Wednesday, June 30, 2010

The Palin Pregnancy


I'm sorry, but I just cannot resist any longer. The fantastical, magical realism surrounding the events of the birth of Sarah Palin's 5th child Trig just have to be reviewed. (Come on, there's a medical slant to the topic, right???)

Please take a moment to listen to or read the transcript of an interview ex-Governor palin gave to a reporter in 2008. To recap:

In April 2008, Sarah Palin was 43 years old and 8 months pregnant with a known Down's Syndrome child. She had had two previous miscarriages. For some reason she flew to Dallas, Texas to give a speech at a national governor's conference. Early in the morning on the day of the speech, Mrs. Palin states that she started to feel some cramps and noticed leakage of some fluid. So she called her OB in Alaska who apparently reassured her that everything was cool (and who now refuses to speak to anyone from the media about the incident). Again, she describes fluid leaking from between her legs, suggesting a possible premature rupture of membranes (i.e her water broke). While 8 months pregnant with a special needs child. At age 43.

Well that was again if, if I must get personal, technical about this at the same time, um, it was one, it was a sign that I knew, um, could lead to uh, labor being uh kind of kicked in there was any kind of, um, amniotic leaking, amniotic fluid leaking, so when, when that happened we decided OK let’s call her.


So Palin delivered her speech. She then elected to skip the post-speech reception (sort of awkward mingling at a cocktail party with amniotic fluid running down your leg, you know), got on a plane and flew to Seattle, Washington. She then took another plane to Anchorage, Alaska. Finally, she drove the 50 or so miles from Anchorage to Wasilla so that her fifth child could be born in his hometown. (Can't have no fishpickers born down there in the Texas!)

Digest that for just a second. A 43 year old woman carrying a child with known Down's Syndrome in her 8th month of pregnancy voluntarily embarked upon a transcontinental adventure to give some dumb speech. Then, after noticing some cramps and the passage of amniotic fluid, she went ahead with her speech and, instead of proceeding directly to the nearest Dallas high risk pregnancy center, boarded a four hour flight to Seattle. Then she hung out in the Seattle airport lounge for a while and took a connecting flight to Alaska. Then she drives to Wasilla. Finally, she decides to seek medical attention at local Wasilla hospital, a facility lacking a NICU and other high risk specialists. That's her story. In her own words.

There are only three explanations for this extraordinary compendium of events:

1) The Andrew Sullivan Answer: In this theory, Palin was never pregnant and Trig is not her child. To me, this is the least valid of all the theories. The odds of a woman giving birth to a child with Down's Syndrome increase with increasing maternal age. Again, she was 43 years old. I just don't buy it. (But a simple confirmatory birth certificate would be nice!)

2) The Mommie Dearest Answer: In this theory, everything that Palin says is true. In other words, Palin willfully and wantonly placed herself and her unborn child in tremendous danger by flying cross country with amniotic fluid running down her legs. This to me is the scariest possibility because by willingly telling the story, she seems to be under the impression that people would be impressed by her "hardiness" and "toughness". (That's the way we do things up here in the Alaska!) And she is completely oblivious of the fact that this story makes her look reckless and selfish and completely insane. What kind of mother would take a risk like that with her child, let alone a high risk, premature one?

3) The Bridge to Nowhere Answer: The other possibility is that she simply lied. She made it all up. She thought it would make her look tough. So her water never broke. She never felt cramps. None of these things actually happened until she was in Alaska. I suppose this one, banal as it is, represents the most likely answer.

Again, this woman is a major political player in the GOP. She could easily win Iowa and New Hampshire in 2012. She's frightening....

Monday, June 28, 2010

Work Hours Ctd.

Th ACGME has come out with new and improved recommendations for resident work hour restrictions. Some highlights:

*Interns have to inform patients of their role in patient care (i.e... Although I'm wearing a white coat and a stethoscope around my neck, I'm a pretty green neophyte at this whole doctoring business. Just thought you'd like to know. Enjoy your chicken broth and cold coffee.)

*Interns cannot work more than 16 consecutive hours. Fortunately, the ACGME chose not to co-opt the Institute of Medicine's (IOM) recommendation that residents are allotted time for a five hour nap period after 16 hours or work. Because that's just, you know, sort of embarassing. Because then you have to assign blankies and pillows to all the fresh faced interns and make sure snackies are available in the call rooms and it just becomes a logistical nightmare for residency program directors.

*According to the wording of the ACGME report, it appears that interns are not allowed to do anything involving patient care without "level 1 or 2a supervision". That means the attending physician either has to be standing right next to the young doc or at least somewhere on the premises. So all those central lines and chest tubes and code blues that happen in the middle of the night have to be handled by older residents.

Ah, the slow death of general surgery....

Sunday, June 27, 2010

What Does Dave Weigel have to do with Sermo?

