Relatively cheerful

I saw, ahead of me, one of the best physicians I know, a general surgery resident - sharp in his clinical acumen as well as his wit - walking, shoulders slumped, head down. I caught up to him, and he was clearly feeling down.

'I have to present at Mortality and Morbidity conference tomorrow' - a weekly conference where the entire surgical body meets to review all of the cases with poor outcomes - 'on cases where I wasn't even involved. I'm going to get skewered for other people's fuck-ups.'

'With great power comes great responsibility.' I said 'but the inverse is not true in medicine - with no power, still comes great responsibility'.

We laughed - he and I often laugh together - and this time, as others, somewhat bitterly.

'Well, it's not that so much, as some of my patients are doing poorly. I don't know why I didn't become a dermatologist, or something where people aren't so sick - or maybe just outside medicine entirely.'

A chord resonated - I have been feeling crushed by the pediatric neurosurgery rotation. A parade of children dying, at various speeds. I realized that the child who had been buoying me, the light of the service, was a 13 year old who was shot in the head on Hallowe'en for wearing the wrong colored shoes in the wrong neighborhood. He was intubated, had passed the worst of the brain swelling, and was communicating with us and ready to have the breathing tube pulled. I came back from clinic to find the ICU team trying to resuscitate the patient - he had stopped breathing. I checked his pupils in the commotion and noticed his pupil was fixed and dilated - meaning his brain had herniated and he was about to die. ... we managed to stop him from dying with aggressive medical therapy, but he is probably going to neurologically devastated. After that moment, I realized that I had pinned my own hopes on this kid pulling through. The story came out of me like a catharsis.

I expected commiseration with a similar story. Instead, my friend turned to me and said:
'Well, I suppose I can always remember that if I'm ever feeling down about my patients, I can always talk to a neurosurgeon.'

He laughed, his head arched back, and walked away.

Happy that

the phrase "pre-existing conditions' will become extinct. Recently, an insurance company, on the day of brain surgery for a family that had traveled internationally, called to say they wouldn't be covering the operation because they had recently discovered the procedure was for a pre-existing condition. Which was true ... since the large cyst compressing the child's brain was, in fact, congenital. It didn't stop it from growing, rendering half the boy's body weak, and getting weaker. Nor did it make the surgery less necessary, or cheaper. So we did it for free. It only cost somewhere around $100,000, I'd guess.

I've actually heard of this happening at least twice in the past few months - insurance companies denying needed operations for congenital conditions. Utterly insane.

(yes there are problems with the health care bill - but this isn't one of the them)

The most accurate television show about the medical profession? Scrubs. - By Joanna Weiss - Slate Magazine

The most accurate television show about the medical profession? Scrubs. - By Joanna Weiss - Slate Magazine

As many of you know, I have long maintained that Scrubs is the most accurate medical show on television. For once, people agree with me.

Relative value and public health

Dr Thomas Bodenheimer explains the importance of the RVU (the 'relative value unit') to the finances of American health care. It is probably the number one reason we don't have good primary care: the federal government does not value it.

The RVU is the basis of physician reimbursement. A committee of physicians determines, by a 2/3 majority, based on the difficulty, the expense, and the malpractice costs, the relative value of each action a physician takes. Medicare then modifies this and decides how much to pay per RVU (currently about $36), and the physician reimbursements are determined. An initial preventive exam is worth 2.57 RVUs, where surgical repair of a neonatal diaphragm is worth 151.38 RVUs. (Neurosurgical procedures vary between 30 to 115 RVUs, depending on their complexity.) Office visits rate up as high as 7 RVUs for the most complex, but most visits are awarded around 1-2 RVUs. A visit dedicated to smoking cessation rates about 0.5 RVUs. A lung transplant is between 60-80 RVUs. So Medicare pays the physician $20 to counsel a patient to stop smoking (which probably does not even pay his overhead of staff, rent, etc), and pays $3000 to replace a destroyed lung.

