Thursday, February 25, 2010

J.D. Salinger and the Doctors of Tomorrow

Jerome David Salinger died a few weeks ago at the age of 91. The famously reclusive author who chronicled the fictional exploits of Holden Caulfield and the precocious Glass children last published a work of fiction in the mid 1960's. For the past 40 years he has lived an anonymous, unassuming life in New Hampshire. I mean can you imagine an author/artist/actor at the top of his game in this day and age suddenly withdrawing from the public eye, never to be seen again? Rumor has it that Salinger never stopped writing, that his private archives contain volumes of unpublished material.

I'll get this out of the way in the beginning---I'm an unmitigated devotee of J.D. Salinger. I've read everything he ever wrote, multiple times. There's something slightly embarassing about that fact, I realize. Especially at my age. At the beginning of Hemingway's "The Sun Also Rises", Jake Barnes describes how Roy Cohn read a book called "The Purple Land" too late in life and was corrupted by its sentimentality and romanticism. Many say the same about Salinger's "The Catcher in the Rye". You're supposed to read it when you're a teenager, so you can identify with the adolescent angst and sense of betrayal that dawns on a young sensitive soul when he realizes the world is full of selfish phonies, but then you move on, to richer, more nuanced literary takes on human existence. It isn't meant to be a book for a mature sensibility; if anything it can be dangerous to read it when you're into your twenties. I gently disagree. It's a soulful, meaningful book that I plan on reading many more times before I die. I read about Holden Caulfield and Franny and Zooey and Seymour and all the other Glass children for the first time when I was 23 years old. I was living in my mom's basement, working at a lousy plastics factory during the day, waiting to find out if one of the medical schools in Ohio would accept me. I wasn't exactly feeling too enthusiastic about my future prospects. My friends had all seemingly moved on in life, consulting jobs and grad schools and such, while my life had stalled for the first time. Reading Salinger that year kept me sane and hopeful I suppose. When the phone call came in the early summer announcing that I had been accepted, I drove around like a madman, happy and delirious, sort of like Holden at the end of the novel, crying in the rain as he watched his little sister Phoebe spinning in circles on the Merry-Go-Round in the park. I couldn't exactly articulate why I was so happy, at that point. I had been chosen was all I knew. Chosen to embark upon a life of service and honor. And all that jazz. I think all medical students start out that way, wide eyed and humble and full of idealistic hope. But it doesn't last; life rolls on and consumes you and the next thing you know you're anxious about grades and AOA status and what specialty to pursue and which residency program to apply to and all these things that have nothing to do with Phoebe on the Merry-Go Round. Without losing those moments of inchoate happiness completely, a young doctor has to somehow figure out how he's going to go about fulfilling his promise to himself, his profession, and his patients. How should he go about being an actual doctor? With what mindframe ought he to adopt? Ecstatic joy is no match for the cruel grind of actual existence, the years on top of one another, the petty torments of human aspiration. You need a more enduring strategy.

There are talented, intelligent college students right now across this country considering whether or not to make a run at medical school. Nowadays, it isn't the slam dunk decision it used to be. If you were smart, top ten in your class, Dean's List--- medicine automatically went to the top of the list of possible career options. It had prestige. It payed well enough and possibly even better depending on what specialty you chose. It made your parents proud. It represented a low risk path to legitimacy in life, an assurance that your social standing wouldn't be contingent on such factors as personal relationships or fluctuations in the business cycle or mere chance. It just seemed to be a smart, conservative thing to do for an otherwise intelligent, hard working youth who harbored vague aspirations of "helping people".

Things have changed. (Not entirely; you're parents will still be proud of you.) But medicine isn't necessarily the default career pathway for a new generation of hard-working, intelligent Americans. Frankly, I don't know why anyone would want to pursue a career in medicine anymore. It's a tough gig, one that has lost luster over the past ten years. The pay isn't what it used to be--- there are pediatricians in this country who earn less than high school athletic directors. The debt one must take on to pay for medical school (close to $200,000) is simply absurd. And the prestige has correspondingly dropped. At some point in the near future, the local doctor will be perceived as a mere civil servant, a health provider who is seemingly interchangeable with other providers like nurse practitioners and physician's assistants and whatever other iteration of primary care develops in the future. And then there's the mentality in American medicine that errors and bad outcomes are unacceptable. We have "never events" now. Doctors order tests not to identify diseases necessarily, or to search for an unidentified source of a patient's discomfort, but rather to cover themselves from any future accusations that they "didn't do enough". There's an antagonism that has crept into the doctor-physician relationship, prompted by our corrupt medical malpractice system, unreasonable patient expectations, and physician cowardice and detachment that threatens to permanently blacken the soul of our profession. It's sad and depressing for those of us young enough to know we will have to wade through this transition phase for the next 25 years. For those who haven't committed yet, who stand on the brink of life with all its possibility and glory shining before them, medicine starts to seem far less appealing than other choices, even to the idealists.

