Wednesday, December 31, 2008


Here we go again. We come to the close of another year. Astronomically speaking, it's all relative. Tomorrow is really no different than any other. But it's nice to have points of demarcation. It's reassuring to know that at some point, you can say that the old concludes and that something new begins. Tomorrow represents that yearning for fresh beginnings.

But those are all cliches about the new year, sentiments pleasurably considered during the New Year's festivities. Those resolutions we all promise ourselves. Things are going to be different. Just you wait. Believe me, plenty of times I've written up New Year's manifestoes on a "better way to live" that were unceremoniously discarded by the Super Bowl. But for that brief period of time every early January, we are enchanted by the possibilities of starting over, rekindling lost loves, working harder, reaffirming lapsed disciplines, learning more, discarding old hindrances, eating less, exercising rather more frequently, reading those dusty medical journals, being a better doctor, a better husband, father, a better man, et cetera, etc. We can temporarily apply the brakes to the rushing onwardness of life, halting it miraculously with the chime of the midnight bell tonight. It all stops and then resets. Let me try again. Give me another chance. I'll do better this time. I promise. Two weeks later, old habits crop up. The alarm goes off at 5AM for your new exercise regimen and you roll over, hit the snooze. The most recent JAMA once again functions as a placemat for your morning Cheerios while you surf the web. We fail ourselves in so many small ways. But it's no biggie. There's always next year.

For some of us, however, the chance at redemption is elusive, even with the casual flip of the calendar. There are those unfortunate souls who have experienced real loss, the kind for which there are no magic elixirs. For those who have had to prematurely say good bye to a loved one, the coming of the new year is merely a bitter reminder of precious days lost and the ineluctable forward march of unforgiving time. Those moments in 2008 when you watched a woman hold her dying father's hand in the ICU. Or the gunshot victims crashing in the trauma resus bay and the wails of wives suddenly alone. The mother who collapses on the floor in the OR waiting area because you've just told her that her 30 year old son has metastatic colon cancer. This is a terrible business sometimes, this thing called human existence and as a physician I sit ringside at the carnage. But we all end up with front row seats at some point. It isn't an exclusive club. In the coming year there will inevitably be new travails and unexpected sorrows and you may very well find that it is you who sits forlornly next to a loved one in the last moments of life, watching the ravages of illness or old age irrevocably take from you everything that that person was. That day is coming for all of us. Maybe not this year but soon enough. I'm not sure what I'm trying to say. I just started typing. It's New Year's Eve. A new beginnning. Make the most of it. Don't neglect the nuances. Savor the absurdity of simple times. Memories, no matter how piquantly vivid, are like ethereal sidelong glances compared with even fifteen minutes of actual, living, tangible time. A cup of coffee on a Saturday morning. An unannounced visit. A phone call randomly in the middle of the week. An unexpected apology. A dropped grudge. Those moments are there for the taking every single day, whenever you want; not just on January 1st....

Happy New Year


Sunday, December 28, 2008

Afferent Loop Syndrome

I performed a Whipple not too long ago for a pancreatic head mass. On the fifth post-op day, she started spiking fevers. The ensuing fever work-up included a CT scan of the abdomen (images shown above). What we see is a dilated loop of small bowel trekking transversely across the abdomen. The rest of the bowels appear normal. Closer inspection also reveals some oral contrast refluxing back into the intrahepatic biliary branches.

What we're dealing with is a classic case of Afferent Loop Syndrome. When you do a Whipple or a Billroth II gastrectomy, there is a loop of bowel (jejunum and/or duodenum) that extends upstream from the gastrojejunostomy toward the pancreas and common bile duct. The efferent limb extends downstream through the distal jejunum and on down towards the cecum. Afferent loop syndrome is a mechanical bowel obstruction (internal hernia, volvulus, stricturing, etc) that results in an effective biliary outlet obstruction.

In a post-op Whipple patient, an acute afferent limb obstruction is especially concerning because there's a fresh bilary anastomosis potentially at risk. If the intestinal limb of the choledochojejunostomy is all dilated and inflamed, you worry about suture line breakdown and development of a bile leak. Moreover, if the bile can't flow downstream, it's going to tend to reflux back into the liver, along with the bacterial flora of the small intestine. This can lead to a severe form of ascending cholangitis, with liver abscess formation.

Now you can't screw around if you suspect afferent loop syndrome. The treatment is surgical. It's a mechanical problem. Sitting around and assuming there's just an ileus or a motility problem will only delay the inevitable. The longer you wait, the worse your patient will do.

When I took her back, the obstructed, summer sausage-swollen afferent limb was confirmed. The choledochojejunostomy looked ok, but seemed to be ready to burst at the seams. The etiology wasn't entirely clear to me. It wasn't a volvulus. There wasn't an internal hernia. It just didn't seem to want to "lay right" without kinking (perhaps secondary to some redundancy in the afferent limb). So I rerouted the afferent limb downstream via a Roux-en-Y reconstruction. Subsequently, the cholangitis cleared up and she ultimately went home a week or so later...

Saturday, December 27, 2008

Mandated Health Insurance

President-elect Obama has his work cut out for him. A recent poll from Consumer Watchdog suggests that the majority of Americans are opposed to any federal proposals that would mandate that each citizen demonstrate proof of health insurance. Lack of mandated coverage would then result in tax penalties or other fines.

Frankly, this finding is outrageous, but all too illustrative of a "gimme something for nothing" tendency we see in this country. Currently, about 16% of our entire GDP is spent on health care. That's a lot of dough. Opting out of health insurance places an enormous burden on those who play by the rules. It's a violation of the social contract. It's certainly unethical and one could make an argument that there is something almost criminal about such a choice. Isn't it a form of stealing? People didn't blink an eye when laws were passed ten years ago mandating car insurance. It's easy and not all that expensive. Shop online. Choose a cheap collision-only plan, if that's all you can afford. But when it comes to insuring our health; how dare you force me to buy coverage? I'm not sick! I haven't been to a doctor in years!

Obviously, I'm glossing over pertinent issues such as the cost of purchasing individual health insurance independently of your employer. And the problem of insuring unhealthy people. And the lack of choice individuals have if they decide to strike out on their own (as opposed to the car insurance example where you can browse Progressive, GEICO, State Farm etc online until you find the best deal). But the results from the (admittedly a limited sample) poll are disturbing.

If we can't be more self sufficient and act in a manner that is most conducive to the benefit of the greater whole, we just give more ammunition to proponents of single payor, federally directed, monolithic "National Healthcare" plans. You see, they argue, Americans can't be trusted to do the right thing. Unless we place all the power in the hands of a giant federal bureaucracy we will continue to have 50 million uninsured and exponentially rising health care costs! With nationalized coverage, there will be no need for "mandates"! Everything will be paid for. By wealthier Americans! No worries!

Turning our health care system in a giant version of the VA or a County Hospital with physician remuneration via a hypertrophied Medicare/Medicaid is surely not the corrective antidote. Individual choice still matters. Foisting the responsibility onto our populace is not necessarily a bad thing. There have to be consequences for those who choose not to fulfill that repsonsibility. Once health insurance is mandated, we can manipulate things to make some form of coverage available to all Americans. But it first has to be ingrained in the societal conscience that going through life (irrespective of how 'healthy' you are) without health insurance is unacceptable....

Tuesday, December 23, 2008

Debt Free

Medical student debt is the first thing we need to rectify as we try to address the primary care issue. One quarter of students are graduating with loan obligations totalling over $200,000. Consider that most med school grads are in their late twenties/early thirties and often have families to support. The pressure is on to make some money fast. Why pursue a career in a field that pays pennies?

The article notes that $2.5 billion in federal loans are available to medical students every year. What if, as part of the Obama health care revolution, we invested that $2.5 bill in our future doctors? Or even half that. What's a billion buckaroos when we've already doled out hundreds of times more than that to cover up corporate malfeasance?

What if medical school was free in the country, given that you signed a contract stipulating an agreement to pursue primary care (family practice or internal medicine) as your specialty? Wouldn't that be enticing? If you changed your mind and just had to be an interventional cardiologist, then you would have to pay back the costs of your schooling. Like if you decide to drop out of ROTC before fulfilling your obligations, you owe the government the costs already accrued.

Medical school debt is no doubt the driving force behind the primary care shortage. Merely increasing the remuneration by a certain percentage points on office visit billing codes is like putting duct tape over a smashed windshield. Plus it looks unsightly. It isn't enough. It's not going to significantly alter the distribution of grads who opt out of primary care.

It's time this country bailed out something besides Armani-attired executives who fly into Washington DC on chartered jets. Whether or not Chrysler totters along for another twenty years isn't going to affect American prominence in the world nearly to the extent that a crumbling health care system will. It's time we invested in something a little more worthy of a liberal democracy....

Sunday, December 21, 2008

Dark Star

Hey, it's the Winter Solstice, longest night of the year. If you have Sirius/XM, channel 32 (Grateful Dead radio) had a Dark Star marathon. Yes, they played different concert versions of Dark Star all day long. It's one of the Dead's best compositions; a long, languid, jazzy/trippy, improvisational, mind blowing exploration of beautiful sound and discovery. If you're into that kind of thing.

