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.....