Dave Weigel is a libertarian, right-leaning blogger who had been writing for the Washington Post. Although his politics veer right of center, he has no tolerance for the radical, wacky wing of the Republican Party (think Tea Partiers, Glenn Beck, Sean Hannity, etc.) Weigel was a member of the liberal-leaning listserv called JournoList (a private, by-invitation-only email group comprised of professional journalists and bloggers). JournoList provided a forum for these guys to exchange ideas with one another in an off the record fashion. Weigel, this week, in a moment of reckless writing, posted a thread on JournoList implying that the world would be a better place if Matt Drudge suddenly decided to self immolate.

Someone read the post and decided to break protocol. Ultimately, several of his off the record email posts were published for the general public on both the Daily Caller and FishbowlDC. Weigel subsequently resigned his position as a writer/blogger for the Washington Post.

The embroglio got me thinking social media and professionalism, in general. On places like Facebook and private blogs and Twitter accounts, people often present a far different characterization of themselves than the one they perhaps proffer in the office, at the hospital etc. Perhaps we sometimes trust too much that these two versions of ourselves do not overlap, that our secret rebellious, outgoing selves are secure behind passwords and restricted access walls. (This is why I don't do Twitter or Facebook--- Buckeye Surgeon is the sole source of learning about Dr Parks; no contradictions or duplicity. As long as I keep writing honestly, I don't feel any need to worry about reprisals.)

Sermo is a social network restricted to physicians (you have to give a verifiable medical license number in order to join). It's a great resource for docs. I've run cases by strangers on Sermo in real time while trying to decide upon an appropriate treatment plan for a difficult patient and have been aided immeasurably by the advice and comments I've received. But there are also posts about the political aspects of medicine and complaints about other specialties and rants about difficult patients and malpractice claims. And not everyone on Sermo chooses to be anonymous.

What if someone obtained access to Sermo for nefarious purposes? Perhaps a physician-turned-hospital administrator who went looking for dirt on a trouble-making internist. Or a malpractice attorney who used his brother-in-law's log-on ID to troll for cases.

Dave Weigel lost his job over a careless post on what he thought was a secure, private listserv. You figure it's not a question of if, but when, something similar will occur to casually flippant doc on a site like Sermo....

Friday, June 25, 2010

Drug Testing Docs?



I got this link from Sermo. Lucian Leape MD, a public health professor at Harvard, wants to subject doctors in America to strict random and periodic drug testing to help identify those physicians who are impaired. All in the name of patient safety, of course:
"I'm very much in favor of random testing," Dr. Leape says. "We have a responsibility to identify problem doctors and bring them into treatment." And to protect patients in the process.


Ok, I get it. Impaired physicians are bad. We don't want strung out cokeheads and stumbling alcoholics roaming the halls of our hospitals. But random drug testing? Listen, it's hard to argue with someone like Dr. Leape without appearing to be some uber-lefty, bleary eyed, tie-dye wearing hippy freak. But consider:

1) A doctor who is on vacation with extended family in the Outer Banks. After a day of surfing and tanning and several cold frosty beers, one her cousins busts out a joint late night on the back deck while the ocean rolls into shore. And let's say she partakes in such activities 3 of the next 4 nights in similar fashion. That THC will be floating around in her system for the next 30 days, potentially. What if she is called to give urine a week after the trip?

2) Let's say an internist goes to a Super Bowl party with friends. The day turns into an all night fiesta as they celebrate the Browns' first ever world title. Many beers are consumed. Knowing that it was going to be a long night of carousing, the doctor had cancelled his office hours for the following Monday morning, planning to just drop by the office in the afternoon to do some charting. The next morning, his office manager calls at 8 AM sharp and tells him he has to have his urine/blood sample in by 10AM. He stumbles out of bed, still hung over, and rushes into the hospital. The result shows his blood alcohol is 0.09 (enough to get you a DUI). What do you do with him?

What are the consequences? Do you lose your license? Are you reported to the medical board? Are your privileges at hospitals suspended? Does your name wind up on the police blotter section of your local Sunday paper?

To be clear-- I am strictly against the idea of physicians practicing medicine while impaired. But this totalitarian encroachment on what a man or a woman chooses to do in his/her free time is rather disturbing. As a professional class I think it is our own responsibility to identify and report those doctors who have a problem. An impaired physician cannot hide for very long. We just need to stop being such timid cowards and do a better job of self-policing ourselves.

Wednesday, June 23, 2010

Work Hour Reform Redux

Kevin has a good article in the USA Today about the negative consequences of resident work hour reform. In it, he notes that patient "hand off" errors and the lack of operative exposure a surgeon-in-training gets during residency can adversely effect both patient care and the ability of future doctors to handle complex situations.

I also just read a crappy paper in Archives about the effects of the 50 hour work week limitation currently in use in Switzerland. The overwhelming majority of attending and resident physicians stated that the reforms negatively affected operating room experience and overall patient care. Who would have thought that working as much as a middle manager at a Toyota plant would adversely effect a surgeon's training and performance.