Check out a sample:

Dark Star

Saturday, December 20, 2008

What are we doing?

Take a minute and read through this article from the NY Times. It's a great review of the nefarious doings at Merrill Lynch right before their house of cards caved in. In 2006 the division of Merrill concerned with bundled mortgage securities distributed close to $2 billion in bonus payouts to about 2,000 employees. The head of the unit, Dow Kim, received $35 million for his efforts. Of course, the "profits" claimed by Merrill during the housing/real estate boom were based on smoke and mirrors. The mortgage derivatives market collapsed (unsurprising, in retrospect) and the consequences shook the foundations of Wall St. Lehman Brothers went bankrupt. Merrill was acquired by Bank of America, ending 94 years of existence as an independent firm. And our government sanctioned a $700 billion bail out of the corporate barons of high finance. $700 billion buckaroos. $700 billion. Another $80 billion was fronted to AIG. And just this week, W approved a plan to grant the auto industry $13 billion now, with more to come in the spring.

To put that in perspective, we've spent somewhere around $600 billion thus far to finance the war and occupation of Iraq since the 2003 invasion. And that's over five years. Our government just forked out 30% more than that in a matter of weeks. We throw these numbers around like it's nothing. The word "billion" apparently has lost all connection to reality because, hey, the federal government can just dole out checks with nine zeroes after the integers whenever they feel like it. But it's a lot of money. The entire budget for the Departments of Education and Labor combined for fiscal year 2009 is "only" about $120 billion.

So what does this have to do with medicine? Not a whole lot. I admit that I'm probably stretching it a bit here. But we do have a crisis of epic proportions in health care. Too many people either don't have enough coverage or aren't covered at all. Morever the cost of health care is rising at astronomical levels. In 2007, we spent $2.3 trillion dollars on health care expenditures. That's 16% of our entire GDP. Finally, we face an impending shortage of the very professionals needed to provide the sort of cost-efficient, excellent care that any all-inclusive health care reform would hope to implement. Younger doctors are opting to pursue careers in higher paying, less stressful specialties rather than slogging through the rigors of a standard primary care practice setting. And who can blame them? Graduating from an accredited medical school in the country oftens saddles you close to $200,000 in student loans. Now we have a President who has made it very clear that he has every intention of rectifying most if not all of our deficiencies. And he's going to need doctors who buy into it and want to make it work. So that puts us in the driver's position, right?

Well then I read the vitriolic op-ed piece in Emergency Medicine News by the eminent Dr. Jonathan Glauser (from the Cleveland Clinic Foundation of Higher Medical Instruction and Sophistication) where he basically embarasses himself in front of the country in writing. The article is hilarious.

Countering the idea of improving payments to primary care physicians he writes:

Say what? Fund physicians to promote primary care? Why throw good money after bad? If ever there was a group that has failed in providing care, it is our primary care system. To fund such a venture for groups that are singularly inept at performing anything of value to society is pure folly and a waste of precious health care dollars.

Now that's just schoolyard bully talk. It's harmful only in the sense that it damages the professional reputation of a singular ER physician on the banks of Lake Erie (I'm sure Toby Cosgrove's henchmen have "taken care" of this little problem). It's a rant by a nut-job. Why should any of us be bothered by it? This is like being worried about the state of the NFL just because OJ Simpson is in the Hall of Fame. Dr Glauser wrote an extremely shallow, poorly thought-out, amateurish, overly emotional piece that surely, given his education and prominent position, he now regrets. And that ought to be the end of it.

But my concern is with a commonly held position that this sort of attack on primary care is just the beginning. The Medical Webmaster himself, Kevin MD, hints at this in a post from last week:
The nature of budget-neutral reform means that physicians like Dr. Glauser will take a substantial pay cut to adequately fund primary care.

He's merely laying out the groundwork for a furious specialist assault on primary care that will be sure to come.

In other words, all specialists deep down harbor a fear of any sort of remuneration reform and it's going to lead to irreparable animosity between the overpaid specialists and the true soldiers of American health care, the noble internists and family practice docs.

Unless I'm misinterpreting things, this is an entirely disingenuous stance. As Max Baucus avers, any payment reform will need to be conducted in a "budget neutral" manner. That means the current pool of health care dollars that is directed toward physicans will not be increased, it will just get divvied up differently.

And why are we comfortable with this? Why, as professional group are we content to passively take whatever federal regulators want to give us? Why is it a done deal? This "spat" between the Kevin MD faction and the Jonathan Glausers of the world is just what the government and insurance companies and everyone else wants. Infighting and disunity. Physicians battling each other over ever diminishing scraps. It's the wrong outlook.

I have my own issues with the theory that simply increasing your family practice doc's pay is the fundamental solution to our nation's health care ills. If a doc has to see 30 patients a day to make 130,000 grand a year and you increase his pay so that he is compensated, let's say $150,000 a year, you really haven't solved any problems other than the one specific problem of low primary care pay. That family doc still has to see 30 patients a day. He still will need to keep his office booked for months in advance. He still won't have much time to take care of emergent issues, shunting acute problems off on the ER. The internist will still need to see the same number of inpatients to reap the rewards of higher pay, thus perpetuating the shotgun consult method of practicing medicine. Nothing really is going to change with a modest alteration in the salary structure. We need to aim higher. After all, there's plenty of money out there, apparently. Just ask the failed barons of Wall Street.

Rather than dutifully accepting "budget neutral" reform, consider the following:

1. Make it financially doable for doctors to spend time with patients. Instead of thirty a day, what if you could see five in the morning and five in the afternoon? And you had scheduled gaps to account for acute care issues that arose unpredictably? Think of how thorough you could be. Think how many fewer consultations would be necessary.

2. Student loan forgiveness for those who pursue primary care/internal medicine.

3. We'll need more doctors

4. Market forces alone will make it unsustainable for graduating medical students to opt for speciality careers, assuming that better paid doctors who can spend more time on individual patients will not need to rely on specialist consultations as before.

5. It's going to cost a lot of money

Listen, change is coming. It's inevitable. Obama has his mandate. But he's going to need us, and I stress us, all physicians, to make it work. Without the cooperation and enthusiasm of all doctors, the Obama revolution is doomed to a similar outcome as that seen in the 1990's with HillaryCare.

Friday, December 19, 2008


So Dr. Siemionow at the Cleveland Clinic Foundation performed the first face transplant in the United States this week. I say good for her. Good for the patient. Let's just hope that it works.

Transplant surgery is an incredibly complicated amalgam of immunologic manipulation and technical expertise. Successful outcomes depend on two things: flawless surgical technique and tricking the body's defenses into thinking that a foreign protein (the donor organ) is not a threat. The surgical aspect requires meticulous dissection and the creation of tenuous anastomoses (bowel, vessels, nerves, etc) in patients who are high risk and exceedingly fragile. The immunomodulatory issues, however, are a lifetime challenge. Rejection is a constant threat requiring vigilant montioring. T-cell mediated rejection afflicts 30-50% of new liver transplants within the first 6 months. Most of these can be managed with high dose steroid pulses but a small percentage progress to chronic rejection despite all best efforts.

If your kidney graft starts to fail, a patient can go back on dialysis until another one becomes available. When a liver graft fails a patient will often end up back on the top of the recipient list because of a high MELD score. But what happens when your face graft fails? You can't just slap on another one from the donor list. You basically get one shot at it. The graft is removed and the defect is covered with skin auto-transplanted from your thigh or buttocks. Once again, the patient is ostracized from the rest of humankind by his/her deformity.

Self identity is what we feel we project onto others. The way we smile, an arched eyebrow, the way we tilt our heads when asked a question, these subtle gestures and tics are the tools we use to hint at what's going on in the depths of our heretofore unfathomable consciousnesses. Without the face, we are, in many ways, sundered from our fellow man. The ability to project ourselves, to communicate the inarticulable, is crippled without it. Too often, the Other is too lazy to look beyond the superficial reality of what presents itself; a face, a body, a skin color. The despair of not being able to express yourself because of a "defect" in physicality must be indescribable. And so this concept of "face transplantation" is a noble endeavour. But I worry about the long term results. Can you imagine living in social isolation for years after an injury/accident, then being given a new face, a new identity via a graft which allows you to re-enter society and present yourself as a complete physical human being, just like everyone else, only to have that torn away from you after a couple years because of rejection issues? I can't imagine...

The ultimate solution likely is going to come from advances in stem cell research. Instead of using cadaveric or live donor grafts and subsequently engaging in a life long battle to outwit our immune system, we could grow tissues from our our own cells, avoiding the problem of rejection altogether.

Thursday, December 18, 2008

Staying Overnight for the First Time

I have a guy in house now who underwent a repair of a giant paraesophageal hernia last week. He's in his 70's, retired and tough as a box of nails. He served in Korea and then came home and was a foreman on a factory line for 30 years. For the past several years he'd been suffering from this giant hiatal hernia where half his stomach was lodged in his chest, crushing his left lung. For years his GI guy and his wife had been insisting that he consider surgery. Hell no, he'd always replied. Finally he relented. He couldn't sleep at night, couldn't catch his breath while recumbent.