But don't let the negative discourage you too much. Let me tell you a secret: this is still the best job in the world. And not because I'm a surgeon and get to do "cool procedures" and occasionally get to directly affect the course of a patient's life through a timely intervention. I like that part, don't get me wrong. I'm not some sort of Marcus Aurelius Stoic saint unperturbed by the dramatic viscissitudes of life, possessing such powers of self restraint that I refuse entirely to pat myself on the back occasionally. I'm only human. But when you do this long enough, you start to realize that whatever good you did for that patient, some other surgeon did just as well in the town next door, and if you weren't on call, whoever was would have done exactly what you did. You did your job, that was it. It wasn't about you. What you realize soon enough is that when you save someone or cure them of cancer, the lucky one in the transaction is you, buddy. Anyone can cut out a colon cancer. A million surgeons can do it with sufficient technical excellence. So don't go getting all high and mighty about it. You did your job as well as you could, based on your training and experience. No one would expect anything less. The patient would have been served just as well at another hospital. You are the one who ought always to feel privileged---that a patient would give herself to you, open her heart and soul, bare herself in all her failings and infirmities and suffering to this stranger who struts into her room in a white coat with all the answers and an indecipherable plan to somehow heal her pain. The sudden intimacy of the encounter is enough to stop your heart if you don't watch it. The trust and the view that our patients grant us is an incalcuable gift. We see humanity in these unvarnished, stripped down moments of vulnerability. Your gaze upon the stricken is a rare glimpse into the depths of what it means to be human. I like to think sometimes that heaven is all around us, if we look hard enough. I see it in my daughter every morning, standing in her crib in the morning dimness with those deep dark eyes of hers, looking up at me, the nascent beginnings of a smile forming in her lips. But too often we miss it in our everyday dealings. We miss it entirely, consumed as we are in our silly strivings and pronouncements and righteousness and posturing. We miss it all. But in the doctor-patient encounter, there is no averting of the eyes. You must look, gaze upon the wretchedness. Maybe you can close your heart off to it, forget what you've seen once the encounter ends, treat it as some detached clinical experiment, a problem to be solved empirically. For some, that is the only way to avoid involving themselves too emotionally in their patients. Regardless, open hearted or closed, you can never forget the things you see and hear and touch. It burns itself into your soul. It is the great Gift bestowed upon a physician. I wrote once about a little old lady who hid a giant fungating melanoma from her family for years as she ministered to her dying husband and how she finally broke down, opened herself up and asked for help. Those moments in my office discussing what had to be done with her and her daughters will never fade from my memory. The piercing brittleness of existence surges to the forefront of your consciousness. The things you will see. The worried, raccoon-eyed mothers in the ER with their young children right before surgery for appendicitis. The elderly husbands who dutifully sit by their intubated wives for hours in the ICU. The way a family will turn a hospital room into a shrine to the grandmother resting in bed; pictures from a foregone time when she was hale and hearty, hair a different color, crazy little scribblings from elementary-aged grandkids, fading bouquets of flowers, the rows of cards. The joy in the post operative waiting room when you tell someone everything went well, your wife is fine. The eruption of relief when you inform a woman her biopsy was benign. The quiet courage and resolve in the quivering, red-eyed visage of a woman told she has breast cancer, the husband who autonomously squeezes her hand white. The 22 year old guy who screams bloody murder when you lance a tiny boil and the old Korean war veteran who tells you about an old girlfriend he once had in Oklahoma the whole time you drain his giant perianal abscess. Broken hearted lonesome single middle aged guys who tell you not to worry about calling anyone after surgery; there's no one to call anyway. The physical maladies are no different than what you read about in textbooks. But the tapestry of human failings and strengths and triumphs you will experience as a doctor are not described in any textbooks I know of. Perhaps they are portrayed in art or literature, but the thing about art--- you never know quite to believe if it is real or not, that small nagging doubt that perhaps it's all made up. The reality of subjective experience-- it's all yours for the taking buddy. All of it is yours to observe, to learn from, to acquire. The entire spectrum of humanity on display, unadorned, vulnerable and full of absolute trust that you will do the right thing. Fear and joy and sorrow and pain and doubt and weakness reside within us all, to varying extents. You will find yourself through your experiences over a career. In Seymour, An Introduction, Seymour Glass tells his brother Buddy that all we ever do is go from one little piece of Holy Ground to the next. When you walk into a patient's room, the holy grounds open up endlessly before you. Respect where you tread.

And that's the catch. You cannot betray this gift of the Gaze. You must never forget that being a doctor is not about you. It's not a reward for getting good grades and working hard and volunteering at the local hospital. No one cares what your grades were. That AOA plaque on your office wall is meaningless to the suffering souls who come to you seeking solace. No one cares about your fellowship or that you went to Harvard or about your giant research endowment. It isn't about being president of your local medical society and making speeches. It's not about you. You owe your patients this Spartan-like self-denial. The benefits of being a physician will come to you only when you stop expecting them.

