To Cut is to Cure

It didn't last long

2011-03-22T08:17:00.000-07:00

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.

Maximum treatment

2009-09-04T13:22:00.000-07:00

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:

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.

Impregnate them now

2009-08-25T14:02:00.001-07:00

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.

Welcome

2009-08-24T17:26:00.001-07:00

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!

Ebb and flow

2009-08-23T14:21:00.001-07:00

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.

The do-nothing decision

2009-08-14T16:23:00.000-07:00

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.

I might be, but do you have to say it out loud?

2009-08-11T15:50:00.000-07:00

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.

Death threats? Really?

2009-08-08T14:22:00.000-07:00

I read today that some senators are now facing death threats because they support health care reform. Death threats. Seriously. It makes me wonder whether belligerence is the only response of some to concepts with which they disagree (let's kill abortion doctors and liberal senators.)

Here are a few thoughts, then, on the whole concept of health-care reform:

1. We don't know what Obama's health plan is. This is what people seem to forget—nothing has been released, so when you hear people saying things like, "I've read the plan and..." they're probably lying. All the arguments, the heated, spittle-flying fights, the death threats are based on sheer speculation and fear-mongering. I will tell you that I have a friend who works on the Hill for Health and Human Services. I asked her what she thought, and all she was allowed to tell me was: "The plan is much better than it's being made out to be in the media."

2. I spent a good bit of time in a socialized healthcare system (this, by the way, is in response to Dr. Burson's comment earlier—my salutary opinion of the Canadian healthcare system is not just some pie-in-the-sky idealism. I worked there. For years). I learned a few things.

More people in Canada are happy with their healthcare system than in the US (something like 75% vs. 45%)
Doctors are quite well compensated in Canada—yes, they'll never make the two- and three-million dollar intakes that some doctors make here, but they're not struggling against insurance and the like.
There's a bigger focus on quality (actual, as opposed to perceived) than on quantity. Certain tests that are de rigeur here in the US, but that have zero data to support them, for example, are simply not offered in Canada. And care is no worse.
Canada's life expectancy is longer than in the US.
If you don't have a life-threatening illness in Canada, you do wait longer to get your care (sometimes up to a year for things like hip-replacements). It's called "rationing by queue"—and before you start saying we should avoid rationing healthcare at all costs, realize that we already do. Except we do it in the most unfair of ways—"rationing by cost." Meaning, if you can afford it, you can have it. If you can't? Well...sorry.
If you do have a life-threatening illness, you're often in the operating room within 2-3 weeks.

On the main, I've said it before--if I get sick, like really sick, take me to Canada. So bear in mind that I'm a strong proponent of "socialized medicine", that bugaboo that's scaring everyone but really shouldn't be.

3. We have learned, in the last hundred years, that the free market is not a good regulator of medicine. This is all over the economic literature. Human beings respond to incentives--the whole concept of incentivization is not new in economics. It's what drives advertisers and presidents' day sales. So: pay doctors by how much care they give, and they'll give as much as they can (more, not necessarily better). Pay lawyers a percentage of the winnings they extract, and they'll go after the deepest pocketbooks they can. Allow pharma companies to charge $50,000/year for a drug, and they'll lobby and advertise and ghost-write papers until they can. I've quoted Dr. Berwick before: "Every system is perfectly designed to achieve exactly the results it gets." Meaning, if we're seeing a rapid increase in healthcare costs, just wishing it away isn't going to work--the system we've set up is driving those costs up. And that system, right now, is the free market on health care.

4. Take a look at this graph:

Source: Grande D, Polsky D. Health Care 2009: The burden of health care costs for working families—implications for reform. NEJM 2009. 361:437-439.

Essentially, what it tells you is scary. Within the next ten years (and probably within the next five), overall income of middle-income families is going to start decreasing simply because of the rising health-care costs. Families that are in the 80th percentile (ie, around $100K/year) are safe for another 20 years, but then they start becoming poorer. It's only the families that make upward of $150K/year (which is 5% of the US) that are safe from this trend. What this means is that we, as a country, will start becoming poorer within the next two decades, just because of our health-care costs.

