Sunday, September 23, 2012


The Surgeon had been handicapped by a burr in the plantar aspect of his left foot.  All summer it had been causing discomfort on jogs, during soccer games, and,eventually, even just walking barefoot across the hardwood floors in the morning.  There was something lodged in the thick skin of the strikeplate of his foot--- a splinter, a piece of glass, whatever the hell--- and it was really starting to cramp his style. 

His wife tired of his frequent moaning and groaning and dutifully instructed him to "see a podiatrist".  The Surgeon considered this.  Why would I do that, he thought.  I'm a surgeon.  I can take the damn thing out myself.

So one Friday evening after finishing up the weekly charting/computer work, he gathered some lidocaine, a hemostat, a scalpel, gauze, and betadine swabs.  He situated himself on one of the exam tables and directed the light on his foot.  He prepped it sterilely like he had done a thousand other times for other people.  He drew up the local anesthetic.  And then he paused, staring at the needle.  Five minutes of silence elapsed.  There was a disconnect between what he was about to do and the consequences of said actions.  Normally, he jabs these needles into people all the time without hesitation.  Every time he moved to inject, however, the realization that the target was his own foot made him draw back.  He felt foolish and cowardly.  For chrissakes it's just a 25 gauge needle, he thought. 

Tuesday, September 18, 2012


This man is not fit to serve all Americans as President.  For the first time during the long election season, Romney actually presents his authentic, real self.  He is a crass elitist who sneers contempt for anyone not earning at least a quarter million a year.  Even Americans who fall into the 53% category, the majority of them at least know someone in the no net federal tax paying fold--- a parent who lost a job during the recession, a grandma on social security, a cousin in grad school, an old college friend with three kids who works as a school teacher and gets a small check from the IRS every year due to child credits and his mortgage deduction.  This is the Ayn Randian worldview on full display, without ornamentation. 
"It's not my job to worry about those people".   One won't find the source for this quote in the red verses of the King James New Testament.   
The Surgeon finds himself resigned to voting for a man who keeps Gitmo open, who assassinates American citizens on a "kill list", who has opened the Pandora's box of secret, unregulated drone warfare without any congressional oversight, who launched a war in Libya without authorization, who refuses to hold the torturers in the previous administration accountable for war crimes.  It is difficult to stave off a sense of cynicism when it comes to the increasingly corrupt American political stage.  

Saturday, September 15, 2012

Last Rites

At age 39, Michel de Montaigne retired fom public life to his estate in France to write and think.  His collection of essays, on everything from virtue to vanity to cannibalism to masturbation, became a timeless classic.  Arguably, Montaigne was the world's first blogger.  The Surgeon turned 39 this year but his two children are 15 and 17 years, respectively, from attending college.  The Surgeon will not be retiring to the countryside anytime soon in order to contemplate the state of human affairs.  He will content himself with slowly plowing though Montaigne's 800 plus pages of diverse riffs over the next several years.

His essay "That to Philosophize is to Learn to Die" recently struck a chord.  Death, being ineluctably the ultimate end of all men, is strangely absent fom the modern dialogue.  It is something to flee from, a unpleasant flaw to lock up in a chest in a cobwebbed, dusty attic.  Especially here in 21st century America where we almost beatify accomplishment and material achievement, Death has become an embarassing scandal, an unmentionable.  The cycle of life has been overrun by the concept of unending progress and self-improvement.  There is always another day.  Anyone can become or achieve whatever she wants, if she puts her mind to it and works hard enough.  This is the orthodoxy of an America that has found a way to fuse Christian elitism (we are the exceptional, chosen nation) with a crass free market materialism that rewards the strong and purposeful.  Willful neglect of the final leveling force, the geat socialist, Death, is the only way to maintain the illusion of interminable vigor and prosperity.  Early death is now always a "tragedy".  The death of the old and decrepit is shunted off stage, to poorly lit vigils in stale smelling nursing homes or worse. 

The goal of our career is death. It is the necessary object of our aim. If it frightens us, how is it possible to go a step foward without feverishness? The remedy of the common herd is not to think about it. 