It's true that conducting a health screening office visit is not the same as transplanting a lung. It is (a) much easier and (b) takes far fewer years, and easier years at that, of training to do. More or less, that's how doctors and ultimately, Medicare, think about health care reimbursements: how hard is x to do well? How risky is it? etc. This is why surgeons make more money than primary care doctors, and why surgeons who do highly complicated and dangerous operations generally make more (per procedure, if not overall) than those who do run-of-the-mill procedures.

While this makes an intuitive sense on an individual level, it may not be the most sensible way to run a system. We might start asking: how important is it to the country that we have good primary care, as opposed to good dermatology, or, gulp, as opposed to high-tech complicated brain surgery?

(Not that this is anywhere, to my knowledge, addressed in Obama's plan. Just one of many interesting nuances of the American health care system. Nor is, my AMA membership compels me to point out, physician reimbursement the major driver of health care costs - hospital costs have increased far far more rapidly over time).

LRB � Walter Benn Michaels: What Matters

LRB � Walter Benn Michaels: What Matters.
A review of an essay collection, Who Cares about the White Working Class? edited by Kjartan Páll Sveinsson. A nice analysis of how race politics and class politics work at loggerheads.

One of my pet peeves has been the prominence of increasing opportunities to different races, rather than increasing opportunities to different classes. While the upper echelon has become more racially diverse, the economic background of those making into the upper echelon has become less and less diverse. It is the rich who have benefited, particularly rich minorities - the lot of the poor, regardless of race, has likely worsened over our lifetimes. The concentration of power in the hands of fewer and fewer, and the inability of the poor to access tools to achieve financial independence, are greater threats to America than racism today.

The reviewer also makes some nice points regarding the parallels between "racism" and "classism". Does the end of "classism" mean increasing equality of means, or does it mean increasing respect for working class culture? Is it enough to respect the redneck? Is it a disrespect to his culture to insist on the superiority of a four year university over technical training? The same questions have defined and troubled feminist politics, racial politics, and all other forms of identity politics. The transformation of class politics into another form of identity politics is probably another book in and of itself.

Fat Man turns 30.

It's the 30th anniversary of House of God, a book every doctor has read or pretended to. I reviewed it here and referenced it here. Whatever its artistic failings, it captures the working conditions of residents well. Yes, things have been reformed (and I've argued, at times, that they've gone the wrong way), but the gestalt is more or less the same.

I don't think most people, even our close colleagues, understand the black hole that is neurosurgical residency.
An ICU nurse practitioner, one of the best ones, in fact, complained to me:
-You already rounded? You know, you guys are supposed to round with us - that's the way I've said I really want to do this. Can't you let me know when you round?
-Ok. We round at 6 am every day. Can you make it?
-Oh. Um, no.

One of my favorite nurses, after sticking around till 10 pm to help us finish a long long case, said:
-Thank God I have tomorrow off. Do you guys too?
A pause, as if she had suggested we might be flying to the moon tomorrow.
-Um, no.
-But at least you come in later or something? When do you guys get here?
-Er, 5:30 or 6.
-No ... really? Every day?
-Every day.
-Weekends?
-Don't ask.

Sometimes it is a grind.

Other times, it is not. Like when the father of a 14 year old girl with a spinal cord tumor wants to hear just one more time how everything went and what the future is going to be like, just as you are heading out for the night, you turn around, sit down, and talk him through it. And you don't mind one bit. Or an emergency comes in, looking like hot death, and you manage to bring them through, operating till the early morning before a full day - and all you notice is how good it feels.

Sometimes, it is a grind.

Other times, it is more than a grind. It's a horrible farce. Your attendings are screaming at you, patients are dying, the health care system and every person in it somedays seems hellbent on preventing you from doing one goddamn good thing for a patient ... and those days, and there are more than a few, you raise a glass to the Fat Man and his Rules .