What's most surprising to me in that graph, though, is the dotted line. Despite the evidence that we will drive our country into poverty, people think that their income increases by a linear amount every year. Which is probably why it's been so hard to get Americans to accept the need for a drastic overhaul. The president said it best in his news conference.

5. So...what does this all mean? I think the reform can go in one of three ways:

It can utterly fail. If it does, I think we might have to move to France, and very soon.
It can be so watered down as to be unrecognizable—essentially, a rewording of the same system. This would be horrible, but the one good that would come of it is that Americans would get over the psychological hump of "getting the government out of my healthcare" (notwithstanding the fact that the government is already firmly, firmly ensconced in healthcare. And not just in medicare/medicaid, but also in the setting of compensations, the regulation of employer-based health insurance, etc).
It can pass, with a public option. As much as I'd actually like a single-payer healthcare model, I don't think Americans are ready for that yet. If, at least, we have a government option—and, most importantly, if that government option is good and isn't just the lowest-common-denominator healthcare (probably my biggest fear with the health plan)—then Obama may have accomplished something good.

Your thoughts?

Doing nothing

2009-08-06T12:59:00.000-07:00

Sometimes, doing nothing is the hardest thing in the world.

A man came in to see me at GGGH about a month ago. He was young, had a supportive and worried wife, a great and fulfilling job. And a tube in his stomach, through which he was being fed.

This isn't all that uncommon, especially in patients with big underlying conditions. The problem is—he didn't have any. He, instead, had significant pain all throughout his mouth and throat—he couldn't swallow, had lost fifteen pounds in the last ten days, and, out of desperation, had asked for the tube.

He was sent to me to evaluate this pain. Evidently, his doctor had looked in his mouth and seen large, erosive ulcers and wanted to know if they were elsewhere in his digestive tract.

They were. Everywhere. On his tongue, in his throat, on his epiglottis. Big craters, some filled with a white residue, some with a clean base, all surrounded by a a very thin ring of angry red. His doctor had appropriately cultured one of the ulcers in his mouth—a culture which yielded no results. This wasn't a virus. This wasn't bacterial.

What it was would go away by itself.

And that's the hardest thing to tell a patient. "I can't treat you. This will go away on its own. There's nothing I can do that will make this better." He looked at me as if I was stupid, as if I was telling him that not because I knew it would go away but because I was stumped. He looked at me as if I was hiding behind ignorance and hoping his disease would disappear.

And let me tell you—the temptation was strong to do something, to send some test, ask for some consult, prescribe some medication, just so it would look like we were doing something. Time is not an accepted treatment.

I've seen this patient every week since then. Every week, I treated his pain, gave him more calorie drinks, checked his feeding tube. Two weeks ago, he wanted to kill me, and his wife wanted to cry.

Last week, he was better.

Perfectly designed to fail

2009-07-15T18:10:00.000-07:00

We all learn to respond to incentives, negative and positive, from the outset of life. If you toddle over to the hot stove and touch it, you burn a finger. But if you bring home straight A's from school, you get a new bike... An incentive is simply a means of urging people to do more of a good thing and less of a bad thing. But most incentives don't come about organically. Someone...has to invent them.

So begin Steven Levitt and Stephen Dubner in their book Freakonomics. Although late into the "incentives" fray in economics, their book did more than many before to popularize this idea—that we respond to external forces, be they economic, moral, or social.

This point was driven home last week. I found out something deeply, existentially disturbing about one of the hospitals at which I work (it's disturbing enough for me not to even want to tell you which one).

At this hospital, employees are paid not to work.

Not to put too fine a point on it. But here's the scenario:

Assume you're a surgeon. Assume you're given eight hours of operative time a week. Assume also that you see a certain number of patients in clinic each week, of which a percentage end up going to the operating room.

Now assume that your residency and fellowship (because this is what they do) have trained you to be efficient. So, you book five cases for your eight hour day, figuring with the average one-hour turnover time between cases (truth be told, at this hospital it can be as high as 120 minutes. That's right. 120 minutes of dead time between the time the last patient got out of his surgery and the time your surgery starts), you should be able to have a reasonable 7:30am-5:00pm operative day.

