Friends:
Sadly, medicine in this country got the best of me. I am hanging up my scalpel and pursuing a career in health policy. While I am hoping to continue to work clinically on an ad-hoc basis, curing cut too deep. Thanks for viewing this short-lived blog.
Tuesday, March 22, 2011
Delicious!
Friday, September 4, 2009
Maximum treatment
I wasn't expecting this.
I got an e-mail earlier this week about a patient I'd operated on last month. A little background:
Will is a gentleman in his mid-fifties with a long history of a slowly-growing mass on the side of his face. The tumor he has is extraordinarily common, and its treatment is fairly uncontroversial. Quite simply, you take it out.
There is one small wrinkle to that last sentence, however. See, back in the day (before many of us were born), these tumors were just shelled out. After all, they're benign (most of them), and they have a very well-defined capsule. Plus, there's a relatively important nerve that is usually found directly beneath them—injuring that nerve shackles the patient with a face that doesn't move, and sometimes permanently.
Soon, people realized that wasn't the right thing to do—the capsule turned out not to be a real capsule, and the tumor was peppered with little fingers of tissue that extended past this non-capsule. If, however, you took some normal tissue along with the tumor, you could cut your recurrence rate four-fold.
Which is what we now do.
The only wrinkle in this wrinkle is that the nerve that I mentioned above is sometimes apposed directly on the back side of the tumor—meaning you can't, in that part of the resection, take normal tissue, unless you want to sacrifice the nerve itself. This is never considered a good idea. Not for benign disease, at least.
And this brings us to Will. Will's tumor, as expected, grew right along the nerve. As expected, we peeled the adenoma directly off his nerve. And as expected, the final pathology showed tumor right up against the capsule.
Will went home the next day, with a face that worked, as uncomplicated a patient as one could ask for.
Until the review team got their hands on him.
I didn't know about this team until this week. I also didn't know that it is made up of nobody with any knowledge of anything remotely related to what Will had. They're all massively intelligent people—don't get me wrong—but their expertise is in things other than this particular surgery. They don't let this stop them. Naturally.
Their e-mail read:
Now, first of all—I didn't even know someone was reviewing my pathology. My jaw dropped. Quite literally. But that's ok. I got over that surprise quickly—truth be told, it's not a bad idea to do that for a young surgeon. I'm all for it. Once the shock wore off, I actually liked the idea. I still do.
But seriously? My "plan for further treatment" for a patient who needs no further treatment? Email exchanges back and forth, replete with published literature supporting the need for no further treatment, were met with skepticism. They wanted nothing to do with it. As far as they were concerned, the decision had already been made: This patient was inadequately treated (according to a paradigm of which I am still unaware) and required further interventions—by which they either meant re-resection (and consequent sacrifice of his nerve, I suppose) or irradiation (which is five to seven weeks of unmitigated overkill).
Maybe one of the final lines in their e-mail should have given me an indication. Maximum treatment is not, after all, always best.
Wish me luck. I may raise a little Cain next week.
I got an e-mail earlier this week about a patient I'd operated on last month. A little background:
Will is a gentleman in his mid-fifties with a long history of a slowly-growing mass on the side of his face. The tumor he has is extraordinarily common, and its treatment is fairly uncontroversial. Quite simply, you take it out.
There is one small wrinkle to that last sentence, however. See, back in the day (before many of us were born), these tumors were just shelled out. After all, they're benign (most of them), and they have a very well-defined capsule. Plus, there's a relatively important nerve that is usually found directly beneath them—injuring that nerve shackles the patient with a face that doesn't move, and sometimes permanently.
Soon, people realized that wasn't the right thing to do—the capsule turned out not to be a real capsule, and the tumor was peppered with little fingers of tissue that extended past this non-capsule. If, however, you took some normal tissue along with the tumor, you could cut your recurrence rate four-fold.
Which is what we now do.
The only wrinkle in this wrinkle is that the nerve that I mentioned above is sometimes apposed directly on the back side of the tumor—meaning you can't, in that part of the resection, take normal tissue, unless you want to sacrifice the nerve itself. This is never considered a good idea. Not for benign disease, at least.
And this brings us to Will. Will's tumor, as expected, grew right along the nerve. As expected, we peeled the adenoma directly off his nerve. And as expected, the final pathology showed tumor right up against the capsule.
Will went home the next day, with a face that worked, as uncomplicated a patient as one could ask for.
Until the review team got their hands on him.