If you live in the Atul Gawande world, none of this bothers you. In this world, sub-sub specialist physicians are only responsible for a tiny sliver of medical knowledge and so there's really no reason to be spending 100 hours a week in a hospital during your training. A fully integrated, multidisciplinary "system" will take care of everything. You won't need a general surgeon. The thyroid guy will take out your thyroid gland. The biliary guy will remove your gallbladder. And the colorectal guy can take care of your hemorrhoids. Don't you worry.

Yes!

Sunday, June 20, 2010

Happy Father's Day

Ok, so I've obviously decided to continue churning out a mixture of pithy anecdotes and other assorted detritus on Buckeye Surgeon. Thanks to all who commented, either on the post or via email. As my buddy Goose wrote: "nice to see you've snapped out of your early mid life crisis and are back blogging."

I've been reading William Shirer's Rise and Fall of the Third Reich lately. (It's long, but reads like a Tom Clancy thriller. Just fascinating that an entire nation could fall under the spell of a complete and utter lunatic.) Anyway, there was a part describing one of the speeches Hitler gave to the Reichstag in 1938. He used the occasion to respond to FDR's official query into his intentions with regards to several of the other remaining free nations in central and eastern Europe. Hitler had already secretly obtained declarations (in the gentle, diplomatic Nazi way, you can be sure) from those countries announcing that none of them had any fear of further German aggression. He then proceeded to mock Roosevelt in faux indignation. How dare the President of a country that just ended slavery a generation ago, a country that liquidated/relocated the native population to allow for the Manifest Destiny of its white pioneers, how dare they lecture Germany on good behavior. Apparently this set off thunderous applause and laughter throughtout the Reichstag.

Hitler hadn't really scored any real points with this line of thought, of course. One doesn't lose all moral credibility just because of past transgressions. You don't lose the right to call out someone for immorality or an ethical lapse just because you have sinned in your own past. You only lose it when you fail to ackowledge your past failures. Atonement is impossible without an honest self-interrogation. And I guess that was the point of my little blog sabbatical and the subsequent to be or not to blog post. As my fantasy football friend Jeff said: it's about time you wrote a self critical post contra the shiny white knight of compassion you've created on the blog. What took you so long? What kind of self-loathing post-modernist would you be otherwise?

I guess that's part of it. But not all. I'll be honest---I write this thing for my little baby girl, mostly. I want her to have a way to find out what I was like and what I thought about when I was younger man. It's corny, I know. But I dont care. Go read Kevin MD if you dont like it.

Gawande on the Matrix



Atul Gawande gave the commencement address at Stanford medical school this year. I thought it might be fun to rip-off a Bill Simmons schtick and do a retro-diary of my thoughts as I read through it. So here goes. (Text borrowowed from the New Yorker.)


Many of you have worked for four solid years—or five, or six, or nine—and we are here to declare that, as of today, you officially know enough stuff to be called a graduate of the Stanford School of Medicine. You are Doctors of Medicine, Doctors of Philosophy, Masters of Science. It’s been certified. Each of you is now an expert. Congratulations.
(Frank Drackman additionally received a Masters of His Own Domain upon graduation)

So why—in your heart of hearts—do you not quite feel that way?
(Because we just finished the entirely useless, waste of time, summer vacation known as fourth year of medical school!)

The experience of a medical and scientific education is transformational. It is like moving to a new country. At first, you don’t know the language, let alone the customs and concepts. But then, almost imperceptibly, that changes. Half the words you now routinely use you did not know existed when you started: words like arterial-blood gas, nasogastric tube, microarray, logistic regression, NMDA receptor, velluvial matrix.
(I use the word 'microarray' at least 17 times a day)

O.K., I made that last one up. But the velluvial matrix sounds like something you should know about, doesn’t it? And that’s the problem. I will let you in on a little secret. You never stop wondering if there is a velluvial matrix you should know about.
(When I was 11, my older cousin Chris told me all about his girlfriend's velluvial matrix. I acted like I knew exactly what he was talking about.)

Since I graduated from medical school, my family and friends have had their share of medical issues, just as you and your family will. And, inevitably, they turn to the medical graduate in the house for advice and explanation.

I remember one time when a friend came with a question. “You’re a doctor now,” he said. “So tell me: where exactly is the solar plexus?”

I was stumped. The information was not anywhere in the textbooks.

“I don’t know,” I finally confessed.

“What kind of doctor are you?” he said.
(Now come one. Solar plexus? Did this anecdote really happen? And was Gawande truly upset that he didn't know the location of a solar plexus? Did he crack open his anatomy textbook, frantically leaf through the index searching? In the words of my pretentious feminazi freshman English comp instructor---it just doesn't "ring true".)

I didn’t feel much better equipped when my wife had two miscarriages, or when our first child was born with part of his aorta missing, or when my daughter had a fall and dislocated her elbow, and I failed to recognize it, or when my wife tore a ligament in her wrist that I’d never heard of—her velluvial matrix, I think it was.
(Damn. Don't I feel like an ass after all those anti-Cost Conundrum posts. I hereby retract all jokes re:Gawande. The dude's had a tough life.)