The surgery was tough. Usually I can get the stomach and the hernia sac down into the abdomen laparoscopically but his was chronically incarcerated. It didn't want to slide down the way they sometimes can. I didn't want to tear the stomach so I had to convert to an open procedure. The post operative course was complicated by a pulmonary embolus (despite compression boots and prophylactic Lovenox, never event indeed!) and so his hospitalization has been longer than any of us anticipated. Initially, after the PE was diagnosed, he was on a non-rebreather mask and you couldn't really converse with him all that well. Is was like someone trying to talk to you underwater.

One day, he grabbed my hand while I was making rounds. He has these thick, hulking, calloused hands, the knuckles gnarled and jutting off in odd directions and I'm always nervous if I'll ever see my palm again whenever he wants to shake it. I have to tell you something, he said, his voice muffled and distant behind the mask. I helped him lift it away from his mouth. I watched his oxygen saturations closely.
-I'm going to be Ok, right? he said.
-Yeah. You're a tough old bastard. You're going to be fine.
He nodded. He took a deep breath. He was gasping a bit.
-You know in 51 years of marriage we've never spent this many nights...
He stopped. His eyes were swollen and red rimmed. He was fighting to catch his breath, but also, he just didn't want to go on, having said too much already to this young doctor.
-It's ok buddy, I said. I know what you're saying. I slugged him in the shoulder, or some such awkward attempt at male affection and helped him with the oxygen mask.
-You'll see her soon, I said. You be sleeping next to her again before you know it. I promise you....

Monday, December 15, 2008

Small Bowel Carcinoid

Unusual and interesting case of a primary small bowel carcinoid tumor recently. This was an older guy who had been diagnosed with a low grade lymphoma 5 or 6 years prior to our encounter. He presented to the ER with a high grade small bowel obstruction and renal failure secondary to dehydration. He'd never had an abdominal operation before and there were no obvious incarcerated abodominal wall hernias on exam. In that scenario, any halfway decent clinician ought to be worried about an underlying neoplastic cause of the obstruction, especially given a history of lymphoma as in this particular patient.

The CT scan above demonstrates a patially calcified mass in the mesentery of the small bowel, very close to the terminal end of the superior mesenteric artery. I explored him and excised a segment of ileum that had 7 separate carcinoid tumors. Then I basically shaved this mass off the distal SMA/ileocolic artery. Most of the lymph nodes in the mesentery had been totally replaced by metastatic carcinoid tumor but the intestinal margins were clean.

Carcinoid tumors are an odd ball in surgical oncology. Overall they are rather rare, but they are the most common tumors seen in the appendix and the second most common cancer seen in small intestinal malignancies. They derive from neuroendocrine tissue and can secrete hormonally active substances (serotonin/kallikrein) that can cause what is known as the "carcinoid syndrome", an uncommon presentation that includes such symptoms as flushing, diarrhea, bronchoconstriction, cardiac valvular lesions, and telangiectasia.

Carcinoid tumors also tend to be multicentric, so make sure you run the entire length of the intestinal tract when you've got that abdomen open; 30% of the time you'll find another one. They also have a tendency to incite a severe desmoplastic reaction in the surrounding tissues. Mesenteric deposits near major blood vessels (SMA) can sometimes encase themselves in a hard, fibrotic shell, making safe resection hazardous, if not impossible.

The good news is that carcinoids are generally slow growing, indolent tumors. Long term survival for early stage tumors is on the order of 70-90%. Even patients with distant metastases can live for several years or more. Manifestations of the carcinoid syndrome can often be effectively palliated with somatostatin analogues such as octreotide.....

Saturday, December 13, 2008

Ghostwriting and the New Gilded Age

What exactly is going in America right now? Are we better off just assuming that truth and transparency are elusive? The Blagojevich scandal that now dominates the headlines is merely the apotheosis of a trend toward corruption and dishonesty in all facets of American life. In sports, the feats and record setting performances of an entire era are tainted by the specter of steroids. In journalism, the fabrication scandals of Phillip Glass and Jayson Blair aroused doubt as to the veracity of the stories we read everyday in our newspapers. In finance, the thieves of Wall St. are walking away from the greatest financial disaster in 80 years, their own pockets lined with gold. Our Commander in Chief cavalierly led us into a calamitious, profligate war under false pretences.

And now we hear of unscrupulousness in the the field of science. One would think that, even in this jaded time of relentless exploitation and frivolity, something like the scientific method would be sacrosanct. Not so much. The NY Times reports that the pharmaceutical company Wyeth paid ghostwriters to produce articles for the medical literature supporting the safe use of Prempro (a hormone replacement drug given to women for alleviation of the symptoms of menopause). Subsequent data (real science) has shown that treating menopause with estrogen is extrememly dangerous; a woman's risk of developing breast cancer is increased by 5%-6% for every year of use. In fact, the decline in the incidence of breast cancer has been attributed to the fact that the use of hormone replacement therapy (HRT) has decreased over the past five years. Just this past week, the San Antonio Breast Cancer Symposium presented indubitable evidence from the Women's Health Initiative that HRT doubles a woman's risk of acquiring breast cancer.

It seems that Wyeth subcontracted the business of science paper creation out to a private firm called DesignWrite. The completed papers were then given to chosen physicians for review and the final product was then forwarded to medical journals with the name of said prominent doctor listed on the abstract as author. Now this isn't a small thing. This isn't something that ought to get swept under the rug as soon as the next news cycle washes in to shore. The ethical compromises that are apparent in this are staggering. We have to live in a world where 2+2=4, no matter who is performing the computation. We have to be able to trust our science. There has to be a complete separation between the hard cold reality of pure empiric science and the vested interests of a corporation whose profits depend on whether an experiment turns out one way or the other. Our medical journals need to draw a line in the sand; no more papers "sponsored" in any shape or form by the pharmaceutical or medical device industries will be published. One small step at a time, we have to re-assert the primacy of truth and objectivity in our lives. One would think that science would be the easiest place to start.

Wednesday, December 10, 2008

Nap Time!

The Resident Coddling Movement (RCM) has just about reached its nadir of absurdity. Recently, the Institute of Medicine (whoever the hell they are) submitted a report recommending that residents ought not to work more than 16 consecutive hours without a break. This, the latest salvo in the work hour reform crusade, supplements previous ACGME mandates such as the 80 hour work week and the prohibition of working more than 30 hours consecutively (already adopted by most residency programs). The Institute cites new "research" unequivocally proving that medical errors rise exponentially past this 16 hour threshold.

The problem is that when you are on call, you are required to spend the night in the hospital. That means the math doesn't add up. Let's say you come into the hospital for rounds at 6am. If you are on call that day, your 16 hour limit will expire at around 10 or 11 pm. So how are you supposed to fulfill your 30 hour obligation? Well, the geniuses at the Institute of Ludicrous Medicine propose that on call residents take a mandatory 5 hour nap. That's right. Nap time. They actually use the word "nap" without a bit of irony or tongue in cheek knowingness. Grown adults in their late twenties, serving an apprenticeship as they try to learn the nuances of one of the toughest jobs on earth, will potentially now be required to take a little nappy so they don't get too sleepy-poo. According to the report, these 5 hour naps will be "monitored". Rumors are also swirling regarding whether or not resident "blankies" will be supplied by hospitals.

Now excuse me for being an out of touch, old school pain in the arse. But this is frankly embarassing. I'm embarassed for these people. I've already rambled on before about the value of spending time in the hospital as a trainee. The best lessons I ever learned as a surgical resident all occured after midnight. The middle of the night disasters, and my responses to them, are what made me the surgeon I am today. But I digress. Something is amiss in America. Wall Steet is in shambles. Ford and GM are on the verge of collapse. Jobs are vanishing overseas. This country is in a tough spot. From a health care perspective, we are on the verge of implementing an all-inclusive system that will require more doctors and more of an effort from health professionals to make it work. What does it say for us, for this younger generation, if our primary concern is legislating less work and less dedication into the training of our future physicians. It compromises us. It's disgraceful and ignominious. Residency isn't a "hazing ritual" as the RCM would like everyone to believe. Who gives a damn how they train residents in Denmark? Certainly it's grueling and exhausting and sometimes you come home and pass out on the couch with a half eaten pan of mac and cheese on your belly. But it's a system that made American medicine the best in the world. There's a reason that shahs and kings and foreign dignitaries have come to Mayo Clinic and MD Anderson and Johns Hopkins for their surgery or medical care over the years. Someday, when I'm ill or in pain and I need medical care, I hope I can rely on these younger doctors who have learned their trade under less taxing circumstances....

Smoking and Surgery

We've known for a while that tobacco smoking deleteriously affects surgical outcomes. The theory is that knocking off the cancer sticks for even a few weeks pre-operatively will lead to an increase in oxygen delivery to healing tissues, therefore making it less likely that you'll have complications such as wound infections and anastomotic leaks and the like.

