Saturday, August 19, 2017

Charlottesville Thoughts

I grew up in Massillon, Ohio--- an ethnically and culturally homogeneous small rural town with a foundering manufacturing base. I was raised by a single mother, visited my father in Arizona in the summers. We lived in relative poverty for years after the divorce. We barely scraped by, to be perfectly honest. (We ate a lot of tuna casserole on Wednesday nights). I was always loved and supported but something always felt amiss. I had grandparents and relatives who casually dropped the "N" word at family gatherings. I was told that mixed race children were bad because "they get rejected by both the blacks and whites" as if one needed a certain skin tone for admission to a tribe. My high school was 98% white. I never really had an actual conversation with a black person until medical school.
I was also blessed with a certain unearned, undeserved intelligence. I did well in school and was able to go off to college and then to medical school. Today I am surgeon in Cleveland and 1980's Massillon seems eons ago, and millions of miles away, even though I could drive to my childhood home in less than 90 minutes if I wanted.
But events like the violence and hatefulness demonstrated in #Charlottesville yesterday bring it all rushing back. The notion that White Supremacy is baked into the essence of America cannot be easily dismissed. As Ta-Nehisi Coates has more eloquently stated in his magazine pieces and books, America is built upon the idea of plunder. Plunder of land, of labor, of life by the "more deserving" Anglo-Saxon elite. In this reprehensible worldview only the White Christians of Western European origin are fit for power. For the racists and white nationalists, subjugation of Africans, of Native Americans, of Hispanics, of the non-Protestant religious is not only justifiable but even morally desired for the betterment of all humanity. As Robert E Lee (the man for whom the Alt Right protesters were ostensibly marching to defend yesterday) said: "The blacks are immeasurably better off here than in Africa, morally, physically, and socially. The painful discipline they are undergoing is necessary for their further instruction as a race, and will prepare them, I hope, for better things. How long their servitude may be necessary is known and ordered by a merciful Providence. Their emancipation will sooner result from the mild and melting influences of Christianity than from the storm and tempest of fiery controversy."
Today I live in an ethnically diverse part of Ohio. The majority of my patients are African-American. My colleagues in medicine are Black and Jewish and Asian and Muslim and Hindu. My medical assistant is a strong African American woman who works her ass off and treats my patients with dignity and respect. For all this I am eternally grateful. My life has become far richer with the experience.
It started with medical school, intensified during surgical residency in Chicago and then blossomed here in Cleveland. Something happens to a mind and a body when you are able to escape the arbitrary constraints of provincial narrow-mindedness. There's a wide wide world out there. And the the further you venture out, the more you find that the extent of the world can be found in the heart of your own soul. You never knew the secret was wrapped up inside, that you needn't go far to find it. In sickness, in pain and suffering, we all cry out with similarly pitched wails of protestation. White or Black or Asian, we all suffer. We all are loved. We all err, we all rue lives lost, chances missed, paths neglected. We all have parents who mourn our failings or falls. We all wish we were better, more loving, more understanding. Life for all of humanity is a series of failures. If we are lucky, we rise from bed each morning with the yearning to maybe make things just a little bit better, incrementally. In medicine, the facade falls away and you see people without any of the obfuscatory bullshit. The authenticity available to a physician is the greatest of all privileges. It may have saved my soul, in particular. Too easy it is, in this fallen, inadequate, craven world to succumb to an overwhelming cynicism and despair.
And so today I say, unequivocally, that I denounce in no uncertain terms the UniteTheRight protests in Charlottesville yesterday. It wasn't "both sides". It was one side promulgating the absurdist notion that one's skin color is a marker of human superiority. This "side" has no place in 21st century America. Beneath the relative melanocyte content of your skin, beyond the arbitrary nature of one's parents' provenance, there resides a commonality shared by all the living. We all have had our hearts broken, we all have faced the sudden pre-dawn stifling fear of our own imminent mortality. Life is a shared experience lived through a seemingly singular consciousness. After all these years that's the only thing I have really ever known to be true. All else is up for interpretation......