More Girard Movie Reviews

Courtesy of rbnmrny's twitter feed.

Feel free to create your own, my one other reader besides Mr Moroney.

A Titular Philosopher

If a philosopher were only judged by the qualities of the titles of his books, none, I think, would surpass Rene Girard:

Resurrection from the Underground
Things Hidden since the Foundation of the World
The Scapegoat
I See Satan Fall Like Lightning

(Having read only one of the above, I will still say the brilliance of the title is reflected off every page. )

I can't think of any author - in any field - whose titles compare.

I also can't think of any action/thriller movies that have better titles - would you not see any movie with those titles?

"I See Satan Fall Like Lightning is this year's best - a thoroughly engrossing drama with the gritty authenticity and soupy morality that has infused director Martin Scorceses past triumphs."

This may among Girard's greatest feats: his titles are so good, they could be titles for anything.

Except possibly breakfast cereal.

All right. Back to work.

NHS physicians: Vocation to Vacation

The NHS has reduced work hours for junior doctors again - to 48 hours per week. Frankly, it is impossible to even imagine how this could adequately train anyone.

Other professionals (e.g., politicians, lawyers, financial analysts, CEOs, scientists, engineers, etc) routinely work more hours. Anything important takes a lot of time.

I wouldn't trust a financial planner who spent 48 hours a week in training, nevermind, say, someone doing a heart transplant.

And that's to those who consider work as work - medicine, at least once, was considered a calling. I wouldn't want to read a work-week writer, hear the symphony of a casual composer, console myself with the words of an occasional pastor, nor be led by a punch-clock president.

Medicine, surgery in particular, is demanding, and requires dedication. As a patient, you would want nothing less.

The critic's ad dilemma

I started posting ads, mostly for amusement, on my derelict blog. Funnily, Google's content search has determined that naturopaths, holists, etc -- the people I have been criticizing in not merely a few posts -- are the ideal advertisers for this site. So far, they have earned me $0.08.

On the Harpist who Volunteers her Time in the Hospital

Said my attending: "Is a harp really the best thing to hear when waking up from brain surgery?"

Obsession

I am beginning to feel the obsession. A couple of nights ago, I stayed to do a late case - a suboccipital craniectomy for a brainstem cavernous malformation. It's one of the most elegant surgeries, operating in perhaps the most difficult part of the body. Most neurosurgeons will not operate there, as the complications are both frequent and devastating: double vision, paralysis, numbness, inability to hear, chew, swallow, speak, or worse, breathe. Even getting there is tricky (for a 2nd year resident at least), and the case started late, around 6 pm. I was told I could leave at 8, which I planned on doing...

But after months of struggling, fumbling, hesitating, I unexpectedly felt fluid. Instruments appeared in my hand as the skin, muscle, bone, dura dissipated, seemingly diaphanous, until I was suddenly staring at the yellow glistening bulge, revealing the mass just beneath the surface of the brainstem.

As a young, and largely terrible, soccer player, I remember one game where everything clicked: the ball was merely an extension of my legs, its movement carried by my will. I remember taking the ball from deep in our backfield, passing by opposing players as if they were highway mirages, to the far end of the field. I don't remember even kicking the ball, but as I looked up to see my teammate streaking towards the goal, I also saw the ball arcing through the sky to land just in front of his shooting foot and into the goal.

This felt something like that.

The case didn't finish until midnight, and I had to be back at work in a few hours, so I just slept in the hospital. I was on call, so worked my 30 hours, and wandered out into the daylight, after some 55 hours inside the hospital.

The patient woke up with only a slight problem with eye movement, already getting better.

I could not shake the feeling and the vision of that last operation. The following day, a few of us spent the morning with one of the world's master surgeons, Dr. Peter Black, but all I could think about was getting back to the OR. Maybe it was the extra strong coffee I had to push through the sleep deprivation, but my hands lay in my lap both itching and twitching.