I didn't know about this team until this week. I also didn't know that it is made up of nobody with any knowledge of anything remotely related to what Will had. They're all massively intelligent people—don't get me wrong—but their expertise is in things other than this particular surgery. They don't let this stop them. Naturally.
Their e-mail read:
Dear Barefoot Surgeon:
We have reviewed the pathology report on Mr _______ and have determined that the extension of his tumor to the capsule constitutes an incomplete resection and is therefore a complication. Please attend the ________ meeting to present this complication and your plan for further treatment. We are dedicated to making sure our patients get the maximum treatment possible. Thank you for your attention in this matter.
Now, first of all—I didn't even know someone was reviewing my pathology. My jaw dropped. Quite literally. But that's ok. I got over that surprise quickly—truth be told, it's not a bad idea to do that for a young surgeon. I'm all for it. Once the shock wore off, I actually liked the idea. I still do.
But seriously? My "plan for further treatment" for a patient who needs no further treatment? Email exchanges back and forth, replete with published literature supporting the need for no further treatment, were met with skepticism. They wanted nothing to do with it. As far as they were concerned, the decision had already been made: This patient was inadequately treated (according to a paradigm of which I am still unaware) and required further interventions—by which they either meant re-resection (and consequent sacrifice of his nerve, I suppose) or irradiation (which is five to seven weeks of unmitigated overkill).
Maybe one of the final lines in their e-mail should have given me an indication. Maximum treatment is not, after all, always best.
Wish me luck. I may raise a little Cain next week.
Tuesday, August 25, 2009
Impregnate them now
One of the benefits of working in academia is the people you meet. Or, in this case, run into.
Walking out of the cafeteria, at the university to which WBAH is attached, I passed a gaggle of researchers. Which (because correlation is causation, right? Sir Bradford Hill be damned!) prompted one of them to say to his colleague, "You'd better get your boys impregnated now."
I wish I was making that up.
Walking out of the cafeteria, at the university to which WBAH is attached, I passed a gaggle of researchers. Which (because correlation is causation, right? Sir Bradford Hill be damned!) prompted one of them to say to his colleague, "You'd better get your boys impregnated now."
I wish I was making that up.
Monday, August 24, 2009
Welcome
Just wanted to offer a quick welcome to the visitors from medbloggercode.com Thanks for stopping by. Have a look around. I promise I sterilize all my instruments!
Sunday, August 23, 2009
Ebb and flow
I suppose it happens in every surgical practice. If there are days you're walking on air, there have got to be days (weeks, even) in which you're crushed.
Because complications, no matter how you slice them, suck. They almost always come in fits and starts, in groups of twos and threes. This is the ebb and flow of practice. Or so I'm told.
The thing is, whether they're your fault or not, whether they were preventable or not, whether you could only see them coming in retrospect, it doesn't matter. Complications still bring you face-to-face with your fallibility—which wouldn't be so big of a deal, were the effects of your fallibility not precipitated on other human lives. That's the rub: two men—with families, with jobs, with hobbies, with their own narratives—are different this week than they were last week, because of complications.
When I'm realistic about it, I realize that one of the complications was completely unpreventable; for the other, in retrospect, I would probably have done things differently. And though neither of them is life-threatening—and neither of them is even particularly permanent—they both still exist.
Good judgment, they say, comes from experience, and experience from bad judgment. I just wish the experience could come at only a price to myself. The fact that it comes at a price to others, too: that's a sobering reality—though unmitigatedly harsh—to medicine.
Because complications, no matter how you slice them, suck. They almost always come in fits and starts, in groups of twos and threes. This is the ebb and flow of practice. Or so I'm told.
The thing is, whether they're your fault or not, whether they were preventable or not, whether you could only see them coming in retrospect, it doesn't matter. Complications still bring you face-to-face with your fallibility—which wouldn't be so big of a deal, were the effects of your fallibility not precipitated on other human lives. That's the rub: two men—with families, with jobs, with hobbies, with their own narratives—are different this week than they were last week, because of complications.
When I'm realistic about it, I realize that one of the complications was completely unpreventable; for the other, in retrospect, I would probably have done things differently. And though neither of them is life-threatening—and neither of them is even particularly permanent—they both still exist.
Good judgment, they say, comes from experience, and experience from bad judgment. I just wish the experience could come at only a price to myself. The fact that it comes at a price to others, too: that's a sobering reality—though unmitigatedly harsh—to medicine.
Friday, August 14, 2009
The do-nothing decision
There's a patient in my clinic with cancer. (OK...there's more than just one, but it's this one that's been on my mind for a week).