But how do you do this? How does one adopt the proper attitude necessary to handle the burden of the Gaze? What is the process? Is there a secret? How do I avoid letting it devolve into some voyeuristic sideshow? Well I think the answer is pretty simple once you get down to it. Salinger, I think, articulates it perfectly and succinctly with his admonishment to, whatever it is you've chosen to make your life's work, "do it with all your heart" and to do it for the "Fat Lady" who lives in the hearts of all men. But more on that later. First, I wanted to veer off course for a minute with two stories; one about my Aunt S. and the other about this mentally retarded developmentally delayed(MRDD) young man I saw in the hospital hallway the other week. Bear with me, please.

First, the young man. I was cruising through a long hallway on my way to the ICU, reading my patient list as I strode, when I noticed him out of the corner of my eye. He was in a wheelchair and he was washing or polishing a handrail that ran the length of the hallway. An elderly volunteer was watching him. At first I had the reflexive, complacent feeling of pity--- awww, look at the poor retarded man forced to do demeaning work in public. But I stopped further down the hall. I turned and watched him for a bit. He was sort of slouched over and his mouth was gaping and he frankly looked a little wild-eyed but he was completely focused on the task at hand. He had a rag in one hand and some sort of cleaning agent in a bottle between his legs. Very meticulously he would spray a little of the solution onto his rag and proceed to carefully wipe down the segment of railing to his right. This was drab, yellowed old railing. It would never look fantastic. And it was interminable, extending far down the length of the hallway, which curved ahead to the right so from his position you never knew when it would end. But dutifully he wiped the two foot segment in front of him, even the back side facing the wall which no one would ever see. He didn't skip areas. He wasn't careless. He concentrated. He did a fine job. There wasn't anything demeaning about it at all. Feeling sorry for him just disrespected his efforts. All work is worthy when done with the clean, humble, simple state of mind of the pure-hearted. It doesn't matter what it is. Taking out a gallbladder. Paving a highway. Cleaning a toilet. Polishing a unpolishable railing. It's all the same. We all have our opportunities to match the efforts of that young retarded guy. As doctors we're no different. It's easy to just go through the motions sometimes, to zip through an exam, to cut off a patient who rambles on about an unrelated topic during an office visit. But you can't do that, at least not with any sort of regularity. Every patient we see, every surgery is just another small segment of never-ending hallway railing to be polished as well we can, with all our hearts.

My Aunt S. was an amazing woman. She wasn't famous or renowned or anything. She was just a very loving, loyal, dedicated woman who constantly put the needs and desires of others above her own. She was always someone's biggest fan. Once she was on your side, you had an iron willed supporter for life. She was one of those people who, if something really terrific or fortunate or wonderful happened to you, she would be unconditionally happy and excited for you. There were never any strings attached. The older you get, the more you realize how rare a human trait that is. The majority of people are unable to feel such pure and unadulterated joy for the triumphs of someone else. Too often the moment is tainted by jealousy. It isn't that you aren't happy for that person. You are. But a small part of you sort of wishes such good fortune were happening to you instead and an incorrigible voice deep within will whisper things like "oh, she just knows the right people" or "his parents were able to pay for all his schooling" or "she's just about the luckiest son of a gun I know". The majority of us succumb to covetousness and an overly competitive drive to have all the happiness in the world for ourselves. My aunt was different. She could feel and internalize the joys and victories of another person as if they were her own. The moment I remember most about my Aunt S. was my medical school graduation day. My crazy family had all made the long trip to Toledo for the ceremony and of course they all got there late and had to settle for seats way high up in the rafters. I remember being next in line, waiting for my name to be called so I could walk out across the stage to get my diploma and already there was a commotion coming from somewhere back in the crowd. I couldn't see because it was so dark, like looking into a murmuring abyss. And then I was announced and there was this eruption of screaming and yelling from somewhere in the rafters. It was so loud and crazy and tumultuous I remember seeing parents in the front rows laughing amongst themselves. But one voice stood out. I distinctly remember hearing someone screaming "way to go Jeffer!!!!" My Aunt S. had always called me Jeffer, ever since I had been a little boy. Specifically, I heard her strident, exuberant voice above the cluttered din of screeches and yells. I turned to that spot up in the rafters and waved into the darkness, smiling like madman the whole time. Two years later she developed a lump in her breast that turned out to be cancer. A couple years after the mastectomy, the disease recurred. She battled for another year or two and then she started to deteriorate. She died two years ago this March. Now I wasn't such a wonderful nephew to her. I didn't call her on her birthdays. I didn't even know when her birthday was. I never bought her gifts. I never looked to her for worldy advice or professional guidance or anything like that. I was her only nephew though and she loved me in a way that I can only now truly appreciate.

