Monday, June 27, 2011

The Part-Time Doctor

This is how I meet people:

Them:  "Nice to meet you."

Me:  “Nice to meet you, too”

Them:  “Dave said you’re a doctor.  What kind of doctor are you?”

Me:  “Mediocre, I guess.  Most of my patients do okay.”

Them:  “No, I mean what specialty…”  Then they apologize for the confusion or offense.  Rarely do I get the laugh I wanted.

The Dr Sibert piece in the New York Times got me thinking.  Or, mad, then thinking.  I couldn’t figure out why it rubbed so wrong.  Thanks to the many responses and the NPR discussion, my thinking took a direction.

What is a good doctor and what makes a doctor valuable?  Doctor value is productivity times quality plus happy patients, right?

 V = PQ + H
Or is it,
Or maybe,
V = PH + Q

Should we factor in benefit to society as a whole?  Doctors serving indigent populations get a large B and Beverly Hills cosmetic surgeons get a zero, unless of course I lose an ear there someday.  The equation becomes: 

V = PQ + H + B

My own view of what makes a good surgeon changes with the weather.  As a resident I knew first-hand which surgeon in our hospital had the most technical skill with a given procedure, and I would have chosen ten different surgeons for ten different operations.  Presently, I’m helping choose a surgeon for my nephew in consideration of cross-country travel, rapport, insurance coverage, ancillary service quality, subspecialty availability, and my nephew’s changing needs as he grows up.  I have no way to judge the technical competence of his docs.  And I couldn’t care less if his surgeon is part time if he/she has room on the clinic schedule for my nephew.  A part-time surgeon has a smaller patient load than a full-time, so continuity of care in the long term isn't affected.  In the heat of battle, such as a long hospitalization or a complication, continuity is also valuable, but so are the fresh eyes and rested hands of a partner.  The fears of the so-called shift mentality are overblown, in my opinion.  In fact, maybe the next generation has recognized that a system totally dependent on the continual presence of a single surgeon is a flawed system.

My qualm with the Sibert view is:  the number of hours worked is one factor among many determining a doc’s worth.  To focus on work hours alone is to miss the complexity of good care and debt to our benefactors. 

Imagine handing a career timecard to the taxpayers on the day of your retirement.  What if you’re a terrible surgeon who worked a hundred hours a week for forty years?  Did the taxpayers get their money’s worth?  Yes, if work hours are your only currency.

Qualm number two relates to her response on the NPR interview seeming to equate love for one’s work with willingness to work long hours.  I’m a part-time surgeon working forty hours a week.  I love all forty hours (minus documentation).  I also love sushi.  But even if I could afford it, I would not live on sushi alone, because I also love pizza.  I work part-time because I love my wife and daughter, I love my endeavor at OnSurg, I love writing, running, music, news, and travel.  I even love sleeping in.  I love taking care of patients and I sympathize with the generation who has re-framed work obligation in the larger context of life obligation.  Does this generation of doctors have to answer to the taxpayer?  Not really – this life-balance frame-shift is nationwide and crosses all professions; the taxpayer understands.

Qualm three:  Discouraging a potential doctor from medicine, part time or big time, only worsens the physician shortage Dr Sibert bemoans in the piece.

I welcome the future part-time doctor to our wonderful evolving profession.  Openly planning to balance work life with family life is mature and admirable.  Your contribution will be valuable.

Bring your kids to work, if your hospital doesn’t offer daycare, leave your toddler at the nursing station or in the admin suite while you round.  Management will come around.

I will now make a list of (largely overlapping) variables I consider relevant to a surgeon’s value to the community.  Math whizzes are welcome to provide me the quadratic equation of surgeon awesomeness:

Operating for the right indications
Adherence to proven processes/protocols
Ability to operate
Cost effectiveness
Research contribution
Dedication to an institution
Service to an underserved population
Development of programs or new services
Department leadership

PS – I am an above-average surgeon.

Sunday, June 19, 2011

Chimborazo - Lessons from my Father

My father fell on his face for the thirtieth time.  I hoped he would stay.  I had fallen a lot too – I could only bear this so long before breaking into tears.  Luckily I was last on the line; nobody would see the frozen streaks on my face.

The snow was corn on the surface and rock-hard somewhere below.  You never knew where.  Each step varied – you’d crunch along a few steps catching grip six inches below, then scrooosh – your crampons caught nothing and your leg disappeared in slush up to your hip.  Goddamit.  All you heard besides crunch and scroosh was the brush of your balaclava against your parka hood, and all you could think was, Why the hell are we still climbing?