His cancer isn't serious, honestly. What he's had are multiple small cancers, each of which require a minor procedure to remove (often under local anaesthesia). He's had these for years, and they will likely not kill him.
Another one popped up the other day, but this time it was in his regional lymph nodes. The medical among you know that, while this isn't a great sign, it's also still an exceedingly treatable condition. Surgery would have taken a couple of hours, and he would have been in the hospital for two days, but the long-term results would have been very, very good.
Unfortunately, I'm using the conditional voice for a reason. He decided not to have surgery. In his words, "I've decided to die."
Now, while I will fight for a patient's right to decide not to be treated, this particular decision doesn't sit well with me. Why? I want to know. All I got in response was, "My wife and I discussed this and we don't want anything done."
The thing is, in the face of heroic measures, futile interventions, or terminal diagnoses, this decision makes all the sense in the world. But he has none of these. Which begs the question: in the face of this—of a very treatable disease, which would give him years upon years of more time with his wife, why? Why "decide to die"?
See, you only get one chance in your entire life to make the "do nothing" decision. As such, it's a more permanent decision than any other you'll ever make—there's no divorce, no annulment, no retraction, no reneging. If, in the face of cancer, you decide to do nothing, you decide to die.
But why? Why now? What are his motives? What is he gaining from this?
I know that question sounds harsh—it's not meant to be; bear with me for a moment. If you get right down to it, everyone gains something from decisions they make. You decide to stay at the Waldorf instead of the Holiday Inn, you gain something. You decide to go into work on Monday morning instead of calling in sick, you gain something. You go to this play, eat at this restaurant, read this book, skydive, trek to Everest, or take the Trans-Siberian, and you gain something.
All decisions are about gain—and more than that, in all cases, you make your particular decision because the gain outweighs the loss from not picking the other option. What you gain from staying at the Waldorf offsets the loss to your pocketbook. Going to work offsets the loss of sleep. And so on.
Which brings me back to this patient. What is he gaining? As I see the economy, he is losing his life, plain and simple. What does he get in its stead? The cynical, Hollywood-ready explanations (life insurance policies and the like) don't stand up in this case. They discussed it, he and she. It's also not as if he doesn't understand the surgery, either—he's an extremely intelligent man. He reiterated to me that the surgery would be both simple and potentially life-saving. And he still doesn't want it.
So, if, he has no financial gain, he has no lack of understanding, he has no significant "freedom from massive surgery" gain, what is left?
The only thing I can come up with is heroism.
Is there some modicum of heroism that comes with making the decision to withdraw care—your own, or someone else's? That decision is never easy, but is its difficulty mitigated by the gain you get from the very fact that you're making "the hard decision"?
Does he comfort himself by thinking, "At least I'm choosing the right thing?" Does he think, "I know I'll die, but at least I'm strong enough to decide how that's going to happen?" Is this some final, binding self-affirmation. "I'm that brave kind of human."
I'm trying very hard not to make this post judgmental, because I'm not at all. As I said before, I will fight for this man's right to make that decision.
His decision, though, to sacrifice his life for an ill-defined bravery, has shaken me.
His cancer isn't serious, honestly. What he's had are multiple small cancers, each of which require a minor procedure to remove (often under local anaesthesia). He's had these for years, and they will likely not kill him.
Another one popped up the other day, but this time it was in his regional lymph nodes. The medical among you know that, while this isn't a great sign, it's also still an exceedingly treatable condition. Surgery would have taken a couple of hours, and he would have been in the hospital for two days, but the long-term results would have been very, very good.
Unfortunately, I'm using the conditional voice for a reason. He decided not to have surgery. In his words, "I've decided to die."
Now, while I will fight for a patient's right to decide not to be treated, this particular decision doesn't sit well with me. Why? I want to know. All I got in response was, "My wife and I discussed this and we don't want anything done."
The thing is, in the face of heroic measures, futile interventions, or terminal diagnoses, this decision makes all the sense in the world. But he has none of these. Which begs the question: in the face of this—of a very treatable disease, which would give him years upon years of more time with his wife, why? Why "decide to die"?
See, you only get one chance in your entire life to make the "do nothing" decision. As such, it's a more permanent decision than any other you'll ever make—there's no divorce, no annulment, no retraction, no reneging. If, in the face of cancer, you decide to do nothing, you decide to die.
But why? Why now? What are his motives? What is he gaining from this?
I know that question sounds harsh—it's not meant to be; bear with me for a moment. If you get right down to it, everyone gains something from decisions they make. You decide to stay at the Waldorf instead of the Holiday Inn, you gain something. You decide to go into work on Monday morning instead of calling in sick, you gain something. You go to this play, eat at this restaurant, read this book, skydive, trek to Everest, or take the Trans-Siberian, and you gain something.