The Annals of Surgery just published another article from Sweden that further promulgates the wondrous benefits of smoking cessation prior to elective surgery. This one was a randomized controlled trial that compared 30 day outcomes of patients who had stopped smoking for 4 weeks prior to surgery versus a control group. Patients were given counselling and free Nicorette to facillitate the cold turkey stoppage.

Strangely, over the course of two years, at 4 different hospitals, only a total of 117 patients were enrolled in the study. Even stranger, the overall complication rate was 41% in the control group versus 21% in the intervention group. Now that's a ridiculously high complication rate. Especially given that the surgeries performed in the study were restricted to hernia repairs, laparoscopic cholecystectomy, and joint replacement surgery.

It seems the authors were rather generous in how they defined "complication". Routine post-operative developments such as fevers within 24 hours of surgery, urinary retention and ileus were included. Basically, anything that "necessitated treatment, investigation, or prolonged care" met the criteria. That's casting a rather wide net. Furthermore, even when there were legitimate complications, the article seemingly asks us to accept that the determining factor was whether or not the patient stopped toking up for a month. Are we really supposed to believe that one patient had a bile leak solely because she couldn't get off the Marlboro Lights? Or that another had a stroke because of an extra 28 days of Pall Malls?

We see these types of papers in the medical literature quite often. Little is gained from a scientific perspective (surely, it's clear by now that smoking is bad for you and compromises respiratory reserve and healing capacity). On the other hand, the propaganda value of such a "scientific article" is substantial. It gives you a peer reviewed paper to wave in the faces of patients. But is it necessary? Is it worth the cost and effort of enrolling patients, getting IRB approval, filling out all the forms, and crunching the numbers with complicated statistics equations just so we can have level one evidence that you're better off not smoking prior to elective surgery? What's next? A randomized controlled trial that "strongly suggests" infection rates are improved in surgeons who wear sterile gloves during an operation versus surgeons who dip their fingers in toilet bowls prior to a case and then operate gloveless?

Thursday, December 4, 2008

ED Thoracotomy

I had to open up a patient's chest in the ED the other day. The outcome was predictable. The patient had been shot in the chest and arrived without vitals. Protocol mandates that you slice open the left thoracic cavity right there in the ER, right in front of everyone, the bright lights, the chaos and noise of the trauma bay, cops and nurses and orderlies standing around, mouths agape. You do it right there in front of everyone.

When I was a surgical intern, it was considered a huge coup to get a ED thoracotomy. We all yearned to get one. The excitement! Such a cool procedure! God I hope someone rolls in on the verge of death! The glory! I would get pissed off if one of the other interns got to do one.

But there's nothing glorious about an ED thoracotomy. It's brutal and raw and completely dehumanizing. Here's what happens. Patient arrives in obvious extremis. Airway is established. Gunshot wound to the chest. You splatter betadine haphazardly all over the left ribcage. Someone hands you a #10 blade. Everyone is shouting and racing around and someone is putting in a femoral line and there's someone at the head of the bed bagging the patient. You notice that there's nothing on the monitor. No blood pressure. No tracing on the EKG strip. You push the cold black steel into the patient's flesh. And not like in the OR for an elective case, where you gently glide the knife along the skin surface. You press that sharp blade as deep as you can, firmly, with vehemence. Usually it's a young man, the anatomy clear and distinct. The intercostal muscles are then either cut with the knife or Mayo scissors. You're in the chest cavity seconds after the scalpel hits your hand. This releases a volcanic eruption of old and fresh blood. Someone hands you the rib retractor. It looks like a goddam bear trap. The prongs are wedged between the ribs and you crank open the chest with all your might. You can hear the cartilage and the bone snapping. It's awful. It's necessary. One in a hundred times. Just maybe you save someone. That one person out of a hundred. You clamp the aorta. You open the pericardium. You search for injuries. Counter-intuitively, isolated injuries to the heart are associated with better outcomes. Whipstitch it closed. Stick a finger in the leaking ventricle. But injuries to the pulmonary hila and aortic arch are less forgiving. You know this. You liberate 5 liters of blood from the chest. The aorta is flaccid. The heart is an empty, quivering, non-functional lost cause. It's already starting to turn blue. The patient is blue, blue lips and blue finger tips. Ten minutes have gone by. There's no pulse. There's nothing. Just a large gaping wound in a young man with his heart and his lung hanging out and his wasted blood all over your shoes and pants. He's cold and lifeless, right there in front of everyone, the cops and orderlies and the people passing by. You sign the papers and look for some family but there's no one there, so you just rip off your bloodied, ruined clothes and throw everything in the trash and put on scrubs and go home to your wife....

Loop Diuretics and the Williams Brothers

Pat and Kevin Williams (unrelated), standout defensive linemen for the Minnesota Vikings were recently suspended by the NFL (along with four other players) because traces of the loop diuretic bumetanide were found in their urine. Bumetanide is on the list of banned substances because it can be used as a "masking agent" for anabolic steroids. As of today, the suspensions are on appeal.

From a scientific perspective, this all sounds a little shady. Loop diuretics act by restricting how much water and electrolytes your kidneys absorb. As a result, your urine is diluted and copious. The idea with drug masking is that the excess water in the urine will make the concentration of any naughty substances present artificially low. But it's not necessarily an efficacious way of hiding your devious muscle building strategies. It's all based on concentrations and fluid homeostasis. It's like trying to lower your blood alcohol level at a New Year's Eve traffic stop by guzzling 4 gallons of water in 3 minutes.

But why would they guys be on a loop diuretic? The first line of treatment for an African-American male with hypertension is hydrochlorothiazide, a different kind of diuretic. So it can't be because they're treating high blood pressure. No physician would prescribe bumetanide. Loop diuretics are used in heart failure and certain kidney conditions. I have heard of competitive wrestlers use them because of the rapid weight loss (all water) benefit that can be derived. And maybe these 300 lb behemoths need a little help to keep their weight within reasonable parameters.

But it's horribly unsafe. Dropping weight by hamstringing your kidney's ability to manage your total body fluid levels is unnecessarily dangerous. Too much of it can compromise kidney function and lead to eventual kidney failure. Moreover, electrolyte concentrations (especially potassium) get thrown out of whack when you're on a loop diuretic. All it's going to take is some All-Pro tackle dropping dead on a Sunday afternoon from a hypokalemic arrythmia to get everyone's attention.

Bottom line: there's probably no reason to be on bumetanide, it's dangerous, but I doubt it's being used to mask steroids. If a couple guys have to forfeit a few weeks salary because they got caught using it, it's probably a good thing for the players in the league overall. Now if only we can get them to stop shooting themselves in the thigh with illegal handguns....


An elderly Cleveland lady died tragically earlier this week in a house fire. Today, the Cleveland Plain Dealer reports that the EMS truck from the closest fire station was unavailable because it had been dispatched (via a 911 call) to the comprehensive, internationally known, super-famous medical institution downtown for a very important stat situation. Apparently they had an extraordinarily obese patient who needed to be moved from a clinic office across the street to the ER. Orderlies were not available. The elderly woman almost escaped the fire, but was halted only a few steps from the front door by a wall of flames. Spokesmen from the fire department were unable to determine whether the delay in EMS response played any role in her unfortunate demise.

Well, at least it's reassuring to know that northeast Ohio's largest employer can always resort to calling 911 when they get in a pinch. I mean, what if the floors in the front foyer of the hospital start to look unacceptably grungy as we move into the slush and snow season and janitors can't get it mopped up fast enough? Just call 911! And if the OR turnover times start to drag out, compromising profitability? Call 911! Get the local firemen to transport the patients to the PACU ASAP!

Sunday, November 23, 2008

Trauma center with time on its hands

This article from the American College of Surgeons' monthly newsmagazine Surgery News pricked my interest. Dr Ernest Block, director of the trauma program at Orlando Regional Medical Center, tries to make a case for the "regionalization" of acute care surgery. In English, this means he wants to justify life-flighting acute appendicitis and hot gallbladders out of surrounding community hospital ER's and depositing them at the doorstep of the glorious Orlando Level I Trauma Center. Dr. Block rationalizes this proposed plundering with an economic argument. If community hospitals can ship all their after hours emergency surgical cases to referral centers, they will consequently save themselves the "readiness costs" of maintaining the infrastructure needed to deliver such care themselves. At least that's the theory. Meanwhile, the plan is certainly profitable from the perspective of the large level I trauma center, generating an extra $1.5 million for the Orlando center in this case.

There has a been a push lately from the trauma community to redefine themselves as "emergency care surgeons". They want to be able to scavenge all the midnight appendectomies and free air cases because, well, otherwise they wouldn't ever operate. Trauma has become so non-operative that these guys are just starving for cases. So now we see these pseudo-scientific articles in journals supporting what they want. It's politics cloaked in science. The argument goes like this: the trauma surgeon is in house, might as well let him/her have the case because it can be done right away. I can understand the angst. I couldn't stand being strictly a "trauma surgeon" and going weeks without doing a legitimate operation. However, if trauma as a subspecialty is non-operative and unappealing to its practitioners then perhaps we need to re-evaluate the viability of trauma as a legitimate stand-alone subspecialty. Stealing non-trauma emergency cases from outside communities is clearly not a just solution to the problem of trauma ennui.

