Wednesday, April 27, 2011

Shift Mentality – Kids these Days!



"The children now love luxury; they have bad manners, contempt for authority; they show disrespect for elders and love chatter in place of exercise. Children are now tyrants, not the servants of their households. They no longer rise when elders enter the room. They contradict their parents, chatter before company, gobble up dainties at the table, cross their legs, and tyrannize their teachers."  - Plato, 400 BC


Plato probably never said that.  But I love to tell people he did, as wise Mr Douglas told ranting Uncle Charlie in My Three Sons.

If Plato or Uncle Charlie were retiring surgeons today, we might hear:

“These residents have no commitment to their patients, it’s all about lifestyle now.  I tell you, the eighty-hour workweek has lowered the bar, and all we get is shift-mentality residents trying to hand-off their patients before lunch.  And if the Residency Review Committee (RRC) imposes nap time, and cookies and milk, we can just hand over the whole profession to radiology.”

I’m 44.  Old enough to repair a hernia without mesh, but not mean enough to do so except when no mesh is available (on Neptune, for instance.)  I’m also young enough to be down with Twitter.  And if you think being down with and saying, “Down with Twitter,” are the same, well…

I admire the surgeons who preceded me for their commitment to the profession. 

I admire the incoming generation of surgeons more.  Eighty-hour workweek notwithstanding, they have more on their plate than the generations before.

A third are women.  Demanding enough is the daily fare of patients doing badly, upset families, overbooked clinics, late hours, early hours, and politics.  Add discrimination, harassment, working for less money, and if inclined, pregnancy and caring for an infant. 

While nothing compares to the challenges facing female surgeons, I’ll venture that men today have it harder than their XY forebears.  My father had it easy.  Yes, I said it.  In his day, a man could fully dedicate himself to career and not face questions about his priorities until his grown children were in therapy.

Men today in all careers are attending recitals, cooking, cleaning, shopping, changing diapers, taking children for vaccinations, planning date night, and moving the heavy boxes.  This morning I poured my girl’s Cheerios ™, brushed her haystack of a hairdo, filled her Hello Kitty™ lunchbox with applesauce, then captained the neighborhood Montessori carpool.  If my dad, back in the day, had any idea where the Fritos™ were stored, he never let on.  (I’m eager for a reader to explain this cultural shift to me.)  Just as the RRC imposed the 80-hour limit, wives and children invoked the 80-hour minimum.

Remember this, Uncle Charlie:  While Chip may seem awfully eager to dump his patient list on the night float, Chip goes home to completely different expectations from his wife, children, children’s teachers, children’s soccer team,..

When I hear shift mentality thrown about derisively, I think of two of my favorite residents – two very dedicated doctors.  They give a hundred percent, they make no excuses, and they are fierce advocates for their patients.  I wouldn’t hesitate to send my mom to them for her lap chole.  Also, these young men freely admit they plan careers with shorter hours than surgeons of yore – in exchange for more time with family.  I admire their mature priorities.  I expect they will choose reliable practice partners and won’t plan their abdominoperineal resections on game days.  When the unexpected happens and they can’t leave the hospital, I hope their families understand.  Bless their broods, and moreso the kin of women surgeons; I hope their families appreciate the career sacrifices their parents made for them.

I’d rather have surgery in 2020 than in 1990 for many reasons – all of them having exactly nothing to do with work ethics or the eighty-hour week.  Laparoscopic advances, ICU protocols, evidence-based practice, checklists, and new anesthetic agents have done more good than a generation of lazy residents can undo.  And they’re not lazy, Uncle Charlie.



*  Note:  I hold particular admiration for women surgeons of the previous generations.

Sunday, April 24, 2011

1-800-GET-SLIM

Thanks @DrFlicker for the Twitter invite on the conversation about Promoting bariatric surgery for teenagers


(@ @ @ Thoughts? RT @ Doctors selling weight loss to teens:

The beef with crass advertising is understandable.  As we learned from the Save the Boobies campaign, eye-catching language succeeds in creating awareness, even enthusiasm.  But do health care providers lose trust through such levity?  The public likes to think serious-minded adults rank higher than Beavis and Butthead in the public health hierarchy.  Billboards reading Dieting Sucks and 1-800-GET-SLIM smack of adolescence and aggressive salesmanship, not quality health care from earnest professionals.  