But here's the rub. What happens if you finish early? What happens if, instead of taking you four hours to do a certain case, it takes you one. And what happens if your results are the same? (This last point is important).

At this hospital you are penalized!

I kid you not. You actually get a letter chastising you for "not filling your operative time," for "decreased operating room utilization," and so on.

But wait! Not only that, your bonus is decreased. You get paid less for working better. You are penalized for efficiency; you are rewarded for dawdling.

No matter how you look at it, this incentive makes no sense. Who, after all, incentivizes their employees not to work?

There are a thousand other metrics you can look at for surgeon performance: number of patients seen, number of operations done, number of complications, number of papers published, number of medical students taught, number of patients lost to follow-up...you name it, it can be measured. And any one of these would conceivably spur the surgeon (or anaesthesiologist or nurse or sterilizer, etc) on to better medicine.

Except for one. One single metric will push the entire system toward glacial inefficiency. And this is it.

Reward an employee simply for the number of hours he or she works—reward him, essentially, for being a warm body—and that is all he'll be.

In 1996, Donald Berwick memorably wrote, "Every system is perfectly designed to achieve exactly the results it gets" (BMJ 12:619-622).

Well, this one? This one's perfectly designed to fail.

Pro bono

2009-07-06T05:24:00.000-07:00

I found out today that the WBAH had forgotten something very important.

See, if you remember, I signed my contract with the hospital back at the end of 2008, and after more paperwork than anyone should ever have to fill out in a lifetime, they finally allowed me to start working in mid May. It only took seven months.

Except, in the midst of all that paperwork they threw at me to fill out, they forgot themselves to fill out a small, inconsequential piece. They never added me to their payroll.

So, here I am, six weeks later, realizing that every minute I've spent there was pro bono.

I can't imagine this happens in other jobs—but WBAH was so nonchalant about it, I get the feeling I'm not the first.

Dr. House strikes again

2009-07-06T05:15:00.000-07:00

This time it wasn't an off-the-wall esoteric diagnosis. This time it was a diagnostic procedure.

I'm really not making this stuff up.

Early on in House (for the life of me, I can't remember which season), Greg gives a very specific, if very wrong, directive to his underlings. With solemnity, he declaims:

Biopsy the lymph node under the chin!

This—and what happens next—is wrong for so many reasons, not least of which is the fact that nobody simply has one lymph node under the chin (instead, you've probably got 150. On each side).

I don't mean to pick on House. I love the show. But when a patient comes to me and tells me I need to "biopsy the lymph node under my chin," and then specifically tells me it's because they did it on House, I begin to wonder. There are three physicians whose names appear in the credits of that show. And still, we're biopsying lymph nodes under chins?

Maybe they have room for another physician advisor. FOX?

Socialism redux

2009-07-03T13:51:00.000-07:00

This post comes in response to Grace, who commented on an earlier rant about patient entitlement.

I agree. You may be right. I may be cursing a real-life Obama healthcare initiative.

On the other hand, I may not.

See, contrary to what a lot of people think, the good number of physicians (myself included) support a single-payer health-care system—or, at the very least, a good (emphasis on that word) governmental insurance option.

Interestingly, the American Medical Association is vehemently against these proposals, mainly because it would limit the ability for doctors to increase the sizes of their yachts—but they'd never put it that way. This might just play a part in why I didn't renew my membership last year.

I'm all for us as physicians to be able to make a living—and maybe even a living commensurate with the fifteen extra years of school and training we invest. That would be nice. But for us to do it at the expense of the patients whom we're supposed to be working for smacks of the worst form of capitalism possible. We might as well start peddling snake oil.

Now, I'm neither a politician nor an economist, and I will admit that I have not read up on what the healthcare plan actually entails. But what I have done is practice medicine in both single-payer and market-driven systems; the latter is far inferior. If I get sick—if I get really sick, that is; if, God forbid, I have cancer or need a new heart—send me to Canada.

Health care is better there—and, no, I'm not Canadian.

There is, however, a chance that I'd curse the Obama health plan, were it finally to see the light of day. See, the one problem (and this comes from someone who already works in a government-run hospital) would be for Obama's plan not to go far enough. If the governmental plan remains a last-ditch option for people who otherwise cannot find other insurance, we'll most likely remain in a self-perpetuating state, in which government health care is the least desirable option.