The reality is that such a policy would destroy community hospitals. Surgeons are the big money makers at hospitals in the community setting, let's be honest. And emergency surgery is actually a big part of a typical community general surgeon's practice. The gallbladders that come in overnight. The incarcerated hernias. The GI bleeds that end up being secondary to a colon cancer. Even the laparoscopic appendectomies on the uninsured can lead to long term benefit. That kid whose appendix you took out remembers you and is appreciative (even though maybe you dont get paid). And then someday when he's older and has a job and is properly insured, he comes back to you for his thyroid surgery or hernia repair or whatever. Or maybe he mentions to his brother-in-law that he ought to see Dr. Buckeye down the road for his inguinal hernia because he did such a great job on my appendix. General surgeons, over the course of a career, develop a relationship with the community in which they practice. Transferring out all the patients that need emergent or semi-emergent surgery would only serve to sabotage that relationship over the long haul...

Five in a Row!

Overall, this season was somewhat disappointing (despite returning the core of a team that played in the BCS title game in 2007) but such are the expectations in Columbus, OH during the Jim Tressel era. Nonetheless, they still shared the Big Ten title and topped it off by throttling that team from up north by five touchdowns. It's a good time to be a Buckeye fan.....

Friday, November 21, 2008

Transplant gone wild

The University of Pittsburgh (UPMC) has been the center of the transplant world for almost thirty years, ever since Thomas Starzl MD assumed command of the transplant program there in 1981. Dr Starzl is the father of modern liver transplantation. He performed the first one in 1963 (patient died shortly thereafter) in Denver, CO and also the first successful one in 1967 (graft functioned for 13 months). During his time as the chief at UPMC (he retired from surgical practice in 1998, but continues to be active in research) a legion of transplant surgeons learned the techniques that Starzl invented and honed, and have dispersed themselves across the country to teach a new generation (I actually was privileged to learn from one of them in Chicago at Rush University). So it's a bit of shame to see the program now attracting some negative publicity regarding this Amadeo Marcos business.

Dr Marcos was hired in 2002 by UPMC to head the transplant program with a mandate to increase surgical volume. During his 6 years there he was able to successfully fulfill his boast of doubling the number of liver transplants UPMC performed yearly. But the means to achieve such ends raised some questions, not the least from Dr. Starzl himself. The allocation of transplantable livers in this country is based on a recipient's MELD (Model for End stage Liver Disease) score, i.e. need rather than time that the patient has been on the list. The sickest patients get get first choice, in other words. Seems fair and balanced, right? So how could somebody manipulate the system?

Well, it became evident that Dr Marcos was putting bad livers in patients who weren't that sick. Let's say your patient is number 25 on the MELD list. A liver becomes available. But it's a bad liver (old patient, prolonged ischemic insult prior to harvest, steatotic, etc) and transplant surgeons representing patients 1-24 on the list have all turned it down. It's a terrible liver, they say. Odds are, it won't work all that well. Your patient isn't that sick. In fact, said patient is living independently at home and was buying groceries for her family when you called her to tell her a liver was available. Nevertheless, you book her for the OR that night and stick that liver in her anyway.

On top of that, Dr Marcos was also a serial womanizer who liked to beat his girlfriends. But that didn't seem to bother too many people, especially not the executives of UPMC. After all, Dr. Marcos had fulfilled his pledge in doubling the volume of liver transplants performed. This productivity coincided with a very profitable time at UPMC. To this day, it brings in over $7 billion in annual revenue. The CEO, Jeffrey Romoff, nets a cool $4 million annual salary. UPMC headquarters are now located in Pittsburgh's tallest skyscraper downtown and employees are flown to distant rendezvous in a leased corporate jet. All this from a non-profit institution.

It seems that the breaking point actually centered around Dr. Marcos' claims with regard to the safety of his living donor liver transplant program. Living donor liver transplantation entails removing the right lobe of a completely healthy person's liver and reimplanting it in someone with a failed native liver. Dr. Marcos then published data that exaggerated the safety of such procedures done under his guidance. Now let's examine the ramifications of this. We have a renowned transplant surgeon meeting with a prospective living donor and eminent surgeon explains to the donor that his complication rates both for donors and recipients of the proposed procedure are much lower than the quoted national averages, when the reality of the situation suggests the opposite. There is an implicit trust between patients and doctors that I have addressed in other posts. The minute you start to betray that trust is when you cross into the purview of unethical behavior and destroy the foundations of everything we try, in good faith, to do for our patients.

Fortunately, the old lion Dr Starzl liked to keep a close eye on his baby at UPMC. He grew apprehensive of Dr. Marcos' claims. His subsequent investigations threatened to expose the truth but he was "encouraged" to withhold publishing his findings until they could be confirmed by an outside review committee. (Yes, the father of liver transplantation was told by his home institution to bury unsavory findings until someone else could look over his data. Basically this is like having the Paris Review inform Gabriel Garcia Marquez that they wouldn't be able to publish his latest short story until it had been properly vetted by an outside authority.) Of course the findings were corroborated by the outside committee and, ultimately, Dr. Marcos was given his walking papers in May of this year......

Tuesday, November 18, 2008

Max Baucus and Budget Neutrality

So we've all been reading lately about the Baucus plan to re-invent healthcare delivery and to save primary care in America. It's the hot topic on KevinMd right now. Most of it is over my head and, frankly, uninteresting to me. It's 100 pages of wonkish policy drivel, as far as I'm concerned. (For example, here's a paragraph from the section regarding malpractice reform: "Malpractice reform could address money and time spent on litigation, as well as improve patient and provider satisfaction with the resolution of complaints or grievances. Additionally, changes made as part of reforming the health care system would affect medical malpractice. For example, damages awarded for care necessary as a result of malpractice would be reduced because the cost of care would decrease across the board. Also, improvements in preventive care and care coordination would reduce the likelihood of risky procedures that are a source of malpractice claims." Um, whatever the hell that means. As I read the words, the only sense I can make of it is that by lowering the overall cost of health care delivery {via the genius of Max Baucus} then if there is malpractice committed, the costs of paying for care provided to correct said malpractice will be less. Circular and vapid reasoning, at best.).....Just give me a bunch of of patients with peritonitis and I'm happy.

One thing to address, however. The plan clearly spells out an intention for "budget neutral" increases in the remuneration of primary care physicians. That means taking money out of the pockets of specialists and sticking it in the white lab coats of your local family docs. Obviously, primary care isn't paid commensurate to the work they do. Reimbursement is tilted overwhelmingly toward proceduralists. Dermatologists and gastroenterologists are making three and sometimes four times as much as the primary care provider who refers them business. As a result, medical students are fleeing careers in primary care like a bunch of gazelles that spot a lion stalking them in the savannah. Why work long hours with miserable pay when you can work less and earn more and do cool procedures instead of managing the tediousness of chronic diseases? Isn't it human nature to opt for the latter? I guess I don't blame these young kids.

With the Baucus plan, the discrepancy will be corrected by moving money from the overcompensated specialists to our poor, bedraggled primary care docs. Budget neutral. Because, you know, it's not like you could conceive of simply improving reimbursements for primary care independently of how specialists are paid. That won't do. There won't be enough money to pay for the massive federal bureaucracy soon to be created to administer the One's inchoate national health care delivery system.

In football, for the longest time, the guys who got the big contracts were the glamour positions; quarterback, running back, occasionally wide receiver. And then everyone realized that the "skill position" stars were useless you had a decent offensive line. Linemen are extremely unglamorous. You couldn't identify these behemoths if you sat next to them at the Multiplex watching Quantum of Solace. They're anonymous and large and seem to earn paychecks by banging their bodies with utmost violence against other enormous humans lined up across from them. But it became obvious that your pretty boy QB wasn't worth a mound of dirt unless you had a stud left tackle protecting his blind side. That Jim Brown-esque running back of yours was a waste of a signing bonus unless you had the beef up front to open up holes for him. So what happened is, the really good linemen started getting paid. Guys like Steve Hutchinson and Alan Faneca and Bryant McKinnie now have compensation packages not far off from what the top tier of QB's get.