These two stories best illustrate the two aspects of "doing something with all your heart". It's a delicate fusion of an almost dispassionate utter seriousness, as if what you were doing was the most important thing in the world no matter how banal and tedious it seems, along with an exuberant joy in seeing someone through a period of illness, a joy that transcends anything that has to do with you. One of my favorite passages in all of Salinger is from Seymour, an Introduction where Seymour writes to his brother Buddy about what it takes to be a great writer. The advice could apply to anyone, no matter what your career aspirations. So forgive me a little poetic license to paraphrase old Seymour in doling out some words of wisdom to all those young peope out there who are contemplating pursuing their life's work in the field of medicine:

When you die and the Man up in the sky reviews your oeuvre, do you know what He will ask you? One thing he won't ask is how many honor societies you were a member of, that's for sure. He won't ask how fast or fantastic of a surgeon you were or how marvelous of a diagnostician you were. He won't care about your awards or diplomas or honorariums. He won't ask if your patients loved you or just sort of respected you. He won't ask if you were nice to all your co-workers and colleagues. He won't ask how many medical missions you went on or how many indigent patients you treated. I mean, those things are nice and all and certainly worth aiming for. But He won't ask you about those things. You'll get asked two things and two things only: were all your stars out and did you practice medicine every day with all your heart? That's it. It doesn't get any more complicated than that. So to all of you thinking about venturing off into this holy profession you better make damn sure your skies are clear and your stars are shining bright. Keep your eyes peeled for that secret and mysterious Fat Lady who lives deep in the souls of all men--- she can be quite beautiful. And listen close for the exuberant scream of unconditional joy and love coming down from the rafters of your own lives....

A Soldier Speaks

Who is this Petraeus guy? What does he know about how to treat and interrogate prisoners? Doesn't he realize that decorated politicians and propagandists like Dick Cheney, Marc Thiessen, and Charles Krauthammer have already determined that it is essential to American security that we torture these evil Muslims whenever we can?

Tuesday, February 23, 2010

Malrotation in the Adult

This was an interesting one. A middle aged woman presented to the hospital with a year and a half history of crampy abdominal pain and weight loss. The pain worsened right after eating and the only relief she could get was by vomiting. She had adjusted her diet such that she only ate small meals with soft foods like mashed potatoes and casseroles. Otherwise she was a very healthy, well adjusted female. Never had surgery before.

Now we see a lot of patients as consults who come in with these complaints of chronic vague abdominal pain and nausea. The work-ups usually end up going nowhere. Negative CT scan. Negative endoscopy. Negative ultrasound. They get diagnosed with Irritable Bowel Syndrome (IBS) and get sent home with a crazy concoction of IBS pharmacology. Surgeons don't like these referrals so much. Some might even use a phrase like "waste of time consult" while commiserating in the OR lounge. (Of course not me!)

So I reviewed this lady's case. Sure enough, she'd been admitted several times over the past year. Her radiographic imaging, up to that point, had always been negative. Her blood work was stone cold normal. So I went in see her thinking I'd cruise through a quick little interview. The exam was unremarkable. Nothing appeared awry. Her abdomen was absolutely benign. But something nagged at me. She just seemed so normal. Often times these patients with chronic abdominal complaints can be a handful to deal with. There's a psychosomatic component to their issues that is very hard to quantify. This lady on the other hand was pleasant and genuinely distressed by the symptoms she was having. She couldn't eat the way she wanted. She was losing weight. And the symptoms seemed to consistently occur whenever she ate a larger meal. So I ordered a small bowel follow through (radiology test where you swallow barium and a series of images are taken tracking the barium through your GI tract).

The SBFT showed external compression of the duodenum, suggesting a mechanical problem. Therefore I booked her for surgery, expecting to find either some form of congential malrotation or perhaps the SMA syndrome. Boom goes the dynamite on the malrotation diagnosis. Her duodenum was the size of a summer squash and there was this rat's nest of snarl on the right side of her abdomen involving the cecum, the mesenteric pedicle and the proximal jejunum, all abnormally affixed together. Bands of congential scar tissue had partially entrapped the duodenum with a resultant partial torsion of the mesenteric vessels. Her SMV, compensating for reduced return over the years, had swollen to a ropish diameter, like what you see in cirrhotics with portal hypertension. The operation to fix this, Ladd's Procedure, is actually quite cool. You divide all the bands, straighten out the mesentery, lyse interloop adhesions, and what you find once everything is freed up is that the cecum wants to lie on the left side of the abdomen. So you can perform a cecopexy, affixing the cecum to the parietal peritoneum under the spleen. You also take out the appendix because if the patient ever develops left upper quadrant abdominal pain in the future, appendicitis won't be suspected.

It's a fun operation. For some reason this was my third case of malrotation on an adult. Fortunately all worked out well. The lesson as always: listen to your patients, especially those who seem reasonable...

Friday, February 19, 2010

Laying on Hands

You know what medical phrase I really hate? I hate when someone, usually an ER doc, asks if I could swing by and "lay some hands" on someone. Typically, the patient comes in with a chief complaint of abdominal pain but the work-up in the ER (CT scan, ultrasound, labs) comes back completely negativo. But the patient still complains of pain, so the ER doc wants a surgeon to check the patient out before discharging home--- the classic CYA consult.

But I absolutely loath that phrase. Laying on of hands. I can't help it. Makes me sound like I'm some sort of 19th century itinerant faith healer, a modern-day Esau performing sacraments in the trauma bay.

Anyway, that's the end of this blog post. I still love you ER guys.