Death viewed from a dark place

Something I wrote during a particularly grisly month of work:

I had started in this career, in part, to pursue death. To grasp it, uncloak it, and see it eye to eye, unblinking. Neurosurgery attracted me as much for its intertwining of brain and consciousness as for its intertwining of life and death. I had thought that a life spent in the twilight between the two would grant not merely a stage for compassionate action, but an elevation of my own being. Surely, getting as far away from petty materialism, from self-important trivia, getting right there, to the heart of the matter, to truly life-and-death decisions and struggles . . . surely some kind of transcendence is there for the taking?

But I now suspect being this close to the fiery light of such moments simply blinds one to their nature, like staring directly at an eclipse. in part to protect one's own emotional state, you do not get to be with patients in their pivotal moments, you merely get to be at patients' pivotal moments. Working as the trauma intern in a busy Level I trauma center, I saw a lot of suffering. I became inured to it. Drowning in blood, one adapts, learns to breathe, swim, even flourish. Last week, I went to the cafeteria to grab a Diet Coke and ice cream sandwich (or as I called it, lunch) when the overhead pager announced an incoming major trauma. I ran to the trauma bay and tucked my ice cream sandwich behind a computer just in time. The paramedics arrived, reciting the details: "29 year old male, unhelmeted motorcycle accident, 30 miles per hour, possible brain coming out his nose . . ."

I went to work, calling for an intubation tray, assessing his other vital functions. Safely intubated, I surveyed his various injuries, the bruised face, the road rash, the dilated pupil. Pumping him full of mannitol to rescue his brain, we rushed him to the scanner. The images revealed a shattered skull, heavy diffuse bleeding, and in my mind, I planned the scalp incision, how the bone would be drilled, the blood evacuated. His blood pressure suddenly dropped, and we rushed him back to the trauma bay, and just as the rest of the team arrived, the patient's heart stopped. A whirlwind of activity surrounded him; catheters slipped into his femoral arteries; tubes shoved deep into his chest; drugs pushed into his ivs; and all the while, fists pounding on his heart to keep the blood flowing. After thirty minutes, we let him die.

We all agreed, murmuring that with that kind of head injury, death is to be preferred. I slipped out of the trauma bay as the family was brought in. It was then that I remembered my Diet Coke. And my ice cream sandwich. And the fact that trauma bays are kept sweltering hot. With one of the ED residents covering for me, I slipped in, ghostlike, to save the ice cream sandwich in front of the corpse of the son I could not.

After resuscitating the sandwich in the freezer for thirty minutes, it was pretty tasty.

So, no, I do not think, in my time as a physician, I have made many moral strides. If anything, I worry I have made moral slides.

A few days later, I heard that a friend had been hit by a car, and a neurosurgeon had performed an operation. She coded, was revived, but died the following day. I didn't ask for any details. I already had too many. I miss the days when someone was simply "killed in a car accident". Now, to me, those five words open, like Pandora's box, and out emerge all the images: the roll of the gurney, the blood on the floor of the trauma bay, the tube shoved down her throat, the pounding on her chest. I can see hands, my hands, shaving her head, the scalpel cutting open her head, can hear the frenzy of the drill, the burning bone dust whirling, the crack as the skull is pried off, the sizzle of the electrocautery. I can see how her head became deformed, her hair half shaven, her head misshapen with half her skull removed, how she failed to resemble her self at all, how she became a stranger to her friends. Perhaps there were chest tubes, perhaps her leg was in traction ... as I said, I didn't ask for details. I already had too many.

It is in these moments that all the moments of failed empathy come back to roost. The suffering that everyday I see, note, neatly package into various diagnoses and of which I utterly fail to recognize the significance -- they return, vengeful, angry, and inexorable. It takes days to fight them off, but fight them off we all do; there's no other way to do our jobs.

