Sunday, May 3, 2009
Baudrillard and the Hyperrealism of the Parathyroidectomy
This is going to be a bizarre post; I'm just warning you.
I've been reading from Jean Baudrillard recently. Baudrillard is a post modernist French thinker/philosopher who writes about the preponderance of images, signs and representations in our technologically-driven, post modern lives. A lot of what he writes is almost deliberately obscure and esoteric. You find yourself re-reading entire chapters two or three times because nothing makes sense and you get pissed off thinking hey I'm not a moron, I have advanced degreees why is this guy being so intentionally obtuse? I sort of hate Baudrillard, actually, for that reason. But he does have some interesting takes on the nature of reality that are rather illuminating.
Baudrillard comments on the deluge of signs and images that are pounded into our collective consciousness in modern America. We are overwhelmed by ubiquitous advertising, television, celebrity culture, media supersaturation of "important events", mass information, instant communication via the internet and Blackberry and Twitter, the constant forward march of technologic innovation. What happens after a while is that the the signs and images start to become more important than the actual events/objects that they represent. It achieves a reality of its own, which he dubs "hyperreality". After a while, the images and signs become so disconnected from the objects they represent, that the objects themselves start to disappear, leaving us with this unsubstantiated, hollowed-out simulation of post modern America. The hyperreal as depicted on "reality" television becomes more "real" than the lives we actually lead, becomes a model to pattern ourselves after. The manipulative images of advertising alters our perception of what is important, of what has value. Henceforth, commodities become not just objects of desire, but function to define who we are, our social status, our relative value in American society. The SUV isn't necessarily a utilitarian, modern transport device; rather it is now a status symbol, a sign of the successful, modern, happy, American upper middle class family. The function (mode of transport) of the object (vehicle) now assumes a secondary role, while the sign/image of the object takes on the primary role in shaping the identity of the subject who acquires said object. We have a strange reversal of the subject/object dichotomy where the the object now dominates the subject, reducing the subject to something more thing-like, rather than an autonomous subjective being. (Baudrillard calls this reification).
So what does all this nonsense have to do with hyperparathyroidism? You'll have to bear with me.
I was reading an article in the March 2009 American Journal of Surgery called "Surgery Improves the Quality of Life in Patients with 'Mild' Hyperparathyroidism". Hyperparathyroidism is defined as an abnormal elevation of one's parathyroid hormone level (PTH) in the setting of hypercalcemia. There are four parathyroid glands, intimately associated with the thyroid gland in the neck. They function to maintain calcium homeostasis in the body. If calcium levels get too low, PTH is released to help bring calcium concentrations back to normal. When calcium levels correct, the PTH is down-regulated. It's an simple, elegant design. In hyperparathyroidism, the negative feedback loop goes haywire (most often secondary to a single adenomatous parathyroid gland) and PTH production occurs independent of body calcium levels. The body then starts breaking down bone in order to liberate more calcium to keep up with the demand from abnormally high PTH. The resultant hypercalcemia leads to a wide range of symptoms. Classically, primary hyperparathyroidism manifests as "stones, bones, abdominl groans, and psychic overtones", i.e. kidney stones, bone pain/fractures, peptic ulcer disease, and depression. The treatment is to identify the source of the autonomous PTH production (usually a single adenomatous parathyroid gland) and remove it. We surgeons love these kinds of diseases; cut to cure.
As usually happens, however, in this new era of extreme subspecialization within the field of general surgery, once a disease is named, an entire brigade of academic surgeons gravitate toward said disease and crank out paper after paper on the intricacies of it, its biochemical basis, surgical approaches and of course papers that boast of superior results when compared to surgeries performed at "low volume" hospitals, with the overall purpose of defining it (hyperparathyroidism) as a separate entity from the discipline of mere "general surgery". Hence, the birth of the "Endocrine Surgeon".
Give them credit though. Parathyroid surgery used to routinely involve a large Colombian necktie incision, similar to the incision of a thyroidectomy. It was also routine to explore all four parathyroid glands, because you could never be sure you were dealing with a single adenomatous gland versus two adenomas versus four gland hyperplasia unless you eyeballed them all yourself. Obviously, the more you dig you around, the more risk of injury to important structures (i.e. the recurrent laryngeal nerves, the thyroid gland itself, the carotid sheath) and the more risk of post-operative complications such as recurrent nerve palsy, neck hematoma, respiratory compromise, and hypocalcemia, not to mention the unseemly cosmesis of a large neck incision. So for many years, parathyroid surgery was done strictly on patients who manifested classic signs of the disease. The surgical treatment was effective, but fraught with too many potential adverse side effects to justify it otherwise.