Thursday, February 18, 2010

Cheney's Colonel Jessup Moment

I'm sorry, but I'm still sort of reeling from the fact that Cheney actually went on national television and admitted he was a "big supporter of waterboarding". And he didn't even use one of the Orwellian euphemisms (enhanced interrogation techniques); he actually said the word waterboarding. Now waterboarding is illegal according to US law, international law, the ICRC, the Geneva Conventions, the UN Convention Against Torture, Amnesty International, Human Rights Watch, etc etc. And he had the smug audacity to go on the air and brandish his unabashed support for an illegal, inhuman practice that ought not to be condoned under any circumstances. Why would he do that?

Because Dick Cheney is a ruthless, arrogant son of a bitch who thinks he can do whatever he wants. It kills him to have to silently bear the world's moral condemnation. He wants to say he tortured. He wants the world to know how "tough" he was. He wants the "liberals" and the "soft underbelly of the American left" to know how he sat on that wall and defended America and made the hard choices that the likes of Obama in their "faggoty white uniforms" would never or could never do themselves. Baring his teeth, shaking his fist like he did on Sunday--- it's like he was just daring someone to challenge his right to call a Code Red. He truly sees himself as some sort of martyred patriot.

But you're nothing more than a common criminal, Dick. None of us are impressed with your bluster. Your time will come.

Wednesday, February 17, 2010

Lowe's Commits to Cleveland Clinic

This is pretty amazing. The Cleveland Clinic has entered into an agreement with the home improvement superstore Lowe's to provide lower costing cardiac care for its employees. From the Plain Dealer:
Lowe's is offering employees incentives in the form of reduced out-of-pocket costs to come to the Clinic for heart procedures. Lowe's said it chose the Clinic among five hospitals nationwide in an effort to improve the quality of medical care for its workers and to lower costs.

The arrangement shows how cost and quality, which won the Clinic praise last summer from President Barack Obama, can drive business to top-performing hospitals.

Neither the Clinic nor Lowe's would divulge financial details, but the Clinic said it gave the company a package price for doctor and hospital services.

The Clinic model of employing its doctors and paying salaries allows it to control costs, which Bob Ihrie, Lowe's senior vice president in charge of benefits, said attracted the Mooresville, N.C., company.

Is this just the beginning of the nation-wide consolidation of health care provision where giant conglomerates like the Cleveland Clinic and multi-national corporations are able to strike deals wherein they can lowball competitors on the costs of lucrative procedures?

I find it interesting that this deal does not have anything to do with primary care or plain old regular "doctoring". It's strictly for the highly lucrative field of invasive cardiology. So that strikes me as a little suspicious. But if costs are held down....I'll have to think about the overall implications. But in general my initial impression is that it all seems a little too exploitative and overbearing. It would be one thing if the agreement meant that employees of Lowe's would receive comprehensive health care for a lower cost. But this just makes it look like the Clinic is trying to vulture a bunch of high paying cardiac stenting procedures.

Disclaimer: I am currently in contact with a representative from my area Lemonade Stand Union to secure exclusive rights on all surgical procedures on the boys and girls manning the stands this summer....

Tuesday, February 16, 2010

Obama Warned

The American Association for Justice (the kinder, gentler American Trial Lawyers Association) is warning President Obama that tort reform is not an issue he ought to be digging around in. Not if he knows what's good for him.

Monday, February 15, 2010

Unabashed Torturer

The brazenly unrepentant Dick Cheney bragged to ABC News this weekend about his unvarnished support for waterboarding. Mind you, waterboarding is torture. It is illegal according to international and American law. Dick Cheney is a criminal. And he continues to shamelessly promote his distortions and lies on major news outlets.

KARL: ... waterboarding, clearly, what was your...

CHENEY: I was a big supporter of waterboarding. I was a big supporter of the enhanced interrogation techniques that...

KARL: And you opposed the administration's actions of doing away with waterboarding?


Crohn's Strictures

This was a cool case. An older lady with occult GI blood loss was sent to her GI doctor for work-up. EGD and colonoscopy were both negative. So they scheduled her for a newer procedure called "capsule endoscopy" which allows direct visualization of the heretofore unaccessible small bowel. Basically you swallow a glorified pill-cam which records a series of pictures as it passes through your intestinal tract. The quality of the images generally isn't great (compared with standard endoscopy) but areas of active bleeding or mucosal ulcerations in the small bowel can often be identified.

This lady swallowed her pill-cam on a Thursday. Five days later, she still hadn't evacuated it in her stool. She ended up in the ER complaining of severe crampy abdominal pain and nausea. The CT above demonstrates the capsule in the RLQ, stuck somewhere in her terminal ileum.

At laparoscopic exploration I found classic manifestations of acute Crohn's disease in her terminal ileum (fat creeping, thickened mesentery, transmural inflammation of bowel wall, etc). So I did the lap ileocecectomy, opened the specimen on the back table and popped out the capsule lodged in the middle of an 8-10 cm stricture.

The capsule found the pathology all right; just not the way it was designed....

Saturday, February 13, 2010

Comparative Effectiveness---- How effective is it really?