The reason I kept climbing was because my father, just ahead of me on rope, was still climbing.  Seven hours and counting.  He was fifty – if he continued, so would I.  Why was he still climbing?  Pathologic determination.

I couldn’t believe he was still going.  This time was his last fall, for sure.  I was glad.  Resting and watching from a few paces back, I heard him cough and wheeze.  Good.  The wheezing should be a clue it's time to turn around.  But he was the doctor, not me.

Climbing Chimborazo was his idea.  My dad was the adventurer in the family.  His need for adventure brought our family out west, where we lost friends in whitewater, avalanches, small aircraft crashes.  On weekend getaways I watched him treat friends and family on the scene of motorcycle wrecks, hunting accidents, and a fall into a vertical mine shaft.  Dad once butterflied my brother's face closed so he could get back on the ski slope.  If it was outdoors and posed risk of injury, he loved it.

Presently, Dad was the dark rounded figure on the rope ahead of me, half-swallowed in the snow.  We could only manage eight or ten steps at a time before stopping to gulp thin air.  I was always glad when he rested.  But this time he just stayed.  Ten minutes maybe.  Didn't even bother to climb out of the hole he'd created in the snow.  Good.  We'd turn around, I thought.

Everything was white or pale blue:  the mountain, the sky above, the clouds below us.  The colors flashing in the corner of my eye were a nice distraction.   I’d turn my head to follow the crimson and orange bursts.  They stayed just out of view for a second then disappeared.  My headache was gone.  Bonus.  The whole day prior, we'd sat at el refugio nursing headaches with sweet tea, acclimatizing to altitude before the summit push to 20,500.  

I hiked up to my father.  When I got close, he scrambled out his snow pit and moved on.  He's full-on crazy, I thought.  I could hear him breathe till he was five paces away.  I should've known he'd never give up.  Forget breathing.  We were so close.  The gentle remaining slope was so reassuring – so close.  Just a straight hike.

We went on.  Another two hours.

He couldn't stand for the summit photo.  We took one sitting together, and a standing group shot with him on his knees in the middle, smiling broadly.

We’d got our picture, our cocktail party story, and a half-minute of exhilaration:  the morning sun melted the clouds below and Chimborazo's long, pointed shadow parted the earth in perfect halves.  I raised my arms and looked for my own shadow at the tip of the tip, a hundred miles west.  Now.  Let's.  Get.  Off.  This.  Mountain.

He’d used everything to make the summit.  How will we get down, I wondered.  Nine hours up.  He was spent.

The self-arrest became very important.  My dad would take big lumbering steps on the frozen down-slope, knees locking and unlocking uncontrollably, then tumble like a drunk and skid to a stop.  No big deal, we were making progress. 

The slope steepened.  He no longer skidded to a stop but had to self arrest after every fall, digging his ice-axe into the mountainside.  I stopped looking back.  I could hear him on the rope behind me scraping to a stop every few minutes.  Then, for a while I heard nothing.  Looking back, I was surprised to see him on his feet for a full five minutes or so.  Caught his second wind.  Thank god.  I’d been worried, and tired of waiting for him.  I wanted off Mount Chimborazo.

I heard his muffled voice just before he hit me behind the knees like an overloaded inner-tube.  I was thrown and landed on head and shoulders, disoriented, yelling to him:  Arrest, arrest!  He was sliding away, listless, accelerating as the slope ahead steepened and disappeared from view.  Before I could position myself, the rope between us lost slack.  After another clumsy jerk, we were both sliding on a disappearing ice slope.

By evolutionary mechanism, the mind breaks moments like this into slow motion.  There is as much cortex storing these ten seconds in my head as the whole rest of the trip.  And while the curved time didn't benefit me in the moment (I couldn't act any faster) I'm sure the prolonged seconds are a self-preservation memento keeping me off future mountain climbs.

As we slid and tumbled, gaining speed on the ice, I recalled a water bottle tossed between us hours before.  It was fumbled and we all watched it for amusement, sliding, sliding and disappearing the same moment it left earshot.  I recall deep anger for the man pulling me over a cliff; I wished for a Bruce Banner moment.  I had whole internal conversations about what to do as I struggled to match pitch and roll with the banking slope.  I held my axe point into the hill, slowing, till the rope went taught again and yanked me out.  Ice plowing from the axe filled my face.  Toes, get the toes going, I thought.  Digging the stuttering crampons into the hillside, I felt us slowing even as the rope pulled.  Then, finally, I got purchase with my axe.

We stopped.  And rested.  Then continued down.

Around noon, we un-roped to move independently through the calving snow line.  I moved quickly.  My father negotiated the glacial cliff and boulders with caution, then stopped completely. 