For amidst that unique suffering invoked by severe brain damage, the suffering often felt more by families than by patients, it is not merely the physicians who do not see the full significance. The families who gather around their beloved, their beloved whose heads contained sheared, battered and bloody brains, do not usually recognize the full significance either. They see the past, the accumulation of memories, the freshly felt love, represented by the body before them. I see the possible futures, the breathing machines connected through a surgical hole in the neck, the pasty liquid dripping in through a surgical hole in the belly, urine dribbling down a catheter, feces sliding down a plastic tube, the possible long, painful and only partial recovery – or, sometimes more likely, no return at all of the person they remember, but instead endless infected skin sores, raw and open down to the bone, and the final fatal and merciful pneumonia. In these moments, I act, not, as I often do, as death's enemy, but as its ambassador. To help those families understand that the person they knew, the full vital independent human, now lives only in the past, and I need their help to understand what sort of future he would want: an easy death, or to be strung between bags of fluids going in, others coming out, to persist despite being unable to struggle.

I do not know whether I have yet learned anything, except there are fates worse than death. I do not spend my free time more wisely, or even in joyful foolishness. If anything, I am both less wise and less foolish. I am more numb.

The physicians' paradox

Medicine is, in one sense, an analogue to episteme as surgical is totechne. Medicine requires the marshalling of huge amounts of knowledge, or, at least, the following of complex algorithms: abstraction upon abstraction. Surgery requires the honing of technique, the immediate engagement with flesh and blood.

Psychologically, however, medicine, at least in its ideal, is about engaging with the patient; surgery requires distance.

In one, knowledge is brought to bear into close relations with the patient's self. In surgery, the physician abstracts himself and his relationship to the patient to materially engage with the patient's illness.

Anyway.

18 months down, 66 to go.

Neurosurgical residency takes a long goddamned time.

(but there's little else I'd rather do)

The clock is ticking ...

The day before I started as an intern, a resident finished orienting me by saying: "Remember, they can always hurt you more ... but they can't stop the clock."

The clock is ticking down on my internship; my vacation starts in a few hours. As much as I didn't want it to happen, I found myself turning into the Fat Man from House of God, dispensing worn mottos spun from wearying experiences.

The Golden Rule: Everyone in the hospital is lazy, stupid and lying to you.
- this includes nurses, technicians, administrators, physicians, patients, and your own self.


Others:
• If someone calls you in a panic, calm down.
• If someone tells you not to worry, panic.
• To get a patient out of the hospital, it is occasionally necessary to purchase them a bus ticket. Or call security. Or, in rare cases, contact the Guatemalan embassy.
• Death is also a discharge.
• Don't open wounds, physical or emotional, at the bedside unless you have a lot of time and gauze.
• Always load the boat (i.e., if your boat is sinking, get everyone else around you on it, so you don't sink alone).
• Time heals all wounds. In other words, if you ignore problems, they go away.
• If the problem doesn't go away, morphine and/or Zosyn will fix it.
• Being confident is more important than being correct.
• No matter what, it's always your fault.
• The more reasonable your decisions, the more likely you will be yelled at.
• Being a good doctor is not the same as being a good person. (But being a great doctor probably is.)

But really the only rule is: Everyone in the hospital is lazy, stupid, and lying to you.

This isn't as cynical as it sounds.

Modern medicine is so fractured and complicated, the health care system combines so many incongruous parts, and the medico-regulatory-financial system is so at odds with itself, that unless you take full responsibility for everything that happens, nothing happens.

You simply can't play "your role" in the healthcare system and assume everyone else is doing their job appropriately as well -- at least, not if you want good, or even adequate, care for your patients.

Obligatory Ted Kennedy Post

Here is one of the more informative news stories about Sen Kennedy's unfortunate diagnosis. He has either a stage III or stage IV glioma. My hunch is that it's a grade IV (also known as glioblastoma multiforme or GBM). Historical data suggests that, without surgery, patients with GBMs die within two months. But recent advances in chemotherapy ( Temodar and, most recently, Avastin) might extend that considerably. The other positive sign is that tumors that present with seizures have better survival (presumably because they are found earlier). The downside is that the older you are, the worse you do.