But things changed. Nowadays, we are able to pre-operatively determine where the offending adenomatous gland is with a high degree of certainty using a combination of ultrasonography and something called a sestamibi scan. This allows the operating surgeon to minimize the incision and avoid unnecessary dissection in potentially dangerous tissue planes. Furthermore, the development of intra-operative parathyroid hormone monitoring has allowed us to determine cure before we even leave the OR. A drop of PTH levels of over 50% from pre-op levels gives a surgeon the confidence to close up shop, leaving the patient with a tiny, cosmetically appealing incsion. Some surgeons are also approaching the adenomatous parathyroid bugger endoscopically via tiny incisions in the axilla, eliminating the need for any visible neck scars.
These are all exciting new developments. Parathyroid surgery has now become more precise, sleeker, faster, more definitive, more cosmetically appealing; in a word, elegant. It's almost a shame that primary hyperparathyroidism is such a relatively rare disease (incidence about 1 in a 1000). And based on some of the recent surgical literature, one gets the sense that endocrine surgeons are also a little frustrated that it doesn't occur more often. I mean, these are terrific new surgical innovations. Wouldn't it be a lot cooler if hyperparathyroidism occured more often?
With the ubiquity of screening blood draws in American medicine, we are identifying patients with hypercalcemia whom we would have missed twenty years ago. A PTH level that is inappropriately elevated in such a setting will instigate a referral to an endocrine surgeon. But many of these patients have never had kidney stones, they don't have peptic ulcer disease, and they don't recall any specific bone or joint complaints. So what do you do?
Well in 1990, the NIH published a consensus paper that determined the indications for parathyroidectomy in patients who were either mildly symptomatic or asymptomatic. Many have found these indications to be far too restrictive. And by "many", I mean endocrine surgeons. The surgical community has consequently responded to this consensus paper with a series of counter-papers arguing for the utility of parathyroidectomy in these minimally symptomatic patients. This article in the March AJS is yet another salvo from the front line of the endocrine surgery battalion.
The common denominator in these pro-surgery papers is an intense focus on that fourth realm of symptomatology, i.e. "psychic overtones". What they aim to prove is that a patient's "quality of life" is significantly ameliorated by successful parathyroidectomy. Generally this has been done via the comparison of answers to pre- and post-operative questionaires which address one's subjective appraisal of such nebulous categories as "energy levels" and "happiness" and "fatigue". How else are you going to do it? It's not like "happiness" can be measured in the same way your calcium level can be (and if it could, I'd be sending off assays of my daughter's every other week). So the data they use is not exactly hard data; it's subjective and contingent on a lot of factors outside of whether or not your left parathyroid gland is incrementally larger than the others.
For example, in the cited article in AJS, 151 patients were evaluated. 133 of the patients had "classic" disease (NIH criteria or stones/bones/groans) while only 18 were patients with mild or asymptomatic disease. Something called the SF-36 Health Survey was administered to all 151 patients. The SF-36 is "a standardized instrument used to assess general health and wellness". (Just reading that, I'm already on the verge of speed dialling George Orwell.) Using the data from the survey, 8 scales of "well-being" are fashioned: Physical Functioning, Role-Physical, Bodily Pain, General Health, Vitality, Social Functioning, Role-Emotional, and Mental Health (yes, they are all ominously capitalized). Moreover, a combination of all 8 scales yields 2 additional derivative scales (Physical Component Summary and Mental Component Summary). Scores are then tallied and compared pre-parathyroidectomy versus post. What they found is that patients with mild/asymptomatic disease had improvement in all 10 scales, while those with classic hyperparathyroidism had improvement in 9/10 scales. Ergo: patients with asymptomatic disease derive a greater efficacy from parathyroidectomy than those with stones/bones/groans. Or something to that effect.
Now let's just take a step back for a moment. Is measurement of Vitality standard operating procedure when you go for your yearly check-up? No? You mean your internist doesn't check your blood pressure, order an EKG, send off blood work for cholesterol, hemoglobin, and Vitality? I mean, Vitality? I feel like I've become embroiled in some bizarre surgical game of Dungeons and Dragons. Shouldn't we also measure Wisdom and Dexterity levels?
What we have is a very Baudrillardian situation where the object is now defining the subject. The surgical procedure, heretofore a response to the ravages of a disease, is now redefining the very disease that it purportedly hopes to assuage. The excellence and refinement of the procedure itself mandates a re-appraisal of where we draw the line between where the actual disease begins and ends. It's a classic reversal of the subject/object dichotomy and I think this sets a dangerous precedent. As medical innovation continues unabated, we will inevitably see more refinement (at great cost) of other procedures/operations, innovations that reduce complications, improve cosmetic results, and augment patient satisfaction, and there will undoubtedly be a corresponding demand to do these procedures more often, given the expense invested in research and development. Even now, for example, we take out way more gallbladders than we ever used to, simply because laparoscopy makes it worthwhile to do so. But at least biliary colic is a definable, reproducible disease. The current push for incisionless abdominal surgery (pull your gallbag out through your vagina!) is more concerning. Will we see papers advocating the removal of asymptomatic gallbladders with stones, based on questionaires and surveys?
Anyway, I have to go. I have a battle lined up with an Orc this evening; if I win, I earn 50 Vitality points.