The must read health care policy piece so far this year is this one from Dr. Jerome Groopman in the NY Review of Books. I'm not kidding. You have to read the whole thing.

The article is about "comparative effectiveness research" (CER from here on out) as applied to the field of medicine. Using best available evidence, accrued from rigorous scientific studies, ought to guide our decision making in clinical practice. No reason to give patients treatments that have been proven to be clinically ineffective. It's a waste of money and potentially dangerous to patients. So the utility of CER is not controversial. What Groopman is getting at in the piece is more subtle, and much more difficult to elucidate. He goes beyond the trope of "CER is good" to find a much trickier question, i.e. "to what extent ought CER to guide clinical decision making." In other words, how should doctors use CER in everyday practice?

Two schools of thought have arisen to answer this question. One stance, led by Budget Director Peter Orszag, is that CER ought to be a coercive force in clinical decision making. Doctors and hospitals who veer from "best practice" guidelines would face negative consequences for failure to adhere to algorithmic guidelines as determined by the latest CER. These consequences could come in the form of withheld reimbursements or actual fines. (Dr. Parks, we are writing to inform you that you owe the Sate of Ohio $1500 for failing to remove the Foley from Patient #1234646 in a timely manner.) This represents a more inflexible, authoritarian application of CER but in theory, standardization of practice allows one to control costs while providing optimal treatment strategies to patients.

The other school of thought is led by Cass Sunstein. This one is much more flexible, allowing physicians the freedom to "opt out", as it were, recommended CER paradigms if said physician deems the default pattern is not appropriate for his individual patient. Most doctors will utilize the CER default pathways, just out of expediency or inertia, but the opportunity for individualized practice is left open.

CER represents the ultimate fusion of the scientific method with medicine. No longer is it appropriate to practice medicine in the old-school, paternalistic way of deference to previous patterns. We interrogate our options in rigorous scientific models to determine which treatments seem to work better than others. But it's not an infallible, all-powerful mode of scientific inquiry. Rather than interpreting the data gleaned from some particular randomized controlled trial as insight into some sort of Hegelian, transcendental Truth we need to use the CER data in a more modest, pragmatic way. We shouldn't use the data to "define Reality" but instead just to figure out what works somewhat, sort of better than the other options under certain circumstances. Groopman gives a few examples where CER can lead to opposite conclusions, over short periods of time:
For example, Medicare specified that it was a "best practice" to tightly control blood sugar levels in critically ill patients in intensive care. That measure of quality was not only shown to be wrong but resulted in a higher likelihood of death when compared to measures allowing a more flexible treatment and higher blood sugar. Similarly, government officials directed that normal blood sugar levels should be maintained in ambulatory diabetics with cardiovascular disease. Studies in Canada and the United States showed that this "best practice" was misconceived. There were more deaths when doctors obeyed this rule than when patients received what the government had designated as subpar treatment (in which sugar levels were allowed to vary).

There are many other such failures of allegedly "best" practices. An analysis of Medicare's recommendations for hip and knee replacement by orthopedic surgeons revealed that conforming to, or deviating from, the "quality metrics"—i.e., the supposedly superior procedure—had no effect on the rate of complications from the operation or on the clinical outcomes of cases treated. A study of patients with congestive heart failure concluded that most of the measures prescribed by federal authorities for "quality" treatment had no major impact on the disorder. In another example, government standards required that patients with renal failure who were on dialysis had to receive statin drugs to prevent stroke and heart attack; a major study published last year disproved the value of this treatment.

Obviously, I'm going to advocate for the Sunstein school of CER thought. Any independent minded physician ought to. The loss of autonomy implied in Orszag-style authoritarian use of CER data isn't just an ego-motivated slight. There is an art and a mystery to medicine even in this pax romana of evidence based clinical practice. A few weeks ago I received consults for two patients who were in extremis. The one was a previously active, independent grandmother who suddenly developed abdominal pain and presented to the ER hypotensive with peritonitis. The other patient was a 88 year old guy with an acute abdomen, but he had been in the ICU for a few days and was already intubated and several organ systems were failing. Both patients ended up having ischemic colon. I operated on the woman and found gangrenous colon from cecum to rectum. After a rocky initial course she improved and is now in a rehab facility. I sat down with the family of the other guy and told them that his condition was poor and that anything I did had a very small chance of making him better; if anything the surgery would likely expedite his deterioration. I told them I would support their decision either way. They decided to just make him comfortable; he died the next day.

Two similar patients, but entirely different in all the important ways. How do you account for those subtle differences in some sort of CER-determined National Algorith? You can't. Try as people like Peter Orszag might, you can't eliminate the role of an asute doctor in clinical decision making. We go to school a long time. We see thousands of patients during our training. You can't replace that human intuition entirely with cookie cutter models.

The ultimate idea behind the Orszag paradigm is, not to sound too conspiratorial, to marginalize physicians in the provision of health care. If doctors are just carrying out orders from above, then why do we need to pay them what they make? Why couldn't a nurse practitioner or physician assistant do the exact same thing? It seems rational enough, right?