Even with surgical resection, chemo and radiation, survival averages around eleven months, extending out to two years, but rarely any longer than that.

Don't Take Zetia

... and sell your Schering stocks.

The Moral Instinct

Steven Pinker, in The Moral Instinct, is less glib than usual and offers a decent summary of the whole biology/evolution/morality picture. In his description, at times, the moral instinct is like other instincts, say, the sexual instinct: a trait that is necessary for the propagation of the species and a central feature of human experience. But he also describes judgments as a kind of moral perception, akin to sensory perception: just as the eyes exist to see objects "out there in the world", human morality exists to detect a morality somewhere out there as well.

It's not clear exactly what Pinker means. While moral reasons "certainly aren’t in the physical world like wavelength or mass", yet "Morality, then, is still something larger than our inherited moral sense." For him, some realities of the universe induce a moral nature. (Specifically, he points to the natural fact that cooperation, by and large, is a far more successful social strategy than constant cheating - it's odd how Darwin characterized nature as red in tooth and see natural selection, and Pinker can see natural selection and characterize nature as moral. But as I have argued here before, I do think this latter view is right.)

As for the substance of morality, a summary of cross-cultural surveys produce five fundaments: non-maleficence, fairness, community loyalty, authority and purity. In Pinker's summary, different views of morality are simply different weights of these five virtues. It's a nice rubric to chew on, and an important mode for respectful dialogue: "One side can acknowledge the other’s concern for community or stability or fairness or dignity, even while arguing that some other value should trump it in that instance." Much better than declaring an opponent immoral and beheading or ostracizing them, certainly.

But just as eyes can be fooled, so can the moral sense - perhaps more easily. Yet, for Pinker, it seems, such illusions are just as easily proved false. Just as we can measure the true distances in optical illusions, we can demonstrate true morality by being utilitarians. Of course, this is where his train of thought goes off the rails. Without a good objective morality measuring stick, we are left to muddle our way through our collective moral fogs. Pinker suggests utilitarianism is the One True Moral Way, and every other moral system "is apt to confuse morality per se with purity, status and conformity". Alas!

If only things were so simple. But the recognition, however subtle, by one of the public voices of science, that morality is a "real" thing is encouraging. There may be hope for us yet.

"Changing horses in mid-ocean."

"The grass is always greener."

Obviously, I love clichés. They so neatly condense our conflicted thoughts and emotions into a trite little package. I too often sympathize with one of Stockton's earlier statements, "being an intern is more or less like a regular office job," you're "bored, tired and frustrated with paperwork." That was from a neurosurgical intern; on his worst days, he's still literally inside someone's skull. In internal medicine, my biggest interventions usually involve a mouse and a computerized ordering system. To make matters worse, after all the hours I've spent tweaking medications (and tracking down sub-specialist opinions), most patients probably don't continue to take these drugs correctly when they get home. Even if they do, it's sometimes not clear if their meds do more harm than good.

All this to say I have, on occasion, wistfully considered other careers (but don't worry, I'm sticking with it; they say, "if being an internist were like being an intern, there would be no internists"). This is probably why I liked the first chapter to Sandeep Jauhar's new memoir, Intern. As a man of unwavering indecision, I can identify with his conflicted relationship to the medical field. "There are many accounts of American medical training, but none related by a narrator quite so wobbly, introspective, crisis prone and fumbling." Sounds like it's bound to make us all feel more competent by comparison. I think it even has a happy and redemptive ending. I love it; Stockton will hate it.

Halfway through the night

... and things are slow enough to blog.

Articles
- describing how the zeitgeist has passed over professionalism for creativity.