I support tasteful promotion of bariatric surgery for teenagers as part of the Teen-Longitudinal Assessment of Bariatric Surgery (LABS) ongoing at several excellent pediatric hospitals.  (Here’s a promotion from Cincinnati Children's Hospital)  Outside of that setting, I’m uneasy with the operation and the promotion.  Operating on teens exposes minors to unknown long-term risks and opens up the question of by-proxy consent.  In my opinion, such negatives in individual patients are offset when clinical trials yield answers (and ease suffering) for the population at large.

I suspect we’ll learn that well-selected teenagers benefit a great deal from bariatric surgery.  Compared to a middle-aged patients, young ones with successful surgery should enjoy twice as many years free of weight-related diseases and their cost, plus improved social and work function.

In Promoting bariatric surgery for teenagers, Carolyn Thomas seems uncomfortable with bariatric surgery on the whole, focusing on uncertain outcomes, on cost in the short run, and on growing popularity of the procedure.  In her blog post, expert majority opinions are overshadowed by the minority opinion of nay-sayer providers.  Let's see outcomes data from a large sample, and hear from the happy patients too!

Wednesday, April 20, 2011

When we were Kings


Spent a sweaty week operating in a hilltop Hospital Nacional in Guatemala a while back.

A patient gave me a hat in thanks for her surgery.  It’s a full-brimmed canvas safari number – I’m sure Hemingway shot a rhino in one.  I’m just mature enough now to value sun protection and always grateful, sometimes to the point of pain, for gifts from those who have almost nothing.  I was also given a painting of the neighboring volcano, a tee-shirt depicting a local politician, two kisses, many back-breaking hugs[1], and endless expressions of muchisimas gracias plus the quiche version of same. 

The biggest gift of all, though, was the respect our patients gave us.

You’ve heard of doctor shopping.  This is when a disappointed patient leaves the ER or the doctor’s office in search of a doctor who understands them better.  How about patient shopping?  Doctors have a choice too.  They engage in patient shopping in various ways.

1.     Specialty (ie, a plastic surgery practice has a different clientele than a trauma surgery practice)
2.     Location of practice
3.     Private vs hospital-employed vs public health practice
4.     Exclusion of payer types (eg, Medicare/Medicaid) or limiting to cash-only

If I were to hand pick a patient clientele, they would be Native American Guatemalans.  By dint of history, DNA, culture, nature, nuture, or whatever, our patients and their families treated our mission group as royalty, priests, or benevolent dignitaries.  We were like travelers of long ago, scaring them and making them laugh with our strangeness.  Medicine is a world of hopes and mysteries for them, not a world of choices.  I sensed their prior patient experiences, if any, hadn’t fostered a sense of consumer entitlement.  They trusted us implicitly, even when things went wrong.


We had a complication. On post-op day three after a vaginal hysterectomy, I had to tell Maria's family she would need another operation. I worried about her mere survival. I approached the family as I do in America—firm in my judgment, apologetic that a complication had occurred, and prepared to explain (defend) the sequence of events to date. There was no need. "I'm sure you know best," said the husband.

I found Maria’s husband again after surgery, I explained that indeed she had suffered a near-catastrophic surgical complication, but that I expected she would recover. “Thank you Doctor, thank you,” he said. Sisters and nephews thanked me. I felt guilty from the gratitude, like I had gotten away with something.

At home, medicine has been demystified in the age of information, packaged and marketed in the age of conspicuous consumption, and cynicized in the age of litigation.  When a bad medical outcome occurs, it is reflex to research.  Why?  We are trying to tell  malpractice from mere bad luck – in a world where bad luck is increasingly exposed as bad choices, bad training, bad equipment, bad people, and other controllable bads.  Good science, good will, and good processes have raised our expectations such that any post-op event is suspect.

So, our spirits soared in Guatemala.  We were trusted and thanked and bestowed with gifts.  Between our team and our patients formed an intoxicating chemistry. 

The gynecologist and I fussed and fretted over Maria, our only complicated patient, all week.  She improved.

On our departure, my last goodbye was to Maria.  I brought the incoming surgeon (my replacement) to the bedside to explain her case and introduce patient and doctor.  The gynecologist and team medical director joined us.  Maria, her husband, and their children looked star-struck by our visit.  They thanked us yet again for Maria’s two operations.  They expressed their honor in our last-minute visit and told their children we had come from far away to help their mother.  Maria asked for a kiss.  I held her naso-gastric tube to one side and complied.  I wished all patient hand-offs were this heady. 