Sunday, August 13, 2017

Sunday Poem


The experts now say that bowel sounds don’t matter
That tinkling awakening of the gut
Like all timeworn customs, time shatters.
When to feed used to be so open and shut
Whether ileus, post traumatic
We listened first, it was axiomatic

Lightly press the stethoscope for guidance
A gray moon in early dusk
But it’s a hollowed-out husk
Here there is something worse than silence
A conch against your ear
But it’s not the ocean, I fear,
It’s all the air in the world rushing to escape;
Breathe deep, before you suffocate

In dreams I linger here, convinced I hear something stirring
Or is it the bed creaking, the diaphragm shifting on your skin
Absent bowel sounds, absent sin
Or just forgotten?
Where have you gone?
I wake thrashing to a shrill whirring
Of wings beating in the early dawn
All we used to know and have, sadly misbegotten

I didn’t want to proceed until I heard a sign you were alive
You must stay right here under my watchful eye
But now they say those sounds never mattered---
You’re free to go.
In the silent winter I went crunching through the snow
To the edge of the creek and stamped my boots
Until all the thick black ice shattered
There’s so much to see below
Sticks and stones, dead leaves, broken off roots.

What would I do instead?
Fall prone and, against the frozen slab, press my ear?
I’d be afraid of what I might hear
Flat against the snow, a shudder, a rising shiver
The flow of a hidden eternal river
Or worse, a nothingness, the feeble sound of the dead

Sunday, July 30, 2017

Politically Correct or Just Correct?

Recently the staid, establishment surgical journal, Annals of Surgery, attracted some undesirable attention regarding a Presidential Address to the European Surgical Society they published in last month's issue.  The transcribed speech---- "Modern Surgeon: Still a Master of His Trade or Just an OPerator of Medical Equipment? ---by Polish surgeon Marek Krawczyk MD was roundly vilified on Twitter and elsewhere for the alleged crime of only using male pronouns when referring to surgeons.

Following the backlash, Annals took the extraordinary step of retracting the entire piece.  Their statement on the retraction is below:

In an era of expected gender equality and, furthermore, in a medical field (surgery) where women are increasingly closing the disparity gap (for the past 5 years, women have represented 40% of all general surgery residents) the idea that such an august surgical publication would perpetuate gender stereotypes is certainly unacceptable.  But a deeper dive into this episode raises some questions.  

The speech by Dr Krawczyk was a rather lumbering, anodyne review of the relationship between surgical excellence and evolving technology, i.e. can a surgeon be truly great or is greatness contingent on having the right tool at the right time.  He does a pretty standard historical overview of surgical innovation, from the Napoleanic Wars through the era of transplantation and robotics.  His conclusion is what you expect: the truly great surgeons would have been great in any era.  Cue applause at dimly lit hotel conference room in Bucharest.

The j'accuse of the matter is that Dr Krawczyk uses exclusively male pronouns when referring to surgeons in general (i.e. no one can get angry if "he" is used in reference to Dr Starzl or Dr Buchler).  I don't want to get into the minutiae of "micro-aggressions" or the "violence of discourse" but we can all certainly agree that using "he" or "him" every time to refer to "surgeon in general" is belittling and crude, especially when potentially half the audience identifies with the other gender.  It trivializes and diminishes the actual role that women play in modern surgery.

So does Dr Krawczyk actually do this?  

Well, for starters, the title of the piece is absolutely garbage.  How that slipped by the editors of Annals is head scratching.  Simply substituting one word would render much of the controversy moot.  How does this sound:  "Modern Surgeon: Master of the Trade or Just an Operator of Medical Equipment".  Better?  Less demeaning?  More inclusive?  