This is a deeper, more fundamental problem than we acknowledge. The truth is that the volume and complexity of the knowledge that we need to master has grown exponentially beyond our capacity as individuals. Worse, the fear is that the knowledge has grown beyond our capacity as a society. When we talk about the uncontrollable explosion in the costs of health care in America, for instance—about the reality that we in medicine are gradually bankrupting the country—we’re not talking about a problem rooted in economics. We’re talking about a problem rooted in scientific complexity.
(Now we get into the meat of his point--that the complexity and depth of modern medicine is "too much" for the individual physician. More on this later.)

Half a century ago, medicine was neither costly nor effective. Since then, however, science has combatted our ignorance. It has enumerated and identified, according to the international disease-classification system, more than 13,600 diagnoses—13,600 different ways our bodies can fail. And for each one we’ve discovered beneficial remedies—remedies that can reduce suffering, extend lives, and sometimes stop a disease altogether. But those remedies now include more than six thousand drugs and four thousand medical and surgical procedures. Our job in medicine is to make sure that all of this capability is deployed, town by town, in the right way at the right time, without harm or waste of resources, for every person alive. And we’re struggling. There is no industry in the world with 13,600 different service lines to deliver.
(Service line? Why are we using corporate jargon all of a sudden?)

It should be no wonder that you have not mastered the understanding of them all. No one ever will. That’s why we as doctors and scientists have become ever more finely specialized. If I can’t handle 13,600 diagnoses, well, maybe there are fifty that I can handle—or just one that I might focus on in my research. The result, however, is that we find ourselves to be specialists, worried almost exclusively about our particular niche, and not the larger question of whether we as a group are making the whole system of care better for people. I think we were fooled by penicillin. When penicillin was discovered, in 1929, it suggested that treatment of disease could be simple—an injection that could miraculously cure a breathtaking range of infectious diseases. Maybe there’d be an injection for cancer and another one for heart disease. It made us believe that discovery was the only hard part. Execution would be easy.
(This part seems forced and a little disingenuous. The multitude of diagnoses and treatment options available to doctors today does not necessarily demand instantaneous memorized command of all facets of medicine. I have no problem using these things called the "internet" and "medical textbooks" to read about topics I don't know or have forgotten. For big cases I prepare by reviewing the surgical atlas and reading up on the latest literature. For management of hypertensive crisis in the ICU, I quickly log on to UpToDate and then call back the nurse with an answer. It doesn't take long. Just because the answer to a patient problem initially eludes you, it doesn't mean you have to throw your hands up in the air and retreat to the safety of the "50 or so diagnoses you are comfy with".)

But this could not be further from the truth. Diagnosis and treatment of most conditions require complex steps and considerations, and often multiple people and technologies. The result is that more than forty per cent of patients with common conditions like coronary artery disease, stroke, or asthma receive incomplete or inappropriate care in our communities. And the country is also struggling mightily with the costs. By the end of the decade, at the present rate of cost growth, the price of a family insurance plan will rise to $27,000. Health care will go from ten per cent to seventeen per cent of labor costs for business, and workers’ wages will have to fall. State budgets will have to double to maintain current health programs. And then there is the frightening federal debt we will face. By 2025, we will owe more money than our economy produces. One side says war spending is the problem, the other says it’s the economic bailout plan. But take both away and you’ve made almost no difference. Our deficit problem—far and away—is the soaring and seemingly unstoppable cost of health care.
(Yes, occupying three countries half way around the world is a mere drop in the pan of federal spending!)

We in medicine have watched all this mainly with bafflement, even indifference. This is just what good medicine is like, we’re tempted to say. But we’d be ignoring the evidence. For health care is not practiced the same way across the country. There is remarkable variability in the cost and quality of care. Two communities in the same state with the same levels of poverty and health can differ by more than fifty per cent in their Medicare costs. There is a bell curve for cost and quality, and it is frustrating—but also hopeful. For those getting the best results—the hospitals and doctors measured at the top of the curve for patient outcomes—are not the most expensive. They are sometimes among the least.
(Aha! It seems the good doctor has backed off a bit from his conclusions in the Cost Conundrum article that communities that spend more per capita on healthcare have worse outcomes. Now he hedges a bit, using the modifier "sometimes" to describe discrepancies in health care spending as they relate to outcomes. See this for details.)

Like politics, all medicine is local. Medicine requires the successful function of systems—of people and of technologies. Among our most profound difficulties is making them work together. If I want to give my patients the best care possible, not only must I do a good job, but a whole collection of diverse components must somehow mesh effectively.
(For now on, all doctors who practice in a hospital setting need to meet for three hours every other Monday morning with representatives from ancillary care, hospital administration, nursing, physical therapy, food services, patient transportation, the candy stripers, the old lady who brings around the gentle giant siberian husky petting dog for patients to touch, janitorial services, etc for a collegial intradiscplinary staff meeting to discuss ways of enhancing hospital teamwork.)