There's an arrogance implicit in such thinking. The limits of human reason ought to be clear enough after two millenia. It's futile and presumptuous to think we have determined "best practices" with the knowledge so far gained. A collective humility ought to prod us into admitting that all the best CER and evidence acquired can only make us a little better than before, with the modest hope that the future will be just a little better than today....

Feeding Tube in the Elderly Demented

Nice post over at Geripal that explores the factors that contribute to demented patients getting feeding tubes prior to discharge from a hospital. One of the more demoralizing aspects of modern practice, for me, is to see these demented lost souls who get admitted to the hospital and are subjected to millions dollar work-ups and undergo needless invasive procedures--- procedures like PEG tubes and tracheostomies that serve merely to prolong life without affecting the quality or meaning of life.

From joint Harvard/Brown University study in this week's JAMA:
In the multivariable analyses, nursing home residents with advanced cognitive impairment were more likely to get a feeding tube if admitted to:

*Hospitals with greater ICU utilization for decedents with chronic illness in the last 6 months of life
*A for-profit hospital vs hospitals owned by state or local government
*Hospitals with a greater number of beds (>310 beds vs <101 beds)

AMA Discredited

The President of the AMA, J. James Rohack has another piece posted up on the increasingly disconnected and corporatized Kevin MD. In this piece, the eminent Dr. Rohack basically pleads for average Americans to call their senators and congressmen about the need to enact permananet repeal of the anticipated 21% Medicare reimbursement slash this year. It's truly an embarassing piece; a faintly concealed public admission of his own organization's failure to adequately represent and advocate for the needs and desires of physicians in the health care reform dialogue.

Let's take a minute to browse through his various posting on KevinMD over the past year shall we?

July 16th, 2008 (Shortly after the AMA officially endorsed HR 3200:
Permanent Medicare physician payment reform must be part of comprehensive health reform this year. Medicare payments should cover the increasing cost of providing care so that seniors can be assured of continued access to physician care.

August 13th, 2008:
The AMA is committed to keeping medical decisions in the hands of patients and their physicians and preserving that sacred relationship. Insurance needs to be affordable and available to all patients though a choice of plans regardless of job or health status. The flawed Medicare payment formula must be fixed. Medical liability reforms must be adopted. We need a system that promotes quality, incentivizes care coordination and emphasizes prevention and wellness initiatives.

Reform of the broken Medicare physician payment formula is necessary to assure access to care for seniors. Without congressional action, Medicare cuts will total about 40 percent over the next five years. The gap between payments and costs will make it very difficult for physicians to keep their doors open to all Medicare patients and make quality improvement to their practices that benefit all patients

October 8th, 2008:
All eyes are on the Senate Finance Committee this week as they prepare to vote to move health reform legislation forward. The AMA is committed to health reform, and as the process moves to the Senate floor, it’s crucial that the Senate include permanent repeal of the current Medicare physician payment formula in its health reform legislation.

Democrats and Republicans have publicly stated that the flawed formula should be scrapped. Chairman Baucus and others have expressed support for a long-term solution. It’s clear to physicians and patients that the time for band-aid fixes is over. Short-term fixes have temporarily averted an access crisis, but it has also led to next year’s projection of a 21 percent cut, with more in years to come.

November 13th, 2008:
This week, our attention turns to passage of H.R. 3961, which repeals the broken Medicare physician payment formula and provides payments to better reflect the cost of providing medical care. The time for band-aid fixes to a long-term problem is over. Congress created the “sustainable growth rate” (SGR) formula that sets Medicare payment rates, and it’s up to them to do-away with the formula that projects a 21 percent payment cut next year and more in years to come. At stake is physicians’ ability to continue to provide high-quality care to seniors, the disabled, military families and the baby boomers who reach age 65 in two years.

These cuts are across the board to all physicians caring for Medicare and TRICARE patients. Active engagement is crucial at this time, and physicians need to call their members of Congress and let them know that Medicare’s physician foundation must be secure and stable for comprehensive health reform to succeed.

Notice how in early 2008, Rohack assured everyone that the AMA would not back down from demands to abolish the Medicare cuts. In November, physicians were encouraged to make phone calls to Capitol Hill. Now, the responsibility has been kicked further downhill to American citizens in general. Just laughable.

From the very beginning, the AMA has proclaimed its dedication to addressing the SRG payment slashes and tort reform. Exploiting the high page view lectern of Kevin MD, Dr Rohack has continuously banged his little drum about how hard he's working and the "victories" the AMA has achieved for physicians. But such self-congratulatory rhetoric is completely disconnected from the reality of actual events. There are no victories. He hasn't achieved any of his objectives. The AMA has failed miserably on all counts. It has turned itself into a pathetic, insular, completely impotent organization that, given its historical legacy and universal "name recognition", functions as a mere prop for for any reform bill that does come out of Congress (i.e. Endorsed by the AMA!!!).