Tuesday, September 11, 2012


The Surgeon recently read another New Yorker piece (Big Med)  from the renowned surgeon/writer Atul Gawande.  This particular piece makes the startling claim that medicine would be better off (more efficient, cheaper) if it started to emulate the kitschy, impersonal chain restaurant Cheesecake Factory.  Yes, the same mega-chain notorious for the massive portions and enough calories per meal to fuel a man for three days.  Again, Cheesecake Factory.  The premise being that American medicine could stand to take a few pointers from one of the leading contributors to the national obesity epidemic. 

Initially the Surgeon suspected the piece was meant as satire, some sort of ironic parody of Gladwellian cross-analogizing of disparate disciplines.  But Dr Gawande is a serious man.  He has always written with a naif-like earnestness that makes him especially compelling.  So the Surgeon read the damn thing again.  And again, it is clear that the way of the future (per Gawande) lies via the corporate business model of the Cheesecake Factory.  The Surgeon is stupified.

Sunday, September 9, 2012


With the coming advent of Accountable Care Organizations and the re-branding of capitation under the banner of "cost containment", the Surgeon realizes his days as an independently practicing general/trauma surgeon are probably limited.  He understands that the only way to make the coming paradigm work (where health care spending is capped for specific inpatient admissions) is if all the doctors are employees.  The idea is to eliminate the stake for physicians.  If you are employed, then it doesn't matter to you if the employer stops getting reimbursed after a set spending limit during a long, complex admission.  You get paid the same no matter what.  A non-employed surgeon who gets asked to see a decrepit old ICU patient with free air at two in the morning when said patient has already gone past the reimbursement cap will be none too happy when he finds out he will get paid zilch for his troubles.  The employed surgeon couldn't give less of a shit. 

The Surgeon understands this "solution" as a quintessential deferral of responsibility.  The main issue (performing unnecessary surgeries, providing futile care, ordering unnecessary tests) is kicked down the road.  All that is addressed is the cost issue; to the extent that, mathematically, final hospital tallies will end up being reliably less than before.  It is so much easier to declare, by fiat, that all this unnecessary medical care that occurs in the USA, especially in the last 6 months of life, will henceforth be written off, a victim of capitation, rather than to delve into the dark quagmires of rationed medicine and recognizing the limits of modern science.  Much more difficult to catechize a generation of physicians who are not afraid of limits, of death, of the futility of efforts--- once a certain line has been crossed---- who are willing to see this calling as something far nobler than an income stream worked in shifts.  And even more difficult to inculcate such complexity of thought in the mind of the general American populace.       

It's pure cowardice.

Saturday, September 8, 2012


The call comes in at 9pm or so.  The patient sounds sick as all hell.  The Surgeon listens to the random assortment of numbers and vitals the nurse provides and clicks off his cell.  He finishes reading a boring Berenstain Bear story to his daughter (horrible children's lit, btw---- unfunny, droning, almost anachronistic are the travails of those generic asshole bears) and tucks her into bed.  He looks at the clock and runs some mental numbers.  By the time he arrives at Hospital, close to ten.  See the patient, talk to family, dictate notes, write all the orders and it's getting close to 11.  Then the wait for the call team to arrive, the inevitable dicking around of anesthesia.  The family questions.  The delay in transport getting patient from ICU to OR and now we're talking well after midnight.  Before he even cuts. 

The lady is in extremis.  Family is pacing in the hallway.  The Surgeon places hands on belly and the diagnosis is clear.  She is on pressors already and her lower legs seem mottled.  Fluids are running wide open.  The urine in the foley bag looks like bourbon.  After the usual back and forth with family--- surgery or no surgery, high risk, but what else can you do, she may make it /she may not, the only hope is to operate, but it could be futile and thus an operation would cause her unnecessary pain and suffering, etc etc---the decision is made to proceed to OR.  The abdomen is exposed, prepped, ready for scalpel five after one.  The arithmetic is just a little off.