Having great components is not enough. We’ve been obsessed in medicine with having the best drugs, the best devices, the best specialists—but we’ve paid little attention to how to make them fit together well. Don Berwick, of the Institute for Healthcare Improvement, has noted how wrongheaded this is. “Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence,” he says. He gives the example of a famous thought experiment in which an attempt is made to build the world’s greatest car by assembling the world’s greatest car parts. We connect the engine of a Ferrari, the brakes of a Porsche, the suspension of a BMW, the body of a Volvo: “What we get, of course, is nothing close to a great car; we get a pile of very expensive junk.” Nonetheless, in medicine, that’s exactly what we have done.
(And if you take the engine of a Pinto, the body of a Edsel, the transmission of any 1980's era Chevrolet you get: a very cheap and ugly piece of shit.)

Earlier this year, I received a letter from a patient named Duane Smith. He was a thirty-four-year-old assistant grocery-store manager when he had a terrible head-on car collision that left him with a broken leg, a broken pelvis, and a broken arm, two collapsed lungs, and uncontrolled internal bleeding. The members of his hospital’s trauma team went swiftly into action. They stabilized his fractured leg and pelvis. They put tubes in both sides of his chest to reĆ«xpand his lungs. They gave him blood and got him to an operating room fast enough to remove the ruptured spleen that was the source of his bleeding. He required intensive care and three weeks of hospital recovery to get through all this. The clinicians did almost every single thing right. Smith told me that to this day he remains deeply grateful to the people who saved him.

But they missed one small step. They forgot to give him the vaccines that every patient who has his spleen removed requires, vaccines against three bacteria that the spleen usually fights off. Maybe the surgeons thought the critical-care doctors were going to give the vaccines, and maybe the critical-care doctors thought the primary-care physician was going to give them, and maybe the primary-care physician thought the surgeons already had. Or maybe they all forgot. Whatever the case, two years later, Duane Smith was on a beach vacation when he picked up an ordinary strep infection. Because he hadn’t had those vaccines, the infection spread rapidly throughout his body. He survived—but it cost him all his fingers and all his toes. It was, as he summed it up in his note, the worst vacation ever.

When Duane Smith’s car crashed, he was cared for by good, hardworking people. They had every technology available, but they did not have an actual system of care. And the most damning thing is that no one learned a thing from Duane Smith. For we have since had the exact same story occur in Boston, with an even worse outcome. Indeed, I would bet you that, across this country, we miss the basic, unglamorous step of vaccination in probably half of emergency splenectomy patients.
(Ok. Now we have to interrogate this line of thinking. No more jokes. Gawande seems to be advocating for an algorithmic, systems-based paradigm of medicine, one in which the parts, i.e physicians, are mere cogs in some sprawling, evidence-based machine of health care delivery. There are too many diagnoses, too many treatment options, and too much innovation to be apprised of, as individual doctors. Therefore, we need to limit our spheres of responsibility. A specialist for every facet of health care. Blood pressure too high? Go see a cardiologist. That rash you got after hiking in the woods? Go see this dermatologist. Need your thyroid removed? Go downtown to see the endocrine surgeon. This is an attack on generalists, an attack on the idea that an individual doctor, dedicated and intellectually curious, can provide optimal care for his/her patients. And the example he provides of Duane Smith seems to paradoxically repudiate his entire theorem. All these good doctors working together but somehow they all forgot to prescribe the necessary vaccination. Gawande would say that the problem lay in an inappropriately designed and monitored 'system'. I would counter that the component parts, the doctors, individually failed the profession and henceforth the patient. How do you forget to give Pneumovax after taking out a spleen? That's simply bad doctoring. That's a general surgery 101 exam question.)

Why does anyone receive suboptimal care? After all, society could not have given us people with more talent, more dedication, and more training than the people in medical science have—than you have. I think the answer is that we have not grappled with the fact that the complexity of science has changed medicine fundamentally. This can no longer be a profession of craftsmen individually brewing plans for whatever patient comes through the door. We have to be more like engineers building a mechanism whose parts actually fit together, whose workings are ever more finely tuned and tweaked for ever better performance in providing aid and comfort to human beings.
(This resigned attitude to the impossibility of staying up to date on the latest medical developments is saddening. I don't know what to say. Maybe I'm just a 37 year old dinosaur.)

You come into medicine and science at a time of radical transition. You have met the older doctors and scientists who tell the pollsters that they wouldn’t choose their profession if they were given the choice all over again. But you are the generation that was wise enough to ignore them: for what you are hearing is the pain of people experiencing an utter transformation of their world. Doctors and scientists are now being asked to accept a new understanding of what great medicine requires. It is not just the focus of an individual artisan-specialist, however skilled and caring. And it is not just the discovery of a new drug or operation, however effective it may seem in an isolated trial. Great medicine requires the innovation of entire packages of care—with medicines and technologies and clinicians designed to fit together seamlessly, monitored carefully, adjusted perpetually, and shown to produce ever better service and results for people at the lowest possible cost for society.
(Yikes. That last sentence evokes an uneasy Orwellian utopia. Do I have to report to room 101 for a session with O'Brien if I write for Nexium instead of Prilosec for GI ulcer prophylaxis on a post op patient??)