During the swerving mountain bus ride to Antigua, I watched shepherds and soaked up a glory which seemed to belong to another century.  As we approached the airport, my mind wandered back to home and work.  Guilt crept in.



[1] Ergodynamics were sub-optimal in the tiny makeshift surgery suite – the operating table only went so high.  Add twelve-hour operating days plus short-statured huggers and the low back cries for bed, or cot, as it were.

Saturday, April 16, 2011

Retrospectology #2 : Catch me if you Can



By 1993, I’d learned that my ice-cream-man white coat brought a privilege I hadn't imagined:  access.  I could walk into a hospital with a clipboard, stethoscope slung over shoulders, and walk right into a nursing station.  Like walking into the Superbowl and down to the field. “Hey, Mr Montana, watch for Frank, he’s beaten his defender on the last three downs.”

I wore a medium-length coat at first, like the residents. 

“Are you house staff?”  asked a nurse.

“Am I what?”

“House staff?”

“I don’t know.”

“Student,” she muttered, walking off.

Later, another student explained the short-coat, long-coat rule.  Who cares, I thought.  Buy another one of these?  Who’s taking measurements, the chief resident?

Turns out, the interns take measurements.  Having worn the shorty for four years, they zoom around the hospital with their extra inches flowing like superhero capes.

“You can’t wear that coat, you know,” an intern tells me.

“Why.”

“Medical students wear the short coat.”

“Okay.  Do you think I should buy a new coat?  A short one?”

“Yeah.  You have to.”

I bought a shorter white coat, and felt the decrease in status immediately.

However, I could still strut into a hospital anywhere and open charts I couldn’t read with total immunity.  So many white coats and scrubs, nurses, docs, techs and transporters.  Nobody knew who anybody was.  I could summon a patient down to the operating room and take out a parathyroid just for practice.

Clock forward seven years, and I’m third-year surgery resident.  I spend two hours a day at the same nursing station, checking labs, talking with nurses, eating soda crackers, answering phone calls, sleeping, writing orders, drinking old coffee, running the patient list with the chief.  White coats and scrubs scramble everywhere. 

Then a med student walks up to the nursing station.  His coat is white as snow.  His stethoscope is more expensive than any other on the ward.  The weight of the Washington Manual in the left hip pocket is not balanced by the hammer and calipers in the right pocket, pulling the coat into a slight hunchback configuration at the shoulders.  The student looks directly at the ward clerk on approach, nods and smiles slightly.  He saunters around the counter, mixing among the other white coats, and takes a seat in front of a computer.  He is showered and unpreoccupied.  He sneaks a look at a 5 x 8 card under the clamp on his clipboard.  Computer codes.  He taps the keyboard with leisure.  He is well-shaved and looks rested.  He is pleasant to everyone.  He is totally incognito.


Friday, April 15, 2011

Momentum



Mr Albers came in bleeding.  He’d been on the toilet, gushing blood, getting light-headed.  Mrs Albers dialed 911.  The momentum of that panic carried Mr Albers all the way to the operating room.  He was 92, and I should have put my foot down.

Imagine you could choose how you die.  In your sleep?  Old age?  Natural causes?  Here’s a secret:  Natural causes are the usual causes in the elderly:  heart attacks, strokes, fatal heart rhythms, ruptured aneurysms.  I dread awakening in the night half paralyzed, short of breath, or with crushing chest pain as my wife deeply sleeps.  Much less do I want to awaken alone, dying.  I would feel a tremendous compulsion to say goodbye. 

Bleeding to death allows goodbyes.

Mr Albers chose surgery over bleeding to death.  Better said, he couldn’t conceive he had a choice.  Watching your blood flow from you unchecked, forming warm purple pudding clots all around?  You’re a man before a firing squad, ready and aiming.  Ambulance sirens, frantic families, and emergency protocols beget consultations and treatment, not ruminations on peaceful passing.

I gave the Albers family my grim prediction and ten minutes alone together before wheeling to the OR – and on to his life of being cared for.  Ventilator.  Sedation.  Infection.  Mr Albers operation had been successful – we’d stopped the hemorrhage.  I’d also robbed the Albers family of a short and dignified goodbye.  Instead, they got many weeks of crushed hopes - the long goodbye.

If I bleed at 92, my care plan is:  Just enough transfusions to share favorite stories and say goodbyes in a calm room full of family, morphine at the ready for shortness of breath, and Bach's Air on the G String.  (Plan subject to change.)

(This post also appears in KevinMD)

Sunday, April 10, 2011

Other brother


Q:  What if this were your brother?