For the president's plan to succeed—really to succeed—it would take either the complete centralization of healthcare (as in Canada), or a lot of money invested in the government system, allowing it the chance to out-compete the competition. And it would take regulation—it would take someone actually saying no to frivolous tests ordered by doctors and frivolous lawsuits brought against them.

It may be idealistic of me to think this might work—I can hear the individualistic drawn-breath horror at the former suggestion ("Socialist!") and the deflated pessimism at the second—but I still hope it does.

I, for one, would be happy to make less money to bring it about.

A black box

2009-07-01T12:31:00.000-07:00

I suppose every job requires a measure of self-censorship, a modicum of silencing that part of your psyche that's protesting: "But! But!!...."

Into my clinic last week walked a guy who was referred by his primary care physician for surgery. And not just "surgery," but a very particular, specific surgery. His primary care physician had not told him, "Go see this surgeon I know to get an opinion about surgery." No, he'd put himself in the place of Ultimate Arbiter and said, "Go see this surgeon I know and tell him you need this procedure done on you."

Fair enough. As much as specialists have the deserved reputation of being slightly arrogant, generalists have the equally deserved reputation of being slightly know-it-all-ish. That's not the end of the world. Usually, we treat each other with mutual respect (after all, I haven't titrated someone's anti-diabetic medicines since medical school; it's simply not my purview).

The problem was, the patient was absolutely, unwaveringly convinced that he needed this procedure done on him. This would be OK were the procedure actually effective treatment for what he has.

Unfortunately, it's not.

It's not that doing the procedure would be wrong, per se. Many others before me have done this particular procedure for this particular diagnosis. Nor is it a particularly risky operation—it would take less than an hour. Rather, the problem is that, as people have gotten more experience with this, it's become increasingly clear that this treatment simply doesn't work. Not in 80% of people. It's, not to put too fine a point on it, a sham.

The patient, his wife, and I had a very long talk about the risks, the benefits, and the alternatives of the procedure. And no matter what I said, he was convinced that this was what he needed done. Because "his doctor" had told him so. Despite my telling him that the procedure would "hurt like hell" (specifically), and that, six months down the road, he had an 80% chance of being in exactly the same situation he was in now, he was unwavering. He would have it done, because his doctor (who, I warrant, had never seen the procedure performed) told him that that was what he needed.

At what point do we surgeons simply become technicians, ready to do the bidding of physcians for whom what happens behind the sterile barrier is one big black box? At what point is agreeing to do the procedure tantamount to swallowing your integrity—and your knowledge of the evidence?

At what point do you risk alienating a patient to maintain your integrity? At what point do you just swallow your pride and do it?

And, more importantly, is it just pride that you're swallowing?

The patient left with a bit of literature from me, and the encouragement to consider what we'd talked about. I wonder if he's coming back.

By the way—thank you to those who wished me luck on my move. The move is done, but the remodel isn't, so I'm living amidst two-by-fours, drywall dust, and a contractor who gets increasingly miffed at me every day.

A brief apology

2009-06-24T19:49:00.001-07:00

Apologies for the current silence. I'm moving this weekend, so will probably be AWOL for a few days. See you on the other side.
Barack Obama

Flagrant entitlement

2009-06-22T18:32:00.000-07:00

A couple of weeks ago, a patient came to see me in clinic. She needs a significant amount of operating done on her—a large surgery which will take the entire day, keep her in the hospital for two weeks or so, and require a fair amount of post-hospital rehab.

She is uninsured, which means every member of her care team—from her surgeons, to her anaesthesiologists, to the consultants who will take care of her in-house, her rehab doctors, and the hospitals themselves—will render her care for free. Every hour in the OR, every clinic visit we have together, every piece of suture used—all free. All unpaid.

For many of us, this is—quite honestly—part of why we went into medicine: to be able to give back to a community that allowed us to get to where we are. If she were any other uninsured patient, I wouldn't even be writing this post.