How about the body of the piece?  In how many instances does Dr Krawczyk flout acceptable pronoun norms?  To find out I went through the speech and counted.  (I'm a ridiculous OCD bastard when it comes to things like this.)  And I found 5 pretty clear cut instances when "him" or "he" is used to refer to a non-specific surgeon.  I also found 22 instances when he uses a term like "surgeon" (i.e. "surgeon's errors" or "assessment of surgeon performance" or "when a surgeon uses laparoscopy") instead of using "him" or "he".  He even uses the unwieldy "his or her" one time!  I mean, if Dr Krawczyk really wanted to be a cartoonish incarnation of misogyny he could have done so in a far more ostentatious and obnoxious manner.  

Further, Dr Krawczyk, in a response to Annals editor Dr Keith Lillemoe, averred that he meant no gender offense, that in Polish, the pronoun he used is gender neutral and can refer to men and women.  Apparently this was not good enough for Dr Lillemoe and, in a statement to RetractionWatch, he said:
In Polish, ‘his’ is not a gender specific term, but it is in this country, and we wanted to make it right….We didn’t want to make the suggestion that we were not sensitive to gender issues, so we wanted to jump on it quickly.
Well ok.  And jump on it, they did, retracting the piece 3 days after initial publication. That's fine I guess.  But I sort of feel bad for Dr Krawczyk.  His transgression, such as it was, seems to have been amplified by the translation process.  Retraction is one of the worst things that can happen to a scientist or researcher.  The stigma attached to having had a paper or piece retracted by a reputable medical or scientific journal can pollute a hard earned reputation and compromise future attempts to get papers published.

And so now Dr Kramczyk is known by those in the international surgical community with cursory knowledge of the whole affair as that Euro-surgeon who had an article retracted from Annals because of "gender insensitivity".  It doesn't seem fair.  Is he a misogynist?  Or just syntactically challenged?  Or perhaps neither?

Instead of going straight to DEFCON 2 and retracting the piece, perhaps the editorial staff of Annals could have simply taken down the on-line version for the 47 minutes or so that it would have taken to clean up the title and switched out a couple of the "he" and "hims" for "a surgeon" or "his/her" and then posted an explanation for why it was altered.  I don't know, that's just me.

The corrected version remains unposted at Annals.

Sunday Poem

Sound is a Wave

Love is when everything seems to fit,
To slide together with a locking click.
I remember that sound from long ago,
But it dulls and deadens,
It’s clear for just a few seconds,
Soundless action on the other side of a window.

I whisper I love you in the morning with the lights off
While you’re sleeping---
My voice hoarse, halting;  as if I’d been weeping---
Might as well have been a cough

We don’t feel safe without those clicks.
We don’t know if the latch really fits.
Pressing harder is ineffectual
Pull it out, jam it in: futile forced ritual
Let it relax----
Or maybe just give it some more slack.

These little assurances are found lacking---
These sounds, these gurgling forest brooks.
An unexpected silence is menacing and grim;
A suddenly quiet pool where the children swim,
The cessation of splashing and waves lapping
Jolts us from our books.

Underwater is the sound of my own beating heart.
I used to hold my breath as long as I could and listen,
The surface world muffled and dulled and distant.
I never wanted to return---
But my chest tightened and burned
And I shot upward like a dart

If you drop your ring in the deep end I’ll find it.
It will strike the bottom with a tiny click.
Sound is a wave that travels to my heart.
I will find it in the deep dark
I will close my eyes and find it quick


Sunday, July 16, 2017

Sunday Poem


The octopus glides through the inky darkness of the deep
While the traps float deceptively meek
Like shells, like planter pots, a garden of skulls,
A fleet of ironclad hulls.
You think you’re safe inside,
You think you’ve found a place to hide.
The creature slides in, curls its arms in an infinity sign
And never escapes its pocket of brine.
Hollowed out cove carved from fathoms of vastness
Inviting, alluring, harmlessly banal
Disarmingly curved, quiet and small----
A perfect shelter for an octopus.
Without locks or doors or gates---you’d think it a flaw.
You don’t know you’re snared, like you would
If you triggered a bear trap claw;
Jagged jaws that snap down crack on bone
Shattering the silence of the wood
With the wails of a beast caught alone.