All decisions are about gain—and more than that, in all cases, you make your particular decision because the gain outweighs the loss from not picking the other option. What you gain from staying at the Waldorf offsets the loss to your pocketbook. Going to work offsets the loss of sleep. And so on.
Which brings me back to this patient. What is he gaining? As I see the economy, he is losing his life, plain and simple. What does he get in its stead? The cynical, Hollywood-ready explanations (life insurance policies and the like) don't stand up in this case. They discussed it, he and she. It's also not as if he doesn't understand the surgery, either—he's an extremely intelligent man. He reiterated to me that the surgery would be both simple and potentially life-saving. And he still doesn't want it.
So, if, he has no financial gain, he has no lack of understanding, he has no significant "freedom from massive surgery" gain, what is left?
The only thing I can come up with is heroism.
Is there some modicum of heroism that comes with making the decision to withdraw care—your own, or someone else's? That decision is never easy, but is its difficulty mitigated by the gain you get from the very fact that you're making "the hard decision"?
Does he comfort himself by thinking, "At least I'm choosing the right thing?" Does he think, "I know I'll die, but at least I'm strong enough to decide how that's going to happen?" Is this some final, binding self-affirmation. "I'm that brave kind of human."
I'm trying very hard not to make this post judgmental, because I'm not at all. As I said before, I will fight for this man's right to make that decision.
His decision, though, to sacrifice his life for an ill-defined bravery, has shaken me.
Tuesday, August 11, 2009
I might be, but do you have to say it out loud?
Early in the morning last Tuesday, I was walking back from the cafeteria at GGGH, an omelet in my stomach, and a Snapple in my left hand, when I was stopped by a three-person family.
"Where can I find the surgery place?" asked the oldest of the bunch (and yes, that's actually how he phrased it).
Since they were about 100 yards from where patients went to check in for surgery, I started to point them in that direction. This, it turns out, was eminently not where they wanted to go. "No!" he snapped. "Not that surgery! The other surgery."
Given that there was no "other surgery place" in GGGH, my face turned quizzical, upon which his son (nephew? catamite?) said, "You want dermatology."
To which another "No!" was snapped. "Not dermatology"—and then to me—"Where's the surgery?"
This went on for a bit, each of us getting a little more exasperated. Finally, he showed me a lesion on the skin of the back of his hand and said, "Where's Dr. Barnstein's office? He's taking this off!" There are, it turns out, more than a few Dr. Barnsteins where I work, but I didn't know that on Tuesday. In fact, I was hard-pressed to name a single Barnstein. So, quite honestly (they teach you this in medical school), I said, "I don't know."
He got louder. "Dr. Barnstein's office? You don't know where Dr. Barnstein's office is?"
Calmly, I said, "I'm sorry. I really don't. But dermatology is on 3." And then I left.
As sonorously as possible, the man called after me: "F**king moron!"
And this is why, dear readers, the halls of GGGH were regaled with profanities at 7:30 on a Tuesday morning. I hope Dr. Barnstein fared better than I did.
"Where can I find the surgery place?" asked the oldest of the bunch (and yes, that's actually how he phrased it).
Since they were about 100 yards from where patients went to check in for surgery, I started to point them in that direction. This, it turns out, was eminently not where they wanted to go. "No!" he snapped. "Not that surgery! The other surgery."
Given that there was no "other surgery place" in GGGH, my face turned quizzical, upon which his son (nephew? catamite?) said, "You want dermatology."
To which another "No!" was snapped. "Not dermatology"—and then to me—"Where's the surgery?"
This went on for a bit, each of us getting a little more exasperated. Finally, he showed me a lesion on the skin of the back of his hand and said, "Where's Dr. Barnstein's office? He's taking this off!" There are, it turns out, more than a few Dr. Barnsteins where I work, but I didn't know that on Tuesday. In fact, I was hard-pressed to name a single Barnstein. So, quite honestly (they teach you this in medical school), I said, "I don't know."
He got louder. "Dr. Barnstein's office? You don't know where Dr. Barnstein's office is?"
Calmly, I said, "I'm sorry. I really don't. But dermatology is on 3." And then I left.
As sonorously as possible, the man called after me: "F**king moron!"
And this is why, dear readers, the halls of GGGH were regaled with profanities at 7:30 on a Tuesday morning. I hope Dr. Barnstein fared better than I did.
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