But she's different. See, while she is unable to scrape together enough money for a surgery that is necessary to save her life, she is somehow able to produce $20,000 for breast implants, notwithstanding the gluteal implants, rhinoplasty, and facelift she has also purchased.

Does this irony escape her? Is this fair? Of course not—but does fairness matter in this situation? Patients get treated because they need it, not because they can or can't pay for it. But this flagrant entitlement (she told us about this)—it rankles just a little bit.
Mila Kunis

Thank you, Hugh Laurie

2009-06-21T11:50:00.001-07:00

Last week, a patient was admitted into WBAH. He had a very mundane diagnosis—nothing esoteric, nothing worthy of Hollywood. Except that his family watches House and, more importantly, uses it as their source of all knowledge medical.

They were convinced—existentially, deeply, inexorably convinced—that their loved one had something else. Because, back in Season Two, Greg diagnosed a patient with a spectaculary esoteric disease, sending all of us medically-oriented fans back to our textbooks. (He did this, of course, after going through his usual differential, "Infection!...It's not infection...It could be a virus!...It's not a virus...Autoimmune!...It's not autoimmune...Cancer! It's got to be cancer! Let's do a biopsy of the patient's brain! Through his eye!...Damn...it's not cancer. Sorry about your brain, sir...")

Bear in mind: there have only been three hundred cases of this particular condition reported since it was first described eighty years ago! Three hundred cases in eighty years, out of a world of six and a half billion people. Not only that, the patient's symptoms come no closer to approximating this disease than to approximating, say, carbon-monoxide poisoning, or bilateral below-the-knee amputations.

Despite these minor difficulties with applying a diagnosis from FOX to a patient eminently human, several hours have been spent in the last week explaining to separate family members why there may be other things on which to concentrate. Hours.

To little avail. Thankfully, their loved one is getting better.

So, the next time the doctor is late for your appointment, realize that she might be trying to explain to someone that a British comedian with an uncannily good American accent may not be the most reliable source of medical information out there.

The homosexual and the can of Fixit

2009-06-17T20:26:00.001-07:00

Today, as I was walking home from WBAH, I was stopped at a relatively busy street corner.

He was an African-American man, well-dressed in an LDS-sort of way. His crisp white shirt contrasted his dark tie and dark pants. All he was missing was a nametag.

"Excuse me," he said.

Now, I have confess something: I'm the stereotypical inveterate city-dweller. I don't like being stopped on the street. Ever. So, I ignored his initial two volleys.

"Excuse. Me!" He was a persistent bugger.

"Yes, sir?" He took this response as an invitation to cross the limbus of urban personal space. I moved back. He moved forward. And again, until I was up against a hip-high wrought-iron fence. Our movements were subtle but meticulously choreographed.

"Excuse me, but could you help me buy a can of Fixit?" His stutter made me wonder if I'd actually heard that. I mean, we all grow to expect any number of things to follow "excuse me". Spare some change? Got a dime? Help me get a bite to eat? I lost my wallet and I need a bus ticket to get home (I fell for that one once. It wasn't until I saw the guy the next month, plying the same canard, that I realized I'd been had).

But a can of Fixit? Does anyone actually buy that stuff? And, more importantly, does anyone (besides, evidently, a random man on a random street corner, in a random city) ask nameless strangers for it?

I asked him again. His response reassured me. He really did want a can of Fixit. And, unregenerate man that I am, I refused. Maybe I shouldn't have.

"I knew you were going to say that from the very beginning," he said, more than a little antagonistically. "Your body was saying that. I already knew it!"

"Well, why'd you——"

"The homosexuals always do that."

Any response that may have considered forming itself in my mouth was drawn up short. He caught me by surprise. Not that it should ever matter, I'm quite happily straight, but in his defense, I was wearing a purple tie. For whatever that's worth. But, "the homosexuals always do that"? Seriously? I don't think I've heard a taunt like that since, oh, the third grade. Maybe.

Because, evidently, were I actually heterosexual, he would have gotten his can of Fixit. I decided he no longer required a response, so I left.

"Don't walk away!" he started shouting. And then, louder (but still with a stutter), "HOMO! RUN AWAY, HOMOSEXUAL!" This, I assume, was for the benefit of any other pedestrians, because I was halfway down the subway steps by this point.