So what the hell am I talking about? Another sports analogy. What else is new from me. What I'm saying is that if primary care docs and internists want to start earning what QB's, I mean specialists, make, then they better be damn good at what they do. I was chatting with one of the ID guys the other day and I noticed his list was almost three pages long. He was pissed off, too. He'd be rounding until past 6pm (this was a saturday). "Most of it's all b.s., he said. This one's a UTI. This one has a decubitus ulcer. That guy has pneumonia. This one, they thought he had a fever in the ER but he really didn't; clerical error." Dr ID pal of mine was busy with a bunch of nonsense. His group had had to hire another doc just to keep up with all the work. They literally are seeing close to 90% of the patients on the medical floors. At another hospital I cover, there are three GI groups to cover a 120 bed facility and they're all busy. This is the world internists have created themselves. A patient comes in through the ER with shortness of breath, admitting internist gives orders over the phone, consults are sent out for cardiology and pulmonology. Patient noted to have a WBC count of 12, ID consult obtained. Patient slightly anemic (hemoglobin 11.9) and a GI consult is obtained with resultant inpatient upper and lower endoscopy. Patient a little bloated after endoscopy, vomits that night; surgery consult requested. It happens constantly. Rare is the patient who comes in under the care of an internist, receives a diagnosis and treatment plan from same internist and ultimately goes home once presenting complaint issues are resolved. In happens in surgery too. I've covered for general surgeons who get medicine and ID consults on young patients who are post op from routine appendectomies. It's outrageous. The admitting physician essentially delegates the decision making and diagnostic work to specialists and then swings by every day to review the chart, work done, and to say hello to the patient. It's like Penn St football right now. Joe Paterno is 117 years old and he can hardly walk six feet without falling. He sits up in the press box during games and lets the assistant coaches pretty much call all the plays and run the game down on the sideline. Many of our younger internists are getting trained within this Joe Paterno paradigm of passive leadership.

One argument is that this simply reflects the highly litigious atmosphere of practicing medicine in America and the shotgun approach to getting consults is simply a way to CYA. Defensive medicine is certainly a source of the high cost of health care delivery in the United States and an honest attempt at malpractice reform will go a long way toward reducing a doctor's initial impulse to get MRI's on everyone with low back pain. But nothing is ever as black and white as we would like to make it. Defensive medicine is understandable. But it's important that we aren't equating lazy medicine with defensive medicine. (That line is going to receive some crack backs, I'm sure. I just hope KevinMD doesn't read this and order my subsequent slaying). If internists and primary care docs shouldered more of the work (with better pay, of course) and didn't consult everyone in the hospital for routine admissions, we would see a reduced demand for specialists and market forces alone would make it unsustainable for graduating residents to flock like lemmings to subspeciality fellowships. Primary care/internal medicine is the offensive line of health care delivery. They ought to be paid accordingly. But they're going to have to bang some bodies and get a little dirty to do so.....

Saturday, November 15, 2008

Fly away surgery

I like this idea. It's certain to catch on. Apparently workers for the Wisconsin company Serigraph can have their copays and coinsurance waived for certain elective operations. All they have to do to qualify is hop on a plane and fly half way around the world to a "fancy tourist hospital" in India for the surgery. Now that sounds awesome. I can't think of a better way to recover from a hernia repair or a knee replacement than to fly coach on Continental for 14 hours.

And what about the part-time workers and the new guys with half benefits? What happens if they need a lap chole? Do they also get the tourist hospital treatment? Or do they have to settle for a voyage across the Atlantic on a wooden raft to Bangladesh for bare bones surgery at some open air tent-hospital in the jungle where they give you a piece of bamboo to bite down on instead of anesthetic?

Now I'm all for globalism but there's a point when too much of anything starts to tip matters into the realm of the absurd. What we see here is yet another bad consequence of the forced coupling of health insurance to employment.

Friday, November 14, 2008

David Foster Wallace and the Old Guy with a Horrible Hairpiece

David Foster Wallace hanged himself on September 12th of this year. He was 46 years old. The news of his death was unexpectedly jarring, a shot to the gut. He was obviously much too young. I was just getting to know him, it seemed. I'd tried reading Broom of the System when I was 23 but couldn't get through it. But I've been reading his non fiction and short stories over the past few years and I realized he was one of those rare authors who speak to something essential yet inarticulated inside me, like Hemingway and Salinger and Chekhov did. He was truly one of our best contemporary writers. Really, he was. For some reason I read his musings on the concept of Infinity while on our honeymoon vacation. What kind of fiction writer/creative writing professor writes full length books about complicated mathematical notions? Currently, I'm plowing through the essays in Consider the Lobster. (My god the piece he wrote for Rolling Stone in 2000 about the John McCain primary campaign (Up, Simba) simply won't get out of my head it's the best thing in New Journalism since that Gay Talese wrote about Frank Sinatra's cold.) Infinite Jest is next. DFW wrote with an energy and originality unmatched by practitioners of modern fiction. And he was cool. He was cool guy. The kind of dude you wish you were friends with or at least a guy who would meet up for beers every once in a while. He wrote about Roger Federer and Tracy Austin and Lobster Festivals and even the National Academy Awards of Porn without fawning or seeming patronizing or smarmy toward the subject matter. He was curious about the world. Things he didn't understand, he simply read and researched them. Because of his youth and edgy style, he brought a cloak of hipness to what was essentially an extremely intellectual and sophisticated mind.

One constant theme running through his work is this entire post-modern angst predicated on self doubt and the tenuousness of a consciousness liberated from historical constraints. It gets away from us, though. We stop being I. We are the voice who watches the I acting in an entirely predictable, banal fashion. And it's supposed to be funny but more than anything else it's frightening as hell...Let me clarify a few things. First of all, this isn't going to be a typical Buckeye Surgeon blog post about dead stomachs or crazy gallbladders or some injustice toward physicians I read about on the NY Times online. This one is going to be long and rambling and it may not be in your taste. Stopping right here may be in your best interest. I'm going to write about things that I don't usually address on this blog. I'm going to open myself up a bit more than I usually would.

Let's start off with this whole concept of Post Modernism. Everyone has heard the phrase. We're in a 'post modernist' era. Deconstructionists and Derrida and Foucault and Lyotard. Those are the names you usually see attached somewhere in a piece about post modernism. It's like if you are writing about "Communism", you're going to see the names Stalin and Lenin and Trotsky scattered throughtout. The difference is that everyone seems to have a solid grasp of what "communism" means: collectivization of resources/wealth, proletariat movement, centralization of power, Gulags, state police, totalitarianism, mass graves, crushing of the human spirit, etc. But post modernism is just a word for most of us. And Foucault and Derrida are just names. We've all come across them at some point and we might be able to answer one of those simplistic Jeopardy questions where the category is "Names that start with F" and the answer is 'this bald guy was a philosopher of the post modernist school' and you can give the question who is Foucault not because of any real knowledge of Foucault or what he wrote about but merely because the Jeopardy game is contrived in such a way that rewards rote trivia retention over true intellect. Anyway. And I don't think it's anything to be ashamed of, not knowing what the hell these guys were talking about. The school of post modernist thought is vague and esoteric and downright unitelligible at times. Here's Noam Chomsky:
There are lots of things I don't understand -- say, the latest debates over whether neutrinos have mass or the way that Fermat's last theorem was (apparently) proven recently. But from 50 years in this game, I have learned two things: (1) I can ask friends who work in these areas to explain it to me at a level that I can understand, and they can do so, without particular difficulty; (2) if I'm interested, I can proceed to learn more so that I will come to understand it. Now Derrida, Lacan, Lyotard, Kristeva, etc. --- even Foucault, whom I knew and liked, and who was somewhat different from the rest --- write things that I also don't understand, but (1) and (2) don't hold: no one who says they do understand can explain it to me and I haven't a clue as to how to proceed to overcome my failures. That leaves one of two possibilities: (a) some new advance in intellectual life has been made, perhaps some sudden genetic mutation, which has created a form of "theory" that is beyond quantum theory, topology, etc., in depth and profundity; or (b) ... I won't spell it out.

Now you're thinking, who does this marginally educated general surgeon in Ohio think he is, proposing to explain post modernism after going to great lengths to portray it as an imprecise, borderline nonsensical fraud, a charade that a legitimate intellectual like Noam Chomsky exposed years ago. And what does post modernism have to do with surgery in general and badly toupeed elderly men specifically? Well I'm not going to explain anything, in the scholarly, professorial sense. I can only simplify a few of the key notions that I have been able to digest. One way to look at post modernism is in contrast to its precursor, Modernism. Modernism is a little more manageable. It's less obscure. You won't find as many sentences like this: (from the scholarly journal Diacritics in 1997) "The move from a structuralist account in which capital is understood to structure social relations in relatively homologous ways to a view of hegemony in which power relations are subject to repetition, convergence, and rearticulation brought the question of temporality into the thinking of structure, and marked a shift from a form of Althusserian theory that takes structural totalities as theoretical objects to one in which the insights into the contingent possibility of structure inaugurate a renewed conception of hegemony as bound up with the contingent sites and strategies of the rearticulation of power." Modernism, for the most part, can be articulated more lucidly. After WWI and the killing fields of the Somme, it dawned on the intellectual elite that maybe universalism and pan-humanistic ideologies and nationalistic fervors weren't such wonderful things. That perhaps it would be better to promote individual perspectives over unyielding previous authorities. It represented a break from the old historical dogmatic shackles, a rejection of previously unquestioned traditions. Institutions such as the church, government, philosophy, and art, were subjected to a reappraisal and were redefined in terms that acknowledged the predominance of the individual. This is probably best represented by the arts of the early Modernist period. Stream of consciousness writing and shifting perspectives, as practitioned by James Joyce in Ulysses and Virginia Woolf in To the Lighthouse, challenged the prevailing literary tradition of having a consistent, chronological narration. The Impressionist school of painting emphasized the ephemeral and the fleeting nature of beauty in the world as opposed to the perpetual exactness of previous art. (Think of the contrast between a series of Monet paintings of the same haystacks but in different seasons versus the austerity and perfect lines and perspective of a Rembrandt portrait.) Basically what we're talking about is the undermining of external authority and preconceived notions of reality by an insurgent individualism. In so doing, two thousand years of foundational standing ground were smashed to bits. Questioning religious dogma was no longer considered "heresy". Protesting authoritarian government did not necessarily make you a rebel or an insurrectionist. According to the precepts of modernism, one has to participate in such fractiousness in order to more fully realize one's individualist potential.