-Stanley Fish arguing the humanities are useless: "they cannot be justified except in relation to the pleasure they give to those who enjoy them. To the question “of what use are the humanities?”, the only honest answer is none whatsoever." He contrasts his view with Tony Kronman's attempt to re-establish the humanities as a basis for "the nurturing of those intellectual and moral habits that together from the basis for living the best life one can" and to "restore the wonder which those who have glimpsed the human condition have always felt, and which our scientific civilization, with its gadgets and discoveries, obscures.” and to recover the urgency of “the question of what living is for.”
Fish's evidence to the contrary is that the humanities professors he knows are, at root, schmucks. "Teachers and students of literature and philosophy don’t learn how to be good and wise; they learn how to analyze literary effects ... The texts Kronman recommends are, as he says, concerned with the meaning of life; those who study them, however, come away not with a life made newly meaningful, but with a disciplinary knowledge newly enlarged." But as Fish almost suggests in this sentence, this is the fault of those who teach the texts, not the texts themselves.

The debate between Kronman and Fish sums up well a cultural touchstone: the place of morality in the modern era. I haven't read Kronman's book, but I was lucky enough to talk to him while he was writing it. His general point is one I endorse: the humanities are the lens through which we see, however darkly, the human condition, and its moral nature; yet that lens has become opacified with ill-use. Modernist experimentation, one hoped, would lead to a grander art form, that it would "forge in the smithy of my soul the uncreated conscience of my race". But that didn't happen. Instead art became increasingly experimental and less experiential. It lost its moral focus.

Some tried to recast the humanities on a scientific foundation. Others propelled humanities into increasing tedium. But the central moral questions of art (not to mention the central aesthetic questions!) were neglected. Fish would say justly; Kronman would say regrettably. The point of the humanities is not to produce humanities professors (if the point of a professor is only to produce more professors, aren't they just a slow growing tumor?): it is to produce humans, in the fullest sense of the word.

Take up your helmet and walk

The first feature on the 'miraculous' recovery of Kevin Everett, the NFL player who broke his neck early this season but is now walking around.

Dr. Barth Green, a neurosurgeon who heads the Miami Project to Cure Paralysis, advocates the use of cold saline in spine injury. Everett's comically-named orthopedist, Dr Cappuchino, had recently heard a lecture by Green's chief scientist on using hypothermia to treat spine injury. Everett's prognosis was bleak - he should have become a quadriplegic. Dr Cappuchino decided to administer cold saline, and then, after the Buffalo neurosurgery team fixed his spine, decided to continue to keep his body well below normal temperatures. And now, the man can walk.

That's the way Dr Green tells the story. I, along with the other neurosurgery residents, had lunch with him a couple months back when he came to visit. (For the record, he has a love/hate relationship with the Miami Dolphins). He's traveling the country promoting cold saline as the next step forward in spine trauma. He's unabashedly in favor of privately funded science. Government-funded science is too slow, bureaucratic, leaving patients without needed treatments. (AIDS advocates made similar arguments to good effect a decade ago). He believes in cold saline, and is not shy about hawking the therapy outside the traditional medium of the academic journal.

Was it the cold saline? Was it the speed at which he was treated? Was it particularly good surgery? Was it his peak physical conditioning? Was it chance? Was it something else? Will, and should, doctors treat spinal injuries with cold saline without any more evidence than this?

It demonstrates the fragile epistemology of medical knowledge, and how hard it is to truly know something. It doesn't, unfortunately, tell me whether I should slam the next car accident victim with ice cold saline.

I am about to be a problem

Before residency, I believed that work-hours restrictions were obvious improvements. Tired doctor = bad care. But in shortening hours, drawbacks emerge. One is the 'shift-worker' mentality: if I can keep this patient's problem underwraps until 5 pm, it's not my problem. This worsens a second problem: transfer of care.
Sure, when doctors are tired, they don't think as clearly. But the other great cause of medical error is transferring care to another doctor who doesn't know the patient. The signed-out story is always unfortunately incomplete, the patient has never met this doctor, the patient's evolution of symptomatology might be the key, etc., etc. Based on necessarily insufficient knowledge, a doctor will give bad care.

