This is a news website article about a scientific finding | Martin Robbins | Science | guardian.co.uk

This is a news website article about a scientific finding | Martin Robbins | Science | guardian.co.uk

Ideas as history changers

Kwame Anthony Appiah's The Honor Code shows how honor drives moral progress. - By Paul Berman - Slate Magazine

A book which has the rare temerity to suggest that ideas -- in this case, of honor -- have driven moral progress. It has always struck me as odd that universities, for which ideas constitute their major product, have, for a generation, denigrated mere ideas as agents of history, seeing, ideas as mere epiphenoma of economic, sociologic, or even biologic forces. It seems refreshing that an academic has attempted to argue that ideas matter, particularly in moral revolutions - in thess cases, the elimination of dueling, foot-binding, and slavery.

Frank Kermode, 1919-2010, RIP

Frank Kermode, 1919-2010, exemplified an ideal that is dying. - By Adam Kirsch - Slate Magazine

An exemplar of the style of criticism to which I once aspired, and whose desuetude made me leave the academy. Cheers to (another) fine Manxman.

Sometimes, the system works

Time trends in outcome of subarachnoid hemorrhage: Population-based study and systematic review -- Lovelock et al. 74 (19): 1494 -- Neurology

It's an assumption that the high cost of intensive care, technology development and delivery results in improved care for patients. It's one of the features of all health care systems that I most admire: taking seemingly insurmountable and devastating diseases and working endlessly to find better ways to understand and treat disease. It's expensive with no guaranteed pay-off.

It's also an assumption that is under attack, as health care costs are increasingly scrutinized. In the zeal to cut costs, it's worthwhile to remember that sometimes, all of that technological advancement actually results in improved care. Subarachnoid hemorrhage, meaning an artery in your brain has burst, usually means death or worse, a twilight life without a well-functioning brain. All neurosurgeons are used to quoting the rule-of-thumb statistics to patients and their families to prepare them for an ordeal: "About half die before making it to the hospital, another half die in the hospital, and of those that survive, about two-thirds are severely disabled." The article above notes that while the incidence and severity of subarachnoid hemorrhage has not changed in 25 years, many many more people now survive (a 50% decrease in mortality), seemingly with less disability. What is that worth? Everything, if it is your family.

Spinal-Fluid Test Is Found to Predict Alzheimer’s - NYTimes.com

Spinal-Fluid Test Is Found to Predict Alzheimer’s - NYTimes.com

Report in Archives of Neurology. 'Particularly interesting: the protein in the spinal fluid may predate clinical Alzheimer's, meaning that, while this blog has been always quite conservative regarding any discovery resulting in the development of a treatment, suggests a road towards developing a new research program for one.

Could be a big deal.

Palliative Care in the ER

Slate has a piece on palliative care in the ER. The problem of overtreatment has at least two prongs. The first leans toward dry policy discussions: the fee for service system may simply be the worst system except for all the others. The second, however, is a very wet kind of problem. Decisions about when to end treatment are rarely clear or easy. There is the old policy chestnut that 90% of healthcare is spent on the last 10% of life (can anyone verify that, by the way)?

Understanding how that can happen is easy. Emergencies requiring minute-to-minute decisions are not the time to make long term decisions; when your mother's heart stops beating is not the time to ponder the nature of eudaimonia. So the emergency room makes poor soil for the roots of such discussion. The place and time is before the emergency; in one's home, in the church, or, ideally, in the primary care doctor's office.

('The primary care doctor's office?' you say. 'Who even has one of those?' Exactly).

Peter vs Chris Hitchens on God

New York Times review of Peter Hitchens book, written in response to his (more famous) brother's book. Probably goes under 'books I had meant to write, but have been too lazy to do so'. In it he defends (according to the review) Christianity, and religion generally, not as a means to personal revelation, but as a cultural preservative. It is, of course, C.Hitchens contention that the opposite is true - that religion 'poisons everything'. C argues that MLK, Jr was a moral exemplar despite being religious (and the secularists surrounding him were the more important actors than the religious ones); that Hitler and Stalin may have been atheists, but were 'quasi-religious'. P argues the opposite, that Hitler & Stalin were atheists, and this is essential to their genocides.


It seems to me that arguing whether religion or secularism can be marshalled in the service of good or ill misses the point.  Both may serve quite well in service of either.

Then on what does the question of religion turn? If I have ruled out metaphysics and social utility, what remains?

I suspect the answer is somewhere between the pragmatists' distinction between public and private, on one hand, and the Founding Fathers' vision of a world of religious freedom. It may be, while religions are certainly cultural and social forces, their nature is essentially private: one person's orientation towards and interpretation of the world, particularly in its moral dimensions. This does not mean it is a solipsistic exercise, but a simply a deeply personal one.