But there's a price to be paid for the destruction of old authoritarian constructs. Suddenly, we're cast adrift, free as can be, but without a net. That can be fun and also not so fun. It can be downright terrifying when someone rips the ground out right from under your feet and all of a sudden you have to tread water or ether or whatever subjective reality it is that we've decided to suspend ourselves in for the rest of our lives. Because that ether is entirely self contingent. You can't take a day off from believing truly in what your mind projects as consciousness. It's all yours, baby. You asked for it and now you have to live with it for the rest of your life no turning back. From TS Eliot's The Hollow Men:
This is the dead land
This is cactus land
Here the stone images
Are raised, here they receive
The supplication of a dead man’s hand
Under the twinkle of a fading star.

Is it like this
In death’s other kingdom
Waking alone
At the hour when we are
Trembling with tenderness
Lips that would kiss
Form prayers to broken stone.

Broken stones are all that's left around us now. Post modernism, then, is modernism turned back on itself. If it's ok to question external forces of authority (church, state, traditional art, etc) then why can't we likewise impugn the veracity and validity of internal sources of authority? Namely, how are we supposed to trust and/or verify that ubiquitous running monologue within our own heads? How do we know it's speaking from a vantage point of objective limpidity? How do we know that what we're feeling or thinking at any one time corresponds even slightly to the actual world or to what 100 other sentient beings would be thinking/feeling under similar circumstances and whether those thoughts/feelings we have are contingent on external forces to varying degrees depending on our education level, our upbringing, our physical environement. Troubling, no? It's like Plato's men in the cave; they didn't realize they were in a cave. The shadows on the walls were a sufficient reality to them because they didn't know any better. So even though shadows on mildewy cave walls are poor substitutes for the lush colors and pungent smells of "reality" as we know it, the truth is, it doesn't matter. Those men aren't coming up out of that cave anytime soon to find out what they've been missing. Post modernism, however, impels one to reconsider one's own self, not just external forces and institutions. It would be like old Socrates yelling down into the cave one night that the cave people were a bunch of idiots because there was a whole different ( i.e. better) reality up with him, only he doesn't tell them how to get there. Not so nice, right? And that's the prick of the post-modernist thorn. We're aware that our own identity/consciousness may very well be arbitrary and foundationless. As a defense mechanism we adopt a mindset of detached irony and amuse ourselves with a knowing cynicism, funnier all the more because we're totally aware that what we're belittling is the same thing that gives rise to our disparaging commentary. Confusing and circular, I know. Makes you want to tear your hair out.

In medicine, we as physicians are privileged to encounter other human beings at their most vulnerable. Illness and pain and suffering break down a lot of the barriers we erect to ensconce us from being exposed. We erect a persona or an ideological front that protects us from the prying gaze of the Other. We can control the projection of an identity. You simply proclaim yourself as doctor, engineer, fireman, vice president of sales. Husband, father. Philanthropist. Criminal. Bad ass. We can spin things so that the message received by most people we encounter is a message we're comfortable with. Image is a powerful force in modern. That's why advertising and public relations are billion dollar industries. But there's no spinning of the truth when you're ill and laced up in an ass hanging out gown, sharing a tiny room on a lousy bed in the hospital. All your cards are pretty much out on the table at that point. There's nothing phony or disingenuous about your situation. And then a well dressed human being in a white coat walks in and starts asking you questions about everything private and embarassing, everything you normally try to avoid thinking about, things your spouse doesn't even know, and then he/she starts examining you, probing you with clinical detachment. A specimen to be evaluated and contemplated.

For doctors, the onus of responsibility in such situations is enormous. Another person is granting you a glimpse of his/her essential being, if only for a few moments. There is an unspoken trust that keeps the whole potentially awkward encounter from going to pieces. Trust that the patient will not lie about his/her symptoms or medical history and trust that that the doctor will act in the patient's best interest. It ought to be as simple as that. But there's more to it. There's more to being a doctor than just an honest exchange of information. Otherwise, it's not such an appealing gig. Although we do occasionally have automaton tendencies, we are also fallible human beings. There's a pay-off that goes unvoiced. We don't like to talk about it but there's something powerfully edifying about being able to assuage a patient's suffering. It's a rush. To help someone. To use a lifetime of study and hard work for the benefit of a stranger. I saw an old lady the other day whom I had operated on several months prior for peritonitis. She was in the hospital for something unrelated and seemed in good spirits. I stopped by just to say hello, recognizing her name on the patient board. She beamed at me when I walked in and grasped my hand. Her daughter was there and they seemed genuinely happy to see me (she'd been lost in the maze of rehab hospitals and long term care facilities). And right as I was leaving the room, the daughter said "Doctor, things moved so fast back then; we never had a chance to say how grateful we all are for what you did." It was heartfelt and real and all I could do was mumble something half way gracious all embarassed as I left. It happens all the time in general surgery. We enter a patient's life at times of great threat and change. With a good outcome, patients are extraordinarily grateful. I always call patients after a breast biopsy to tell them that the pathology is negative for cancer. There's always a half beat silence as it sinks in. And then the warmth suffuses over the phone as they express thanks. You can almost see that death grip on the phone relax as it becomes clear that no, they do not have cancer. Then there was this old lady recently who came in with an incarcerated ventral hernia. I saw her in the ER and made OR arrangements. Before the surgery I met her in the holding area to answer any last questions. I pulled back the drape and had to take a step back. She was surrounded by several large men (all at least 6'3") all talking volubly. She had five grown sons and her husband was hunched over her, holding her hand. Her boys were trying to keep it light, laughing and joking, talking about the Cavs. And then the husband stood and approached me, and he grabbed my hand tight and looked me in the eye hard and forthright and said "I just wanted to thank you so much for taking care of my wife, I love her so much" and his eyes were moist and red splotched and his face was flushed and he was one of those big bears of an old man, white bushy eyebrows and a big paunch and he towered over me with his trembly voice and I noticed his toupee was maybe a little too wooly, didn't quite match the rim of hoary white around his ears and that it wasn't on quite right, tilted forward a bit too much, like he had put it on haphazardly, too quickly, as he rushed to get to the hospital to see his sick wife.

And as the six giant men left, the CRNA whispered to me "you must love that", meaning that it must be such a thrill to be able to be almost a hero for these random strangers who wander into an emergency room. Yeah, I said. It's something. And I really want to believe that it's that simple. It's paramount that what I'm feeling and why I'm feeling it are contingent on human compassion and a simple desire to do a good deed for someone besides myself. Otherwise the the whole system falls apart.

But you wonder sometimes. Post modernist self-doubt compels you. Am I sure that's why I do this work? Am I sure that my motivations are always derived from purely benevolent impulses? I mean, how do I know that the real reason I like being a doctor isn't because I like having people think I'm some kind of amazing hero? Or maybe I just like having people think I'm the kind of person who does good deeds. Or maybe I find compliments self-affirming. Or perhaps I just enjoy the sense of power and control a physician can exert over a vulnerable patient. How do I really know for sure? How do I really know if I'm doing this because I'm such a grand and altruistic guy or if maybe I just like having people be proud of me and impressed by what I do and old guys shaking my hand with reverence and awe. Maybe I just tell myself that I'm acting from humanitarian impulses in order to obscure the true, unacknowledged selfish reasons. And does it matter? Pragmatically speaking, as long as a good deed is performed, the etiology of such action ought not to matter. But I can't let it go. It matters to me. I can't help it.

We've opened this Pandora's Box of ironic detachment and self awareness and life can be analyzed like a plot from an episode of Scooby Doo and it's funny and amusing at first. But eventually, if you follow it through to its logical conclusion, it all just makes your stomach ache your palms sweat your mind spins at night you can't get any rest and it's all, finally, just sort of sad and mournful. Fundamental assumptions like the ineluctability of self identity are suddenly cast into doubt. We begin to doubt whether we can rightly trust our initial emotional responses to situations. Can the uplifting sentiments I'm experiencing rather be explained by something dark and nefarious? We've tossed earnestness to the curb in exchange for unctuousness.