Inside your own head, it’s all dread and doubt.
You swim back and forth.
You’re caged--- it’s a closed space---
Impossible to know south from north.
Pressure builds, the bottom balloons out.
(There’s a little give, just in case).
You act fine but I see it in your face.
Chest hurts, can’t catch your breath.
The water floods in, it’s a sudden death.
No one ever told you the stakes;
The pressure mounts and your fragile heart breaks.

Take my hand, let’s leave this place, let's swim to shore
And build a more stately mansion.
Open all the windows, let the breeze through the door,
Let sunlight gambol in the peaks of vaulted ceilings.
This is a sanctuary, a place for healing.
Look out yonder, our yard an endless expansion.
Wander through the twilight, as far as you can see.
If I lock the door, you’ll always have the key

Saturday, July 15, 2017

Weekend Poem

Poem #1

A poem is the rotten branch or fallen stick
That, whether real or just an optical trick,
Catches the corner of your eye without fail
While scranching along an overgrown trail.
The way it was bent or broken
How its shape conjured, like a cloud or ink blot
Something unsettled, unspoken        
You absently pick it up; you’re non-committal.
Take it home and try to whittle
The wood into the thing you thought

But the vision is ephemeral  
Your honed words, cleaved from their moment of conception,
Left alone are just a projection.
All that’s left of the flash of the seminal
Is just what you hold in your hand
With shavings of wood on the floor where you stand

At some point you have to put it down
It’s finished, you’ve moved on to the next thing found.
Verses are crude ventures to create a lifeline
From a lifetime of millions of half-glimpses of the sublime.
A dour collection of nouns, adjectives and verbs
Piles of sticks bundled on curbs


Tuesday, July 4, 2017

Off Day Poem


“There was no alcohol involved” the spokesman said. “The child just ran out into the street”

The world went and got itself wrecked
Shards of bone and flesh flecked
Into mangled sinews of metal.
Once we had to settle
For tonics and salves and gods
But then a 3 year old boy wandered into the street
(What were the odds!)
As a tan sedan sped past and knocked him off his feet

Blond, blue-eyed, pride of the Chicago South Side
Sacrificed for nothing; wasted filicide
He arrived lifeless, limp and blue
He had no vitals, there was nothing left to do
(In nomine Patris et Filii et Spiritus Sancti)
We stood there in our yellow gowns and gloves and masks
There was nothing to say, nothing to ask

Turn the monitors off, the attending surgeon said
This boy is gone, he’s come to us already dead
Someone pulled a blanket over his small crushed head
But none of us moved, no one said a word
(Father, Spirit, Son)
All names reductive, every one of them absurd

The monitors went dark and the trauma bay filled with silence
As quiet as a cathedral before Mass--- apse, nave, steeple
Just an accident, not an act of violence
Bad things happen to good people
Bless us this day
Now let us pray
Bless this child
His body has been defiled
He is in heaven now, he is with his savior
The things someone would have to say later
When the mother arrived
When the father arrived
When the world found out a Son had not survived

I had been awake for 38 hours
My bones ached and I needed to shower
I went home and tried to write
But the words broke into sounds, squelching and trite
No way to memorialize.
I scratched my heavy eyes.
I could not pray
I feel asleep,and straight away


Sunday, June 25, 2017

This is America

In America, we have millions uninsured (even after the ACA), high deductible plans and ten thousand dollar per month chemotherapy treatments for desperate patients with stage IV disease.  In America, alone among western democracies, medical bills represent the leading cause of personal bankruptcy.  In America, we choose to commodify the health care sector, transform it into a vast, complex money generating machine.  This is the American way: free markets, personal responsibility, distrust of government interference.