I am about to be that doctor. In order to meet the 80 hours requirement, many programs have switched over to a night-float system. Instead of someone from the each patient's team covering overnight, a separate night-float covers all the surgical patients. So in about one hour, I'm going to go in to the hospital and start covering half of all the surgical patients. (Another intern covers the other half). We get a one-line story about each patient: "63 yo male post-operative day 1 from a kidney transplant" ... and that's usually it. Based on that information, one has to handle anything that might arise, from the trivial to the catastrophic.

Not only that, the lack of continuity is terrible for training. Last time I covered overnight, things were pretty quiet. I had one patient who occupied most of my time, an obese gentleman who had undergone a gastric bypass who developed critically high hypertension overnight - not to the point he needed an ICU admission, but getting dangerously close. Knowing nothing about him, I made up an antihypertensive regimen, and applied it to little avail. After hours of pumping drugs, I got aggressive and gave him a very high dose of medication, and by early the next morning, his blood pressure trickled down to high, but safe, levels -- just in time for the next shift-working intern to take over. Had I had a busier night, with more sick patients, that hypertensive fellow could easily have either bled into his brain if I undertreated him, or had a stroke if I overtreated him. Luckily I could check on him frequently since things were quiet -- but I won't always be that lucky. Having never seen this patient again, nor being part of the primary team, I had no feedback to evaluate what I did right or wrong. I don't even know why he was hypertensive. All I know is, he didn't die on my shift. Not a very high standard of care.

As one intern put it, " On night-float, you can't win. The best you can do is not lose." Here's to not losing. In the end, I'd rather have a tired doctor who knew something about me than an alert doctor who knew just one sentence - wouldn't you?

AIDS Patients Face Downside of Living Longer

NYT: AIDS Patients Face Downside of Living Longer. A reminder that major illness is major.

I've heard doctors lament the 'antibiotic' model of medicine:

Day 1. you feel fine.
Day 2. you feel sick.
Day 3. you take some pills.
Day 4. you feel fine.

That this has become the expectation of medical care is more a testament to antibiotics than medicine generally. Most never see Day 4. Heidegger's criticized modernity's imagery of effortless interchangeability of parts, and I detect something of this sense in expectations of modern healthcare, for both physicians and patients. Both patients and doctors want, not to treat, but to erase the disease.

This myth is deeply flawed, on two counts.
1. Chronic illnesses are chronic, and the best we can do is damage control.
2. Serious illnesses require serious treatment, and the treatments are not benign.

As in AIDS, we have made huge strides in treating (but not erasing) pediatric cancers. I've heard a number of pediatric oncologists talk a little wistfully about how much easier it was when children quietly passed away. Now they have hordes of complications, including new cancers, mental retardation, among other problems.

In general, people aren't dying of AIDS, and kids aren't dying from cancer. Instead, they are suffering from these diseases.

Surgeon who took penis photo 'no longer practicing' at Mayo

A surgical resident who took a photo of a patient's penis that was tattooed "Hot Rod" got fired.

Here are the weird parts of the story:
1. The tattoo itself
2. The resident took & showed the photo to a few other staff
3. An employee leaked the patient's name and story
4. The paper published the patient's name and story
5. ... and the resident is fired for violating patient privacy.

Now the resident was obviously juvenile, and completely in the wrong, in taking the photo and showing it around. But the photo surely didn't identify the patient by name. It was the person who leaked the story and the paper who did that. In expressing their outrage, the leaker and the paper decided to trash the patient's privacy (and the law) in the worst possible way: "Patient Sean Dubowik, 37, whose penis bears the tattooed words "Hot Rod," ..."

And that's the way the world works! What a country!

(The way this should have been handled was either:
a) by reporting the resident to the hospital's privacy security officer and his program director.
b) or reporting to the press, but not using the patient's name, for Christ's sake.)