A:  Depends on which brother.

“Treat your patients as you would your own loved ones,” is advice taught throughout training in health care. 

Great advice.  I use it constantly.  Mr Davis is dying of multiple organ failure in the ICU after exploratory abdominal surgery.  His siblings and children trickle in from Florida and Montana.

I’m always sorry for the last to arrive, who visits his dying brother’s bedside minutes before the family conference.  Sister and daughter have been holding Mr Davis’s hands for days, hearing my doubts, letting the gravity sink in, saying goodbye in their hearts.  The last arriver is the one who looks the most stunned at the family conference.  He is realizing his brother was kept alive (or kept dying) for three days, awaiting him.  This is when I tell the family what I would do if Mr Davis were my brother.  This is emotionally difficult, but intellectually easy.

Harder is advising patients when the answers are less clear: 

Mr Jones has gallstones and seems to have had minor gallbladder attack.  I’m not certain.

“Do I need surgery, Doctor?”

“Well, if you were my brother…” 

I would advise three of my siblings the same way:  “Let’s see if the pain happens again.”  All three would take my advice and go about their lives, giving rare thought to gallbladders and operations.

My other brother?  Not so much.  I keep this in mind when advising patients.  Some brothers don’t feel properly managed with simple reassurance; they feel blown off.  Some brothers comb the internet and determine that indeed the gallbladder is the problem.  Brother X, who is very goal-oriented, now has a checklist in a daily planner that reads:

1.     Get gallbladder removed (laparoscopically, by surgeon who performs more than 100 cholecystectomies per year)
2.     Climb Mt Everest (Thomas Hornbein route)
3.     Learn violin
4.     MRI of knee
5.     Haircut
6.     Fold laundry

My job is not only to identify pathology, but to identify suffering.  Brother X will suffer a great deal waiting for a gallbladder attack that may never come.  He will dial 911 the next time he feels pain anywhere between neck and knees.

Yes, I recommend different things to different patients.  The art is identifying, in the few minutes you’ve spent with the patient, which brother he is.  If I’m on the fence, I tell the patient so, and try to coax out his/her personality and philosophy.  If the patient says:

“So I don’t necessarily need surgery?  Great, because the last thing I want is an operation,”  the patient gets reassurance.

If he says, “So the choice is wait around to die from my next gallbladder attack or have keyhole surgery? Take it out, Doc.  Can you do it today?”  That is brother X, who is on the schedule for a lap chole.


Saturday, April 9, 2011

Retrospectology #1 - the stethoscope


They passed out stethoscopes, and I didn’t know who they were.  Like how you show up for football practice and they just start hanging gear on you.  Somebody slipped us freebies before we had any concept of industry swag.  Slick.  



I walked home sometime in August 1991 with it slung around my neck looking like every hospital employee except a surgeon.  (Surgeons don't carry them, I would learn.)  I listened to my heart for half an hour, then my neck, chest, belly.  Next I put it on the wall and listened to the neighbors’ domestic dispute.  Then I used the stethoscope to pick a combo safe with a huge diamond in it.  Kidding.

Got the short white coat, the ear-&-eye looker.  Rubber hammer.  Tuning fork – which amplifies very well pressed against the body of an acoustic guitar.  With each piece of equipment I felt more like a… trick-or-treater.  I dreaded having to give all this stuff away when they realized I was a fraud. 

Introduction


I must start a blog.  An online persona has become necessary for several reasons:
1.     Blogger envy.
2.     I have a whole website to promote at http://onsurg.com/, whose mission, vision, and values are important to me:  http://onsurg.com/about
3.     Too many complaints about my offline persona.  Start fresh.

In the first year of med school, I tried for extra credit in a psych class by keeping a journal.  A few years later Al Gore invented the internet, and I was emailing blurbs about bleeding this, purulent that, suffering here and there.  I therefore already have a blog – I just didn’t know that’s what it was, and the word “blog” kind of sticks in the throat.

Did you watch any Woody Allen movies in high school?  I sat through ten minutes of A Midnight Summer’s Whatever as my parents watched our only TV.  Boring.  A few years later, Sleeper is watchable.  Hit age 40 and Annie Hall is fascinating, hilarious.

In that spirit of changing perspective, I’m digging up old pieces and jogging old memories.  Twenty years have passed since I started med school.  Part of my blog will be retrospectology, the rest, contemporary or atemporary.  I will invent many words as I go.