I stood on the dry gravel slope twenty yards away, looking back.  An ice chunk like a Volkswagen fell beside him, crumbling, and dusting him with snow.  He didn’t even look over.  He just slumped on a round boulder, heaving.  I yelled.

“Let’s get the f**k outta here, Dad!”

He waved me on.  Intense sun worked on the snowline – a cliff of ice and boulders, audible creeks underneath.   The wall fell in pieces left and right; my father was inert among it.

“C’mon!"  I pointed above him.  "That big stuff is coming any time.  You gotta keep walking.”

“I can’t breathe.”

“I know, I’ve been listening to you puff for thirteen hours.  Let’s go. You can’t stay here.”

“You don’t understand,” he said, pausing for air between phrases.

“Understand?  We’re almost down, you’ve got to move!  C’mon.  You stay here and you’re going to die!”

“You don’t understand. Huff, huff.  You’re not a doctor.  Puff, puff.  I can’t breathe…and I can’t walk anymore.  No oxygen."

He was a doctor, and I was not - he just wanted to make that clear before he was killed by falling ice, I figured.  I was a belated college graduate with no career plans whatsoever.

“I can’t carry your ass out of here, Doctor,” I said.  "Hope you have a cure for f**king falling rocks."  I shouldered my backpack, turned and continued downhill.  I started to trot a bit, so he’d know maybe I did have the strength to save him.

I heard him cough and mumble something about pulmonary edema this, partial-pressure that

He saved himself.  I was asleep in el refugio when his tin cough woke me.

"We have to get... to a lower altitude."  He sounded like drainpipes.  I had just enough energy to care again.  Not enough to keep hiking, though.  But I put my boots back on, took a handful of aspirin, drank some sweet tea, and packed our gear.

We continued down the slope.

By the time we got down to 10,000 feet elevation, my dad was breathing easier.  In the morning he was fine, and I’d decided to become a doctor.  I didn’t tell him for a few weeks; I couldn’t stand for him to think he had anything to do with it.

Dr Robert James Porter II - adventurer and father of five

Thank you, Dad, for many lessons and adventures. Happy Father's Day.

Wednesday, June 8, 2011

Sudan - Level One Threats

My first night in Sudan I lay on my cot at midnight, jet-lagged and wired, smiling ironically.  Mission control had briefed me in Brussels:  keep security cash and passport on my person at all times, water and flashlight in a daypack at the ready for urgent evacuation.  Coming here was a calculated risk; now I was re-calculating.  My risk scheme ran from threat level one to five.

The smell of burning garbage occasionally overpowered the squat latrines of our compound.  I lay there, breathing more and more shallow as the stench worsened.  What vapor came from burning batteries and water bottles, I wondered.  Eventually I passed out from hypercapnea or was anesthetized by vinyl chloride or whatever.  I awoke when feral cats entered my tent. Blind in the darkness I waited for them to leave.  They found my stash of cashews and a spinning, slashing fight ensued.  So I emerged from my mosquito net and hissed them out.

I smiled again. Weirdness with a touch of danger were what I’d signed up for, in part. I was overdue to escape the overcomfort of suburbia and hang in the Nile riverbed among the world's most sonorous infectious diseases: kala azar, malaria, trachoma, bilharzia.
A flashlight then shined in my face. The anesthesiologist:  Come quickly.  

A baby was stuck, butt-first, in mid-delivery – mother needed a crash cesarean section.  We woke the on-call logistician by radio:  Fire up the generator for our operating light.  
This was my hospital orientation. The patient was nowhere near our inflatable operating tent.  She was crouched in a dark corner of the female ward, pushing at the nurses’ bidding.  I begged them to stop. (A C-section was a little out of scope for a general surgeon, but I was more comfortable with a scalpel than a breech vaginal delivery.)  The nurses knew better, I suspect. We still had no lights, scrub tech, etc.
The baby moved a bit and I changed gears – I would deliver my first child since med school.  I hooked two fingers at the flexed hip and pulled.  She slid!  Her body was now on the cold cement floor.  I pulled her little blue legs as the mother pushed.  Baby’s head was stuck.  My heart pounded as diagrams from fifteen years prior flashed in my head.  I pulled her, spun her, hooked a finger in her mouth, pulled some more, yelled for mom to push, shoved a hand in mom’s belly, and pulled more.  How much could I pull before..?  Good god, could I separate the..?  Please, no.
And she came.  Lifeless.  Onto wet cement.  The nurses performed a cursory resuscitation and put mom on a cot.  I listened and listened for heart tones, rubbing and pinching the little girl.  The nurses reassured me they’d never heard the infant’s heart beat on arrival, so don’t take it hard.  I was dumbstruck, ill. I’d forgotten how much suffering came to Africans.  And I realized, too, that medicine had changed for me since having my own baby girl. I cried.