Near the end of Up, Simba, DFW writes about the conflicting feelings he has about John McCain. On the one hand he's impressed by John McCain, the POW and his obvious love of country and the credibility he brings to what would normally be a half-assed campaign exhortation like "to inspire young Americans to devote themselves to causes greater than their own self-interest", but John McCain being a man who repeatedly turned down a chance at early release from a prison camp where he was starved and tortured because "it wouldn't be right, it violated my Code", that John McCain brings a lot of moral weight to a potentially vapid, meaningless slogan. On the other hand, there's all the phony b.s. that a candidate has to subject himself to in order to get into a position where he's a viable contender for the presidential nomination. The same speech he repeats day after day at town hall meetings. The broken promise not to run negative ads. The sleekness and controlled professional verve of an organization that is ostensibly promoting the anti-candidate in such a fashion that makes him look like any other typical candidate for office. It's all so confusing, the conflicting messages. Eventually, the battle between what you want to believe and what your inner, cynical voice is saying you ought to believe becomes more important than what's actually going on in McCain's head. Whether or not McCain is a potentially great leader or just a slick salesman ultimately is irrelevant compared to what's happening in your own heart.

Now I realize David Foster Wallace suffered from depression for over 20 years and I won't presume to know everything that was going on in his head leading up to that fateful day two months ago. But I think DFW woke up every day struggling to overcome this conflict within his heart; whether to trust those warm and fuzzy first impressions, or to succumb to the cynical doubts that crept in with enough introspection. Every day he mounted an effort to ignore that doubting voice that questions our feelings and emotions and casts a pall over anything heretofore thought of as an "authentic" response to a life event. I think DFW exhausted himself mounting that effort day after day. It wore him out. He expended so much energy looking at everything from both sides, trying to be reasonable, giving every point of view it's due (inescapable, from a PM perspective), that he lost his drive to have to constantly redefine and justify himself every morning. He got tired. And then one day in September he hung himself.

I've been thinking about that old guy with the off-kilter toupe and the hearty handshake and the glistening eyes a lot lately. I think about him more than his wife, the actual patient. She did fine but I don't even remember much about the operation. Hernia repair, bowel resection, etc, etc. Presumably, she'll be enjoying another Thanksgiving dinner very soon with her brood of boys. Everything worked out for the best and that ought to be all that matters. But I want there to be more to it than good outcomes and high patient satisfaction scores. There has to be something irrefutably genuine that occurs during encounters between patients and physicians. There will be complications and unfortunate outcomes and mistakes are going to be made and I can handle all that; this surgery business isn't an easy gig sometimes and I knew that going in. I can handle complications. Overcoming external adversity often isn't nearly as daunting as reconciling the internal battles that rage inside our hearts. Somehow we have to quell the rise of this creeping cynicism that threatens to poison everything good and noble we do.....

"There are no choices without personal freedom, Buckeroo. It's not us who are dead inside. These things you find so weak and contemptible in us---these are just the hazards of being free."

"Postmodern irony and cynicism's become an end in itself, a measure of hip sophistication and literary savvy. Few artists dare to try to talk about ways of working toward redeeming what's wrong, because they'll look sentimental and naive to all the weary ironists. Irony's gone from liberating to enslaving. There's some great essay somewhere that has a line about irony being the song of the prisoner who's come to love his cage… The postmodern founders' patricidal work was great, but patricide produces orphans, and no amount of revelry can make up for the fact that writers my age have been literary orphans throughout our formative years."

R.I.P. Mr. Wallace

Sunday, November 9, 2008

How dare they!

I found this to be highly amusing. Public defenders in several states are suing to limit the number of cases they take on because of ethical concerns that quality of legal representation rendered is compromised by the current overwhelming workload. Can you believe it? How dare they. Here we have a highly educated professional class that provides a necessary and free service to the community and they expect to be able to deliver said service on their terms? It's just ghastly. Unimaginable. It reminds me of another professional class in a similar situation. I can't recall which one exactly. Not malpractice attorneys; they would never turn down a case with merit. Investment bankers? Plumbers? Country club golf pros? Hmmm. It's on the tip of my tongue. Some profession that provides an essential service to its community but is forced to see three times as many patients, I mean clients, in a day just to make ends meet, thereby spending less time than they would prefer with each individual and therefore relying more on specialists and proceduralists to "figure out" what the client's problem is which drives up the costs accrued....I wonder if the solution is to simply hire more foreign medical, I mean law school, graduates to compensate for the shortages. Surely we wouldn't entertain the unfathomable notion that if public defenders and primary care docs were better remunerated, the quality of work provided by each respective professional class might be better and, in the long run, cheaper.

Thursday, November 6, 2008

Warren Buffett and Angelina Jolie's Cambodian children

Warren Buffett made no secret of his support for President-elect Barack Obama. Renowned as the world's most astute and successful investor for nearly a generation, many found it perplexing that he would advocate for the candidate who proposes higher taxes, more government regulation of business, and freely avers that "spreading the wealth" is good for everyone. To such consternation he replied as follows:
They have this idea that it’s “their money” and they deserve to keep every penny of it. What they don’t factor in is all the public investment that lets us live the way we do. Take me as an example. I happen to have a talent for allocating capital. But my ability to use that talent is completely dependent on the society I was born into. If I’d been born into a tribe of hunters, this talent of mine would be pretty worthless. I can’t run very fast. I’m not particularly strong. I’d probably end up as some wild animal’s dinner. But I was lucky enough to be born into a time and place where society values my talent, and gave me a good education to develop that talent, and set up the laws and the financial system to let me do what I love doing—and make a lot of money doing it. The least I can do is help pay for all that.

Sounds wise and full of scrupulous prudence. Certainly, wealth not ought to be concentrated in the hands of the few as long as there are those who cannot afford the basic human necessities. But there's something rather disingenuous and off-putting hearing it come from the mouth of one of the world's wealthiest men. Under the superficial guise of "philanthropy" and "justice for all" one detects an underlying guilt that manifests itself as a scolding rejoinder addressed to the those who have acquired a surplus of bounty. He attributes his success solely to luck and the society that is constituted by the common men and women of this country. Without luck and without the toil of blue collar America, he never could have attained his financial empire. So he says. If we choose to believe him, it sure as hell does paint Warren Buffett is an appealing light, doesn't it? Isn't it swell of him to think that? Maybe he's not such a cold blooded corporate baron after all...

Whether Barack Obama won or lost wasn't going to affect Warren Buffet's bottom line much either way. When you're worth billions of dollars, if all you have to do to assuage any internal guilt at the disproportionate rewards you've received for a life's work manipulating market forces is to simply vote for the man who will raise your tax bracket from 35% to 40%, well it's a no-brainer. Done and done. Similarly, we see these actors and actresses in Hollywood in the forefront of numerous left wing causes (I'm talking about you Tim Robbins and Sean Penn). Angelina Jolie, shedding a bad girl image of numerous failed relationships and french kissing her brother at an awards ceremony, is now a respected humanitarian who donates time and money and her name to various worthy causes. Warren Buffett himself has pledged to give most of his fortune over to the Bill Gates foundation when he dies. I suspect that there is an emptiness and remorse that comes as a consequence of acquiring enormous personal wealth. Earning 15 million buckarooos to play Lara Croft in a Tomb Raider sequel surely can't be the most edifying of endeavours. Nor can watching your portfolio skyrocket to obscene values just because an old college buddy gave you a tip to buy stock in a company called Google fifteen years ago.

The sort of philanthropy demonstrated by Mr. Buffett and Ms. Jolie, however, is not to be mocked. That's not my point. Too many of their brethren don't do nearly enough, given their privileges. The incongruence with the above Buffet quote is that it tries to equate "wealth" as defined by the Warren Buffetts and Peyton Mannings and George Clooneys of the world with "wealth" as defined by most physicians, lawyers, insurance salesmen, and vice presidents of our local banks. And this discordance has been ignored and instead the quote from Buffett is used as a justification for tax policies that will disproportionately affect those who, through hard work, talent, patience, dutiful observance of societal expectations, and yes, even a little bit of luck, were able to achieve what used to be known as the American Dream. Clustering everyone who makes more than $200,000/yr as the "rich" and expecting them as a whole to be as generous and philanthropic as Bill Gates and Andrew Carnegie (when said earners are already forking over 40% of their income to federal and/or local tax repositories) is a damn good way to dissuade future generations from ever trying to aspire to such heights themselves. Mediocrity, unfortunately, may be more enticing for our more gifted youth.

George Orwell writes about the elusiveness and fundamental impracticality of a utopian society in a brilliant essay entitled "Can Socialists Be Happy" (from the collection edited by George Packer called All Art is Propaganda). I know, I know, I sound like a Sarah Palin-ite reactionary expounding on how Obama is a 'terrorist' and a 'socialist'. But we are at a crucial point in American history and Obama could very well be the fulcrum upon which this country turns, for better or worse. When times are tough, there is a tendency to turn inward and expect to be rescued by Big Brother. But as Orwell says, "all favourable Utopias seem to be alike in postulating perfection while while being unable to suggest happiness." Happiness exists only in the contrast of suffering, as a relief from pain. When history brings us to the precipice of despair and loss, it's easy enough to look outside ourselves to those who have "triumphed" in the game of life and demand that they share the fruits of their labor. The danger is that in promulgating policies to guarantee "universal happiness", we risk compromising the motivations for Individuals to perform feats that advance humankind.....