in the ER.  Most days your efforts and exertions will be directed toward fulfilling your duties as a doctor, a surgeon.  Those days will add up.  In the end that's all there is.  We simply become the person who has lived the life we have had.  And that's OK.  We do the best we can.  There's only so much time.  We read those books at night when we're not too tired, albeit more slowly.  We know we won't get to them all.  We enjoy those moments with our families when we can.  We find ways to unwind without ever completely disconnecting from the essential source of our identity.  We become surgeons without even really intending to.  You can't hide from it.  At some point you have to embrace it.  Let it seep into you, let it be quilted into the fabric of your being.  You'll wake up one day and realize that you are indeed, first and foremost, a surgeon and you will not regret it.    

Sunday, February 8, 2015