In the Trenches versus the Bird's Eye

Timothy Noah likes to state as a fact that the Veterans' Affairs Hospitals are unequivocably superior to conventional hospitals, in particular citing this NEJM article. Yet it is a doctors' truism that the VA Hospitals provide the worst patient care. They joke about the poorly trained, heavily organized nurses ("What's the difference between a VA nurse and a bullet? A bullet can be fired, a bullet draws blood, and a bullet only kills once."). This is a uniform opinion held by almost every doctor I know in every part of the country.

Anecdotes abound: I had a patient, in severe pain, who was being so ignored by his nurse he had to call his daughter on his cell phone to call the hospital to call the nurse manager to call his nurse.  I have, on multiple occasions, walked into a patient's room, to find him on the brink of death or other danger, unattended for hours.

But it isn't just the nursing. One of my colleagues, in trying to care for an inpatient having an acute stroke, unable to rouse any urgency from the staff,  called 911 to transport the patient to a better hospital.

It's not just the floor nurses or the transport staff. In the OR, cases can take 150% to 3 times longer, as in 6 hours instead of 2. Often needed equipment is missing, or broken; the staff are not properly trained to use the equipment. On several occasions, the OR table was missing. (Tricky to operate without one.)

It's not just staff incompetence. OR time is severely restricted (it's expensive to run one - our VA has 8 ORs and by policy, they are only allowed to run 6), so urgent cases get delayed for months. Specialists cost more money, so there is a shortage of them generally. There is, for example, almost no dedicated neuroradiology, so patients have to rely on general radiologists -- who are not competent. In 6 months, I reviewed ~1000 films, and I can think of dozens of errors, most resulting in delayed treatments and at least one unnecessary surgery.

So is Noah just wrong that the VA is superior? Or is there some phenomenon that studies can measure, but that doctors cannot perceive resulting in better outcomes? The NEJM article has at least 3 flaws:

1) the endpoints are all in the realm of general medicine, which may hide the VA's lack of specialty care. Focusing on resources the VA doesn't pay for might highlight some major problems.

2) the endpoints are all in the realm of general medicine, ignoring surgical care. Looking at surgical subspecialty care might also reveal inequities: it is rumored that there is a dataset showing that VA patients with brain tumors only live 60% as long as their private insurance counterparts.

3) the endpoints were all specific tasks the VA had been working to improve for many years. Hardly a fair comparison! If you decided to test 2 classes of students, and to 1 class you gave a copy of the test questions months in advance, you had better hope they did better! Moreover, before the VA began specifically improving these specific areas, they were performing horribly (e.g., ~27% flu vaccination), far below their private insurance counterparts. Which suggests that, in the absence of specific campaigns to improve specific measures, the VA may be performing far worse than fee-for-service.

So, is socialized medicine better than fee-for-service? Maybe at some things (e.g., organizing campaigns to improve certain targets) and maybe with time it can be on many counts ... but for me and mine, should they need health care near a VA, just drive on to the next hospital.

Return from hiatus?

I promised myself that I would start posting again once I finished a brutal year of rotations, which is now over. So this is notice that the odds of a post next week are astronomically higher than say, a post last week. Just serving notice. Watch this space.

Can you really be "addicted" to shopping or using the Internet? - By Vaughan Bell - Slate Magazine

Can you really be "addicted" to shopping or using the Internet? - By Vaughan Bell - Slate Magazine

One of these "thank God some one wrote this, because I have been too lazy to do so" articles.

Solzhenitsyn on Malpractice

From Cancer Ward, Solzhenitsyn's novel depicting life on an oncology unit in Stalin's USSR, a surgeon's diatribe:

'I went to the trial yesterday ... A child suffering from volvulus and twisted bowels was operated on. He lived several days after it was done. He even started going out and playing games... Then his bowels got partially twisted again and he died. The wretched surgeon had to put up with eight months of investigation... [The prosecutor] went on and on about the surgeon's criminally negligent attitude. The parents were brought forward as witnesses – fine witnesses they made! They said something about the blanket not being straight, it was all nonsense. As for the public ... they just sat there ... saying to themselves, 'What bastards these doctors are!' ... This whole case should be under scientific investigation, not judicial at all. You should've got a group of doctors ... and had them do a qualified scientific analysis. ... we surgeons take enormous risks, we walk into a minefield. Our work is entirely based on trust...' (pp 368-370)

Maybe some things about health care are universal.

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.