Needless to say, I don't think he got his can of Fixit that day.

Walking on air

2009-06-17T09:11:00.000-07:00

There are certain cases that test the surgeon's mettle.

Unfortunately, my fellowship was in those specific cases. I spent two years learning under one of the few people in this part of the world that does these cases, and does them regularly. He is a spectacular teacher, but he is known not to allow his fellows to do very much operating themselves. Very few of the fellows he has trained over the last two decades actually got to be left alone in a room, with the patient, without him hovering over their shoulders.

This is a good thing—many times I hear his voice in my ear as I'm operating...correcting my technique, speeding me along, pointing out pearls. And he is, if nothing else, a spectacular surgeon, so his voice is not one I mind hearing.

But there's a down-side. You finish his fellowship, thinking you can do one of these cases. You're pretty sure. If someone asks you on an interview, you wax poetic about how much you love these cases, how you want to make them a part of your daily diet. (This is helps your job prospects, since most surgeons want nothing to do with them).

Deep down inside, though, you remain unconvinced.

You've never done one of these cases by yourself. What if they fail? What if you encounter a disastrous complication? What if you actually don't know what you're doing?

What if...?

Last week, I did my first of these. I think I'm a little more convinced now. Walking home that night, I was walking on air.

Driving without a map

2009-06-12T09:05:00.000-07:00

To many people, anatomy is a black box. This is, of course, fair. You have no reason to know where (or what) the inferior turbinate, tunica albugensis, Fallopian canal, and any number of sesamoid bones are. This knowledge doesn't help anyone in their daily life, their morning commute, or picking up potential dates.

But, for a surgeon, anatomy is paramount. You cannot operate without knowing where you're going. Getting lost in someone's abdomen, someone's neck, someone's pelvis can have disastrous consequences. It's one of the reasons training is (at least) five years long.

For this reason, an encounter with my resident in clinic this past week has rendered me speechless.

I've mentioned this resident before. He graduates this month. He's set to be turned loose on the world, treating you, treating me. Powers greater than I have signed off on his competence and told the powers greater than themselves that he is fit to sit for his board exams, that he is competent in all areas of our specialty.

He is plainly not.

In clinic this week, he called me in to see a patient with him. He'd been scoping the patient and was concerned that there was a foreign body in the particular orifice he was interested in.

"I'm not sure what to do...Do I take it out? Do I leave it in? Will it absorb?" Fair questions, all.

Except what he was seeing was normal anatomy!

Absolutely, 100%, text-book-perfect normal anatomy.

I don't think I can get across how disheartening this is. It would be like your doctor calling one of her superiors because she couldn't find your heart with her stethoscope, because she didn't know where your lungs were, because she wasn't sure what these little flaps of skin above your eyes were ("But they move! And they have hair! Should I take them off? Will they go away?").

As I said—anatomy is specialized. If this resident were non-medical, he'd be forgiven. If he were just starting his training, we'd have a good laugh about it. Hell—if he were a nonsurgical physician, we'd all just shake our heads (because, after all, I get as lost in the finessing of minute ventilation and the different parts of the renal tubule as an internal medicine doctor does in anatomy). But he is a handful of days away from being a full-fledged surgeon with his own practice.

This man is set to drive cross-country without a map. And I'm terrified.

Are you serious?

2009-06-04T11:20:00.000-07:00

Last week, at GGGH, my final patient of the day came to clinic early. This, by the way, is always nice.

Except this patient was carrying a cigarette. And asked me if I had a match. No, I'm not making that up.

"I can't believe you brought a cigarette into your doctor's appointment," I said, slightly incredulously.

Defiantly: "Well, why not?"

I've got a lot to learn.

The 20% Oath

2009-06-03T12:44:00.000-07:00

On 30 May 2009, The New York Times published an article entitled "A Promise to Be Ethical in an Era of Immorality". It tells the story of a number of student-led initiatives in American business schools toward developing an oath for B-school graduates.

The oath—its content varies by school—pledges the students to, in the words of the article, "act responsibly, ethically and refrain from advancing their 'own narrow ambitions' at the expense of others."