Monday, September 3, 2012

Boys and Girls

The Surgeon likes the morning.  He likes them especially when he is off call and has no obligations to drive in to the hospital.  On these mornings he enjoys being in the presence of his two children.  There is a girl and a boy.  The girl is older.  Of course there is an element of sibling jealousy/rivalry but nothing pathologic.  The Surgeon has always worried about his little girl.  He wants to protect her and shield her from harm.  He worries that she doesn't eat enough.  He worries that living in two separate households will affect her negatively.  He worries about her development.  When she runs on the driveway, he catches his breath, terrified she will fall.  When she scrapes her knees he feels the pain as his own.   He wants her to be happy, always.  As for the boy, the Surgeon finds that he wants to tackle him and wrestle him and toss him laughing into the air.  When he bumps his little head, the Surgeon is not wracked with terror.  He'll shake it off, he thinks.  The boy is a litttle rough neck and eats like a starving wild boar and the Surgeon wants him to be strong and resilient, for the world is a harsh and unforgiving place. 

The Surgeon is troubled by these two attitudes.  He feels sexist, or at least somewhat unequal, in his perceptions/behaviors toward the boy and the girl.  One must treat one's children all equally.  This is such an obvious, fundamental principle that to state it out loud is ludicrous.  The surgeon has two children.  The boy has turned one and is not so much a novelty, a lump of carbon, anymore.  The boy has a distinctive personality now.  He burrows his head into the carpet and wails when he is mad.  He smiles and reaches for the Surgeon when he comes home.  The girl is in preschool.  She can spell her own name.  Sometimes she doesn't want Dada (the Surgeon) to take her to the potty because "he is a boy and she is a girl".  She is unaware of the distinction between men and boys.  He has two children.  He loves them both, equally, but in different ways.  He loves them terribly.     

Sunday, September 2, 2012

It is 11pm and the Surgeon sits down to write at his laptop.  His children are asleep.  He checks the baseball scores on Yahoo (incompehensible, since he now hates baseball and is starting to hate all professional sports, the American ones anyway, the way they have been so commercialized and monetized and the way our culture elevates these games of marginal skill to levels of absurd importance, and he checks them self-loathingly, the way an addict feels while falling off the wagon, cracking open that first beer, sliding another needle into a sluggish, anguished vein, doing it once again, irrevocably, for old times sake, a pastime he used to do eagerly, almost joyfully as a boy, hoping the Indians may have won the night before, now rote and mechanical, mindlessly clicking though well-lit, laptop-halogenated boxscores).  The very definition of a desultory existence.   His fantasy football draft is the next day.  Another season awaits where the Surgeon knows he will waste entire Sundays fretting about YAC and 2 yard TD plunges and whether strangers in other cities will accumulate 100 yards of receiving or just 97, about torn ACL's and waiver wires and back up tight ends and sleepers and busts and pick sixes and garbage time scores.  He will concede that he is powerless to resist this allure.  Oh it's so stupid, he will lament.  Another Sunday on edge, worried about his starting RB1's matchup.  Why do you expend so much mental energy concerning yourself with such drivel?  Now, before it has begun, it is easy to wax poetic over the things he "ought" to be doing instead.  The rich vastness of knowledge and art that still eludes him  Go learn the fucking piano.  Memorize those stanzas you love, not to quote them pretentiously at dinner gatherings, but because you want to be able to whisper them to yourself when troubled, when alone, when sad.  Teach your kid.  Be a better Dad.  Call your Mom more often.  Send a hand written note to your cousin or uncle.  But then it will start, another season, another pretend "team", and all noble intentions careen off into the void.    The Surgeon realizes this.  He foresees another fall/winter of self-fulfilled failure.  He will fail himself.  Of course he understands that if it isn't fantasy football, it will be something else.  He'll want his lawn to look a little too immaculate and go to great lengths and costs to ensure an Augusta National-esque appearance.  He will buy amazing mowers and gas powered trimmers and powerful industrial strength fertilizers.  He will read about the difference between crabgrass and foxtail and be able to spot them in his lawn.  When the summer drought takes hold, he will be seized by a throat clutching panic.  He will find himself unable to simply sit in a chair and watch the wind soughing the piercing green leaves of the trees in the sun.  He will want to trim some goddam branch instead.