When you are sick, this is what you want from medicine. When you are a taxpayer, this is what you want from medicine. And when you are a doctor or a medical scientist this is the work you want to do. It is work with a different set of values from the ones that medicine traditionally has had: values of teamwork instead of individual autonomy, ambition for the right process rather than the right technology, and, perhaps above all, humility—for we need the humility to recognize that, under conditions of complexity, no technology will be infallible. No individual will be, either. There is always a velluvial matrix to know about.
(Subsume the individual into the Great Intradisciplinary Whole! The Maoist in me is feeling warm and fuzzy right now. But seriously, it's one thing to encourage greater communication between different specialists and to penalize those docs who are doing unnecessary procedures just for the compensation; it's quite another to throw in the towel on individual accountability and the ideal of the dedicated, astute physician who always strives to do the right thing for his/her patients. Kierkegaardian Individual Ethos trampled under foot by Henry Fordian mechanization and interchangeable parts! Listen, we don't need a brand new system or a restructuring of some quasi private/public healthcare bureaucracy. We need better doctors. We need to inculcate a stronger ethic of personal responsibility, both to our patients and to the health care system as a whole. I've said it a million times in this blog--- becoming a doctor ought not to be some default pathway for high achieving college kids who can't decide what else they want to do. It's a hard job, but rewarding as hell when you approach it with the right mind frame.)

You are joining a special profession. Doctors and scientists, we are all in the survival business, but we are also in the mortality business. Our successes will always be restricted by the limits of knowledge and human capability, by the inevitability of suffering and death. Meaning comes from each of us finding ways to help people and communities make the most of what is known and cope with what is not.
(I can't argue with those sentiments.)

This will take science. It will take art. It will take innovation. It will take ambition. And it will take humility. But the fantastic thing is: This is what you get to do.
/mass of students toss grad hats and gowns in the air and charge out of locker room screaming and yelling like banshees into the Pacific Ocean and swim for an undeteremined hospital in China.
Read more: http://www.newyorker.com/online/blogs/newsdesk/2010/06/gawande-stanford-speech.html#ixzz0rObG9PKa

Saturday, June 19, 2010

Hedging

Pathologists and radiologists don't have the luxury of spending time with actual patients so they have to render professional judgments and determinations based on indirect data (radiographs, a mashed up slice of breast tissue, etc.) I don't envy them; the utter detachment from patient care would make me miserable. But they do have a tough job. They get one shot at getting it right. There's no patient follow up. They never get the opportunity to explain a missed diagnosis to a patient, to soothe things over. Once they stamp their name on the final report, there's no turning back. They can't afford to allow a sliver of a chance that they haven't "covered" themseleves.

And so they hedge. The radiologist will write "cannot rule out possible neoplasm" on an incidentally seen 4mm white blotch on a CXR and recommened "follow up CXR in 6 months advised." I understand it. I get it. But there are consequences to this hedging. And nowhere in medicine do we see this more than in mammography and the pathological analysis of breast biopsy specimens. We are prodded into far too many needle and open biopsies by mammography reports that "can't rule out cancer, biopsy strongly encouraged". Often, these reports come across the desks of primary care docs and they have to call them on the phone and inform them that "something was off on your mammogram; we need to do a biopsy. Please make an appointment with the surgeon as soon as you can."

My initial encounters with breast lesion patients are always emotionally charged. They've been crying, or are on the verge of tears, wrapped in their flimsy exam gowns. Often, a terrified-looking spouse is sitting uncomfortably next to them. They are in a surgeon's office. For an abnormal mammogram. It's every couple's worst nightmare. The first ten or fifteen minutes are spent defusing the situation, reassuring them that the overwhelming majority of abnormal mammograms end up being much ado about nothing.

The pathology reports are similarly hedged. Fine needle aspirations are notoriously non-specific. A result of "cellular atypia" could mean anything. More tissue needs to be obtained, you inform them. Another biopsy needs to be performed. The whole waiting process has to be repeated. You may as well have told them they have to walk non-stop from Cleveland to Buffalo carrying an anvil. I had one younger woman recently (35, no risk factors) whose OB/Gyn had ordered a mammogram for a palpable mass. The palpable lesion ended up being a benign-looking cyst but nearby was a cluster of calcifications that were deemed "suspicious". I sent her for a stereotactic core needle biopsy. Three days later the pathologist filed his report. Most of the core specimens were benign. Unfortunately, on one slide, at the edges of the specimen, there was a small area of cellular atypia. The pathologist noted that, given the location of the area of concern, this most likely represented an artefactual effect of crushed tissue during preparation of the slide. Nevertheless, underlying neoplastic change "could not be ruled out".