On my second night, I zipped closed my canvas tent to keep the wildlife out.  I still hadn’t slept since arrival.  I lay on my cot a few hours then got up to find a core of our mission drinking and chain-smoking.  I estimated the second-hand smoke to be a level one threat, and I joined them for a beer. Then because I was on-call, I refused the second beer.  Instead, I covertly poured an inch of whiskey into a tea-cup and got some sleep.
In the morning, chicken-sized grasshoppers in our mess tent, plump frogs grazing on flies in our latrines, noxious burnt-garbage fumes, and ever-present cigarette smoke all faded to background. I sat in the mess tent waiting for hot tea water. The cook came in, shook rat turds off the tablecloth and returned the same cloth to the table. I ate my toast without mentioning the level-one threat of infectious scat to my colleagues, who I presumed were accustomed.

In a short hospital day and a quick walk about town, I learned how war turns poverty into abject devastation.  People bathed in and drank from Nile. On the wards most of the adult patients were malnourished and had been shot with high-velocity rifles. The children's ward was all pot-bellies, stick legs, flies and diarrhea.  I learned that no virtually no food is produced in an area the size of England – a whole generation of farmers was lost before passing on their knowledge to the next generation. There was no water, sewage, or electrical service. The only concrete structures were our hospital, aid organizations, and a police station.  Thousands of displaced refugees were spontaneously building a haphazard city of tin and tents on the flooding banks of the Nile.  Who is in charge? I wondered.

Next - Threat Level Two

Saturday, June 4, 2011

Sudan - Arriving

The South Sudan mission has urgent need for a surgeon, said the memo.  Please respond by late in the week if you accept the mission.  A far cry from Darfur, I assured my wife.  I thanked her for her blessing and kissed her and our tiny girl.

I was briefed in Belgium a few hours then shuttled to Nairobi, then to the de facto capital of South Sudan. 

The airport was a single, crowded cement room serving as receiving terminal, passport control, and baggage claim.  A giant mirthless man at a card table smashed my passport and travel pass with an inkless rubber stamp.  I collected my bags from the tin slide.  When I turned around, the immigrations man was now a customs man rummaging through my things.

Always the optimist, I assigned the urgency of the surrounding crowd to claustrophobia or heat.  Still, I was nervous. 

“What is here?” asked stamper-man in Darth Vader’s voice.  He shook some wrapped boxes I was carrying.  I had no idea what they contained – they were given to me by mission headquarters to deliver.

I have no idea seemed like the worst possible answer, so I guessed.

“Some books and some sweets.”

The bustling crowd went quiet and watched – let’s see what the white guy brought – as the huge man picked at the strapping tape with huge thumbs.  He handed a package to me and I pretended to be a surgeon completely stumped by devilish wrapping.  What happens when I unwrap a box of hand grenades in a crowded African airport? I wondered.

He got bored before the surprise was revealed and pointed at the door.  Before I got there, a man calling himself Lazarus took my passport and my travel pass and disappeared.  I’d been given his name in Nairobi, so I felt confident…

Kidding.  By now I felt confident of absolutely nothing.  Nairobi felt like a country club compared to this Wild West popsicle stand.  Lazarus was nowhere and I was standing in a dusty street outside a dusty airport evacuating like a fire drill.  I put on sunglasses to cover up fear and do some surveillance.

Soldiers.  The only people not leaving the airport were soldiers.  WTF?  I was sure I’d read of a peace accord several times in the briefing literature I was provided.  Peace was relative, I would learn.

Lazarus then appears from nowhere and shoves me onto the floor of an idling Rangerover festooned with mission logos.  He slams the rear door; filling its window is a decal:  a big red circle-slash over an AK-47.  No weapons! is the message.  But for whom?  Volunteer surgeons?  Water/sanitation volunteers?

Lazarus drives me a hundred yards.  He empties me onto the airstrip I arrived on half an hour ago.  There I await a pilot.  Surrounding me are cows, mud huts, tall bushes, and more soldiers.  Like the opening scene of Platoon, a hundred or so troops are filing into bellies of monstrous flying personnel carriers.

So far, every leg of this journey has brought me to a smaller, scarier place.  I’m steeling myself to depart the unpaved capital on a four-seater Cessna bound for a Nile-bank village in the “formerly” contested south:  Bor.

Next:  Threat level one.