For millenia, physicians have made similar vows:

I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone....
In every house where I come I will enter only for the good of my patients."

Many trades act similarly, and, to take the article at face value, business school seems to be catching up. But this is, by far, not the most interesting part of the piece.

No. What boggles my mind instead is that only twenty percent of the graduating business school class at the institution profiled had actually agreed to the oath.

Eighty percent of business school graduates could not agree to acting responsibly and ethically!

Does this bother anyone else besides me? I warrant that probably somewhere on the order of eighty percent of physicians also do not abide by the Hippocratic Oath, but at least we all take it. At least we all promise to try to live up to its standards, and, I'd wager, most of us do so without our fingers surreptitiously crossed.

Are business school students simply more honest? ("I know I'm going to break this, so why take the oath in the first place?")

Or are they less idealistic and, frankly, more nefarious? Would it be horrible to admit that, given the etiology of our current economic downturn, I'm afraid it may be the latter?

Primum...

2009-05-31T12:22:00.000-07:00

Patients that go to GGGH are unique.

See, you mention to a doctor certain catch-phrases (this is probably true in any service profession) and they can automatically conjure an image of that person. There's the Worried Well. There's the Entitled Poor. There's the Arrogant Rich. There's the Noncompliant, the Doctor-Shopper, the Drug-Seeker.

Well, they're all here at GGGH, but there's a difference, an overlay. It's not just the Worried Well. It's the Worried Well At God's Greatest Government Hospital. And he's an entirely different creature.

Recently, a patient came to GGGH that forced me to struggle with questions so basic they discuss them your first year of medical school. She was a Noncompliant patient. And she was at GGGH, which made her slightly more distressing. Within the last decade, she had been diagnosed with a tumor that, for all intents and purposes, should have killed her. Upon hearing that news, she decided that she was going to treat her tumor on her own. By stopping smoking (bear in mind—the tumor itself had nothing to do with her smoking).

Well, it didn't kill her. And she came back—but this time, the tumor had popped up in lymph nodes near her original site of occurrence. Crazily enough, the primary tumor was gone (I'm sorry, Philip Morris). Now she wanted treatment, but only of her regional disease. Every other suggestion was met with vehement rejection.

What to do? This question cuts to the heart of what we learn as physicians about patient autonomy and the struggle not to be paternal (rather, parental). Do you render to a patient suboptimal care, if that's all she wants? Are you actually doing harm to a patient by operating on her when you know that every textbook you read tells you to offer her more complete treatment? Do we treat her differently because her tumor did what it did?

This question is further complicated by the fact that patients coming to GGGH do so because care is rendered at minimal or no charge to them. In many other situations, it is appropriate to encourage your patient to get a second opinion. Here, second opinions don't exist. Or, they do, but it costs. A lot.

What would you do? (I'd welcome comments, actually).

We ended up following the patient's wishes, removed her regional disease, and strongly encouraged her to consider formal treatment. It's unsettling; it's unsatisfying. But she was happy.

Dilapitated layment people

2009-05-28T13:23:00.000-07:00

Scott Adams has wet dreams about days like this.

All day was spent in a lecture hall, hearing a woman read, word for word, from slides that were both projected on the screen behind her and printed in a book on the lap of each unwitting new orientee.

Her topic? How to handle the disruptive patient. Now, this could be very interesting. Conflict resolution tactics, self-defense measures. It might have been great.

Nobody could have made it any more dry than she.

The problem is, she tried not to. As long as she stuck with her slides, the morning was predictable corporate boilerplate boredom ("Don't treat the patient as just a diagnosis or they may become violent"...you know, the usual thing. Because people become violent if you refer to them as something other than their name, right? I mean, it happens daily, right?), interspersed with a susurrus of snickers around the audience when she'd find herself tripping over a word like anosognosia. As if she hadn't made the slides herself (which she had; she reminded us of this often).

But, she didn't stick to her slides: she would also try to interject her own anecdotes, every single one of which was formulaic ("One day, this patient soiled himself and the doctor didn't know what to do, but we nurses all saved the day!"). This single habit of hers doubled the length of time we would spend on each slide. Because for each bullet point, there was a stupid doctor, and for each stupid doctor, there was a heroic nurse. And behind each heroic nurse? She (capital S) was there.