What do you do with that information? Well, you call the patient and you explain that despite overwhelming evidence to suggest a complete absence of cancer, the pathologist felt that he could not definitively rule out the possibility of a small focus of neoplastic change. She was 35 years old. Do you tell her to not worry, that the pathologist is just covering his ass? You can't say with 100% certainty that I don't have cancer, she asks me? No, I say. We'd have to do a formal open breast biopsy. There's always a pause on the other end of the line. You can hear a kid playing, laughing somewhere else in the house, the television blaring too loud. My son is five years old, she whispers, her voice cracking. I know. I'm sorry, I say. It's going to be fine. I promise you.

Friday, June 18, 2010

Robbed!



What a comeback, but that call (and it's still not clear if offsides or a foul was called, even now, 6 hours after the game) goes down as one of the worst I've ever seen in any sport.

Watch the World Cup! I know soccer gets a bad rap in America but it's the Beautiful Game, dammit! Turn off the NASCAR. You won't get the valium-induced fugue of baseball. You won't be forced to scratch at your own eyeballs after watching Kobe Bryant go 6-24 in a game seven. This is the sporting event you can't miss. It's time for Americans to get on board. Soccer! Soccer!

/Resigned to watching tape delayed MLS games on ESPN 7 in 2015.....

Appy Tips




I always look at my own CT scans on rule-out appendecitis cases. (We surgeons arrogantly fancy ourselves as board certifiable in radiology, didn't you realize?) When I see a scan like the one above, i know the case is going to be a bear. Probably 90% of my lap appies take 10-25 minutes. What you see above is a classic retrocecal appendix. You can tell by how high it is (tip extending toward liver rather than down toward pelvis) and by its location directly behind the cecum (hence retrocecal!). Plus the patient was a rather large, bulky dude. So you know you're going to have to roll up your sleeves and go to work. You find you often have to mobilize much of the entire ascending colon just to see the damn thing and then you have to dig it out of indurated, inflamed retroperitoneal fat. I actually had to place an extra port to finish the case. Took me an hour.

Wednesday, June 16, 2010

In America....


The Nobel prize winning NGO Physicians for Human Rights (PHR) has published a widely circulated white paper detailing "experiments" conducted by physicians and other medical personnel on detainees at Guantanomo. Read the paper. It's a grisly, soul-sapping compendium of state-sanctioned, state-organized human experimentation.

Remember those OLC torture memos that war criminals John Yoo and Jay Bybee wrote, alleging that the US policy of "enhanced interrogation" was both legal and safe? Well, the "safety" of the techniques was determined based on results of "studies" conducted by medical personnel on actual human beings. The effects of waterboarding and extreme sleep deprivation and sustained severe pain were all meticulously recorded and studied. Conclusions were then drawn. Just like a happy little science project! Only instead of making acetaminophen in the lab and determining the yield of product (the only actual science experiment I remember from college), these criminals were distorting the scientific method for totalitarian, undemocratic purposes.

To wit:
1) Experimenters were able to conclude that saline was a far safer liquid to pour over the faces of restrained inmates, rather than pure water. The simulation of drowning wasn't altered (thank god!) but the higher sodium concentration of saline helped prevent the unfortunate side effect of severe hyponatremia and subsequent brain edema seen with the forced swallowing of large amounts of pure water.

2) Clinical investigators determined that combination of techniques that cause severe pain did not lead to an overall increased susceptibility to the perception of severe pain (someone please feel free to interpet whatever the hell that means). Consequently, researchers felt comfortable recommending that Gitmo torturers could freely combine walling, stress positions, and other pain eliciting techniques. In other words, the detainee felt equally shitty whether you just rammed his head into a wall or combined that with forcing him to also stand on his right leg for three hours without moving.

3) Researchers concluded that sleep deprivation up to 180 hours (that's about 8 days of sleeplessness for the math impaired) did not lead to any long term psychological or physical consequences. And then as long as you let the subject sleep uninterruptedly for 8 hours, you could resume another 180 hours of wakefulness! Sweet!

Yes, this happened in America. This is what even the Obama Administration defends to its core. We don't look back in this country. We gaze only toward the future, wide eyed and full of hope. With our blinders on. No one is held accountable for lawlessness and immoral actions. We invade countries under false pretenses. We torture suspects. We detain indefinitely "suspicious Muslims" for years at a time only to release them without any charges. We send unmanned Predator drones into Pakistan and Afghanistan, strafing villages, collateral damage be damned. Our former President can smugly proclaim, "hell yeah I waterboarded KSM....and I'd do it all over again!". We have government employed doctors who conducted illegal, immoral experiments on human subjects, not for some greater good, mind you, but to provide a sham scientific cover for the inhumane torture and abuse of completely subjugated prisoners.

Maybe the AMA could advocate for some transparency on this issue. I realize they are busy fighting the good fight for the doctor fix and against the special tax on plastic surgery procedures. But perhaps it would be beneficial to their moral standing and ethical credibility to update their statement on the torture doctors from April 2009....

Monday, June 14, 2010

Enough Already



Aren't you all sick and tired of hearing about the impending 21% cut in doctor reimbursements on Medicare patients? This farce of a story has been cropping up in the news every couple of months. I'm sick of it. At the last minute, the "doc fix" will get tucked into the back pages of some unrelated Congressional bill and the problem will be deferred till the next fiscal year. Does anyone doubt that this won't happen?