And so it ought to surprise no one that some private companies (from Bloomberg) see opportunity in the misery of others.  Crowdfunding websites like GoFundMe are seeing remarkable growth in the category of medical expense fund raising.  And why wouldn't they?  What else are people to do when you get a bill from a hospital for 12 grand or your company's "insurance plan" carries a $6000 deductible?  It's the 21st century: you go on line and ask for money from strangers.

Of the $2 billion in money raised on GoFundMe last year, nearly half was for medical expense campaigns.  This is both commendable and abhorrent.  Commendable in the sense that it suggests a widespread philanthropic spirit running through our nation.  But is this really the best we can do?  A 21st century version of a spare change jar at the check-out counter of your local diner, proceeds of which to be used for "Jenny Miller's cancer pills"?  It's utterly absurd.  And most of these crowd funded endeavors don't raise nearly enough to cover the outstanding remittances. One study suggested that over 90% of medical expense campaigns on GoFundMe came up short of the requested goals.  In fact, the average fundraiser for medical bills got only 40% of what was needed.  So an American citizen, drowning in debt, gets the double ignominy of having broadcast his financial troubles for all to see, only to come up short anyway.    

But at least GoFundMe makes out all right.  Shed no tears for them.  For every donation, they take 5%.  That's a nice round number when you're talking about billions.

Sunday, June 18, 2017

Surgery Residency: Drop-Out Nation?

In the first decade of the 20th century, William Halsted---using principles he had learned from watching German surgeons---- implemented a new model of training general surgeons in America.  Replacing the old journeyman/apprenticeship paradigm was an intensive, arduous, all-encompassing program that integrated basic science with bedside patient care, emphasized repetition and volume under the tutelage of master surgeons, and introduced responsibilities and skills in a gradual step wise manner.  Resident surgeons basically spent 5 years of their lives living at hospitals, immersing themselves completely in the acquisition of essential skills and knowledge.  The Halstedian paradigm quickly became the standard across the nation as its tenets were adopted by the newly formed American College of Surgeons in 1913.

For most of the next 90 years, he basic training model remained constant.  Of course it was brutal and inhumane.  Young men (almost all men, during these years) literally never saw their families.  Pyramidal structured programs meant that most interns would never make it through the training.  Something had to give. Pyramid programs are no longer acceptable.  Work hour reform has allowed most residents to maintain at least a tenuous grip on sanity.  But there are no panaceas when you are talking about training future general surgeons.  If anything, the demands on a surgical trainee are much greater than even what I faced 15 years ago.  New technology, rapidly changing treatments algorithms, hyper-advances in basic science make it very difficult to acquire a firm knowledge base and technical proficiency in a feld with constantly shifting, expanding foundations.  And despite all the changes with work hour reform, general surgery residents have continued to drop out of training at much higher rates than residents in other specialties, even today.

Heather Yeo and her group at Cornell has a somewhat discouraging paper coming out soon in Annals of Surgery  that attempts to delve into this phenomenon  Theirs is a national longitudinal cohort study designed to identify factors associated with resident attrition.  One important finding, much discussed in a era where women make up slightly more than half of incoming general surgery residency classes, is that the female gender is the most important factor in predicting withdrawal from a residency program.  Further, minority women represent the highest risk cohort for dropping out from surgery training (35% will drop out before graduating).

The thing that jumped out at me was the overall withdrawal numbers, regardless of sex or race.  From an article Christina Frangou of General Surgery News wrote about this paper:
"For the past 25 years, attrition rates have remained steady in general surgery, with about one in four residents not completing training. That is much higher than other specialties, including surgical specialties. Orthopedic surgery has a dropout rate of less than 1%, OB-GYN is about 4.5%, and medicine is about 5%.
“It was thought that changes in work hours and the kinds of things might lower the attrition rate, but they have not. So we need to look at other solutions,” Dr. Yeo said."