To top it off, she was one of a specific group of people—there are many at GGGH—who feel that an increase in the complexity of the words used is enough to allow such egregious constructions as "He didn't had said that" to escape unnoticed. The problem was, the words she chose were often ill-placed and, equally often, mangled.

When speaking of a putative patient with alcohol withdrawal symptoms, she referred to him as being a "dilapitated"—(with two ts)—"man," conjuring up images of a patient mounted on cinder blocks, hubcaps missing, hospital gown flapping in the federally-mandated breeze.

His debilitation, on the other hand, would have to await discussion later. She herself, she liked to remind us, was "a layment person," (by which one can only presume she meant that she wasn't medical. Except that she was a nurse), and would be putting things in "layment people's terms."

The only break in her monotony was a video, a primer in sensitivity toward the elderly.

Remember those bad summer-camp slide slide shows you had to sit through? The ones set to awful Michael W. Smith songs about friends being friends forever? Evidently, the federal government is not immune to spending money on slideshows just like them, except with a PhD (I'm not making this up; his name and degree were in the credits) singing his own bluegrass composition as backdrop. The best stanza?

Dog days are on me
My woman is dead
I look on the future
And shudder with dread.

Yeah. I'm not making that up either.

All told, the entire course could be (and was) distilled into a 10-page hand-out. Just ten pages!

It took eight hours.

Eight hours! Of stories about dilapitated layment people delivered by a woman with a self-inflation so smug it could only have come from too much time spent earning union benefits. Good God, help us all!

Deceptively simple

2009-05-25T09:04:00.000-07:00

After decades of being educated, and even a year spent as an educator, I'm faced with a deceptively simple question: how do you teach?

Deceptively simple, except that lives are spent devoted to answering it. Deceptively simple, except that your decisions in this regard have repercussions on many lives, for many years.

This question has been brought to a head recently, because the resident I currently have assigned to my service cannot operate his way out of a paper bag. He's everything you don't want in a surgeon. He is slow. He is tentative. He gets freaked out by the slightest bit of blood in his field. And he's arrogant and eminently unteachable.

Pedagogy would tell you that no one is unteachable, that you just have to find a way behind each person's innate sense of being right all the time.

But really, this guy? He's unteachable. I try and try and try, and he simply huffs. He knows better. He's even said that.

And he finishes his residency in six weeks. Off, into the real world. Off, to operate on the unsuspecting. Off to take four hours to do a case that should be done in one, eight hours for a case that should be done in two. Off to operate on you and me. Crikey.

In my training, I spent some time under a guy who was fond of proffering such apothegms as "I'd rather watch my kids play on the interstate than watch you operate." After every resident that left his operating room in a huff, red in the face, I wondered, "Why? What makes him think he can get away with that?" Finally, I understand.

The unemployed surgeon

2009-05-24T05:42:00.000-07:00

In lieu of writing the typical "Hi, this is my first blog post!" blog post, I figured I'd jump right in. In media res, as they say.

I signed my first job contract in November of 2008. Yes, after fifteen years of schooling and training, when a good number of the folks I graduated from high school with are living in three-story mansions in the southern part of the US, I got my first real job.

It was for one day a week at an academic hospital in one of the bigger cities on the eastern seaboard, a city I'd never trained in, schooled in, or lived in. Except I still haven't started. Seven months later, I'd still be unemployed, sitting on my tuchus were it not for the generosity of the Federal Government. A surgeon, on welfare. How exciting.

Two months later, I signed my second job contract, for two days a week, at a government hospital. I started there in April.

The World's Best Academic Hospital has yet to let me start working. They are, in a word (or six), even slower than the US government! Unfortunately, I think that irony is lost on them, as they pat themselves on the back for having found a way to employ someone for a day a week, work him for five, and pay him a pittance.

(I've got to clarify...I say I haven't started working at WBAH. I have. I've already seen patients and been in the operating room. They just haven't officially started doing things like paying me yet).

More from the front lines of American healthcare later...