Just like i don't care about whether Brett Favre ever plays football again or retires to raise cattle and alpacas on his Mississippi ranch, I could care less about the impending Medicare cuts. It isn't a story until something substantive is done. All else is just frenzied speculation. The minute I hear the words "Brett Favre" on ESPN, I flip the channel. Same when I see him tossing footballs to randoms dudes in that Wrangler commercial. Enough is enough.

As far as I'm concerned, the "Brett Favre Rule" is in effect for the Medicare Doc Fix. I don't want to hear about it anymore.

Monday, June 7, 2010

To blog or not to be



I've been struggling lately with the raison d'etre of this blog. I tend to write about a variety of topics, usually medically related, but it seems the best posts have been the ones based on actual patient encounters in my practice. And I've been wrestling with the significance of that fact to such an extent that I had to just shut things down for a while.

Blogging is by nature an extraordinarily solipsistic expression of individuality. It isn't enough for the blogger to privately fill notebooks with his ramblings---no, he must publish them to a world wide audience. It takes a certain degree of pompous audacity, let's be honest, to embark on such a task. One has to believe that what one is writing is unique, interesting, important enough to be read by strangers. I've always hated this implication of blogging. To blog is to cry out for attention.

The stakes are much higher for medical bloggers who go beyond writing about healthcare policy and reform. To write about a meaningful patient encounter is to cheapen it somehow. And I have become increasingly uncomfortable with the exploitative, self-aggrandizing solipsism inherent in writing about patients. I grown tired of Myself and the Voice I provide on Buckeye Surgeon. I'm always constructing these narratives where I'm some super-compassionate doctor of mercy, unique in ability to identify those anecdotal moments of human connection. I'm tired of the narrative, the underlying message of I'm a nice guy and a superb clinician that runs through the thread of posts. The blog dangerously veers toward being more about me and my supposed superior compassion and diagnostic acumen rather than about the patients or functioning as some sort of edifying source of inside medical information. It's irritating as hell. I'm a real person, with real shortcomings and faults. I ought to be writing more posts about how I was rude on the telephone late night with some nurse or how I was impatient with a patient's relative because she kept asking the same damn question over and over or the time I made a delayed diagnosis. It wouldn't be such a glowing portrait of me, but at least it would be an honest one. (But then you ask yourself, why do I even need to be painting accurate self portraits for strangers to peruse on the internet? Wouldn't that hurt my career? Isn't it better to concoct some alternative personality that people can read about on line?)

I feel this blog has unintentionally created a Doppelganger Dr Parks who is always kind and wise and decent, who never makes errors, who always sees the little streaks of humanity glimmering under the veil of illness in his patients. I mean I have tried to write honestly about things over the past three years. I wasn't intentionally trying to manipulate facts. But you cant help writing in such a way that makes you look maybe better than what you really were, in retrospect. In the act of writing, I'm able to capture my life and my experiences in such a fashion that I see myself as an agent of good. That isn't a bad thing I suppose. We all have our private little forms of solace as we navigate through unwieldy, unpredictable life. But a blog isn't private. It ends up being a slanted representation of a real person. I can do the same thing and derive the same benefit in a private journal, just perhaps more honestly and with more perspective.

The one good thing about the blog is that its mere existence has forced me to contemplate my life as a surgeon on a more consistent basis. A blog is always starved for material and the experiences I've had have been a fruitful fodder to fill the hungry beast. My reflections on specific encounters have changed me more than the encounters themselves. But I don't want to keep repeating myself. I don't want Buckeye Surgeon to devolve into a bunch of sappy, regurgitated tales from the front lines of the hospital. That's not what this was supposed to be about. It was supposed to transcend its author, a medium through which author and reader alike could possibly make some sense of illness and death and human fallibility.

One thing I've discovered on these travels is this idea that the patients don't so much need me as I need them. The authenticity of a meaningful patient encounter fills some indescribable void in my life (pathetic as that sounds). I need them. I need the 88 year old guy recovering from a perforated bowel surgery who tells me he prayed last night for the first time in 50 years. I need to see the lonesome mother holding the hand of her prodigal son, suffering in the ICU with severe alcohol-induced necrotizing pancreatitis, whispering for him to open his eyes. I need the brash 77 year old Senior Olympian (diskus and hammer throw) recovering from a bowel obstruction who gives me shit every morning about how I played soccer in high school instead of wrestled. But I don't want to exploit them or splash their vulnerability all over some public blog anymore. Conversely, if I dont write about them, I lose them; they slip from the tenuous realm of my active memory. They strike me like those big beautiful snowflakes in early November that quickly melt and dissipate on your sleeve. I want to keep as many of them frozen and crystalline and perfect for as long as I can. I want to be like that kid in the book Snowy Day who hides a snowball in his pocket, hoping it will be there when he wakes in the morning.

I'm not entirely certain what will happen with Buckeye Surgeon. I'm still grappling.