Shit man.  You mean 20-25% of highly educated, extremely motivated young adults who have chosen to embark on a career in surgery end up bailing after a couple of years?  That's outrageous.  We're not talking about young buckos who quit McDonald's after a couple weeks because they can't handle the heat of the fryer in the summertime.   These are elite, highly prepared individuals who have busted ass for 15 years, excelled in college and medical school, done internships and sub-internships, sometimes even research in surgical sciences.  And they are quitting left and right.

I don't feel strongly at all that this persistent attrition rate over the decades has anything to do with race or gender or generational dispositions.  It's just that general surgery is fucking hard, man.  And you don't really see it until you start learning it, doing it, seeing older surgeons living the kind of life it requires.  It's a hard ass life.  Emergency and unanticipated cases will always represent 30-35% of a busy general surgeon's practice.  Doesn't matter who you are.  You will always have to take ER call.  You will always have to smile and say "no problem!" when a Primary doc calls you at 4:30 pm on Friday with a "painful hemorrhoid, can you see him in the office right now".

It's a hard, exhausting, brutal life at times.  Rewarding sure.  I can't imagine doing anything different (that's the brainwashing speaking).  But it will chew you up and spit you out.  The years will pass faster than the cards flying by you at a blackjack table in Vegas.

And this essential FACT resonates with residents.  They see what a community general surgeon has to do.  They see these older surgeons working harder than interns.  And I suppose it just gets a little demoralizing after a while.  Who wants to be a grunt for the next 45 years?  As they say in the military, only the nut jobs, eccentrics, cranks and psychopaths actually volunteer for the infantry.  General surgery, man, you're on the front lines.

Even the ones who make it through seem do do so with a jaded eye.  At many top programs, we see reports of 75-80% of 5th year residents going on to do additional training and fellowships.  No one wants to be this thing called a "general surgeon".

I think that's too bad.  We may be on the precipice of another paradigm shift in how surgeons define themselves.  Maybe there's just too much to know, too much to stay up on, too many advanced skills for one surgeon to acquire. Time will tell.  Maybe the pendulum will swing back in the other direction as wider and wider swaths of geographical America finds itself without enough broadly trained, competent surgeons to meet the needs of its population.....

Sunday, June 11, 2017

Sunday Poem

Goodbye, My Ocean

We went to say goodbye to the ocean.
Our week elapsed, time a despot.
The morning was cold and ashen---
Weather more for a funeral than a summer respite---
And waves crashed in to shore in periodic roars.

I had brought her here as a baby years ago
---she doesn’t remember the picture of me holding her on a patio.
But she didn’t want to say goodbye today.
She was tired of the ocean, the rain and gray.
Instead she danced on a dune, a slow adagio
Her eyes closed, arms outstretched, around and around.
She didn’t hear when I called
(The waves crashing and roaring)
She was way up there and I was down here,
Foreign lands separated by a strip of sand.
She performed alone for lumbering curtains of cloud.
The ocean was vast and unconcerned, and much too loud;
It had been there all week, without end.
A little girl has other things to attend.

And the surf rushed up around my soles,
Soaked the edges of my jeans.
I was not yet ready to turn away.
I could have used another day.
I don't so much return to the sea
As the ocean returns to me.
(Words and phrases apt to fail the more I wish to convey)
It returns to me is the best I can say----
Albeit older now, chastened, more gray;
While the dark waters remain changeless.
And as the shore yields slivers of itself to the inexorable surf
My mind yields to forgotten shame, repressed pains, when it all seemed to hurt----
Inchoate fragments of images and phrases

....Skeletons of shells lie scattered on the sand in the retreat of fallen swells....

It will always be there, the abiding sea.
May it someday be there for her too----
When the dance is done, when her songs go silent,
When the clouds part and blue shines through.
One day she too may turn to the sea in quiet terror, in sorrow, or defiant,
And gaze into an endless, merciless roiling gray----
Into her past, the days lost, a life episodic----
And vaguely recall a summer she watched her father rhapsodic
Turning slowly landward, down below, his form misted in sea spray