Clarification: The above picture is of the vile, hateful JJ Reddick, not JJ Rohack. ;)

Friday, February 12, 2010

Private Health Insurance.....the assholes

Wellpoint, the giant health insurance conglomerate in California, announced recently that they will be raising premiums 39% for some customers this year. This news comes after reports of a $2.7 billion profit margin in the last quarter of 2009. Wellpoint spokesman Brian Sassi attributes the rise in costs to healthier, younger patients dropping their coverage plans because of the poor economy, leaving too many sick patients on the Wellpoint dole.

But it's the evil Gub'mint that wants to implement death panels right?

Thursday, February 11, 2010

The Gitmo "Suicides"

Not enough media attention has been brought to the peculiar story of the three Gitmo prisoners who apparently simultaneously hanged themselves in 2006 in "an act of aymmetric warfare". From the very beginning, the story sounded fishy enough that a formal NCIS probe was conducted. The NCIS findings at that time supported the official military account that all three men died from self inflicted wounds. A recent expose from Scott Horton at Harper's Magazine, howver, raises some serious questions about what exactly happened on the night in question. Horton used the testimony of an former Gitmo tower guard who had come forward with his version of events, along with excerpts from a review of the NCIS report by a group of Seton Hall Law Scool students and professors, to compile his piece. Read Horton's article. Read the Seton Hall Review.

Here's a brief sampling of some of the questions the Seton Hall study raised:
The original military press releases did not report that the detainees had been dead for more than two hours when they were discovered, nor that rigor mortis had set in by the time of discovery.

There is no explanation of how three bodies could have hung in cells for at least two hours while the cells were under constant supervision, both by video camera and by guards continually walking the corridors guarding only 28 detainees.

There is no explanation of how each of the detainees, much less all three, could have done the following: braided a noose by tearing up his sheets and/or clothing, made a mannequin of himself so it would appear to the guards he was asleep in his cell, hung sheets to block vision into the cell—a violation of Standard Operating Procedures, tied his feet together, tied his hands together, hung the noose from the metal mesh of ii the cell wall and/or ceiling, climbed up on to the sink, put the noose around his neck and released his weight to result in death by strangulation, hanged until dead and hung for at least two hours completely unnoticed by guards.

There is no indication that the medics observed anything unusual on the cell block at the time that the detainees were hanging dead in their cells.

The initial military press releases did not report that, when the detainees‘ bodies arrived at the clinic, it was determined that each had a rag obstructing his throat.

There is no explanation of how the supposed acts of ―asymmetrical warfare‖ could have been coordinated by the three detainees, who had been on the same cell block fewer than 72 hours with occupied and unoccupied cells between them and under constant supervision.

There is no explanation of why the Alpha Block guards were advised that they were suspected of making false statements or failing to obey direct orders.

There is no explanation of why the guards were ordered not to provide sworn statements about what happened that night.

There is no explanation of why the government seemed to be unable to determine which guards were on duty that night in Alpha Block.

There is no explanation of why the guards who brought the bodies to the medics did not tell the medics what had happened to cause the deaths and why the medics never asked how the deaths had occurred.

There is no explanation of why no one was disciplined for acts or failures to act that night.

There is no explanation of why the guards on duty in the cell block were not systematically interviewed about the events of the night; why the medics who visited the cell block before the hangings were not interviewed; or why the tower guards, who had the responsibility and ability to observe all activity in the camp, were not interviewed.
-from Andrew Sullivan

Finally, there is the bizarre handling of the autopsies of the three bodies by US Military personnel. According to prominent American pathologist, Dr. Michael Baden, numerous violations in standard operating procedures were apparent in the handling of the bodies. When the bodies were returned to the next of kin, some internal organs had been removed. Requests for the American government to turn over the removed kidneys and hearts (so that a second opinion autopsy/toxicology screen could be performed) were denied. Even more outlandishly, it was found that the neck structures (larynx, hyoid bone) had been removed. Requests for these to be returned to family members were also denied. So what you have is a situation where the US Military claims that the detainees died from self-induced hangings. But in their report, they note that the hyoid bone of one of the victims had been broken. (This is most suggestive of homicidal strangulation, according to Dr Baden.) But because the military refuses to turn over the very structures involved in the immediate cause of death, no one will ever really know the answer.

It's all really quite chilling. But don't worry, we're just going to keep "moving forward". What's past is past.

One of the deceased was a 17 year old kid when he was first detained and incarcerated at Gitmo. He had been there 4 years. At the time of his death he was on a list of prisoners to be released and sent home. No connection had ever been found between him and Al Qaeda or any other terrorist group....

Tort Reform and the Social Contract

Matt Steinglass at the Economist has interesting take on tort reform, specifically that limiting physician liability for adverse patient outcomes must come with an equable cost to doctors. In Europe, the costs accrued due to medical errors are covered by the wide-ranging social safety net; the lottery system of massive med mal judgments is virtually absent.
It's part of the social contract: doctors accept limited salaries in exchange for limited liability; patients accept that they cannot sue doctors for millions of dollars in exchange for a guarantee of access to decent health care.

True or not (certainly not true if you ask internists and family practice docs) the perception in our country is that doctors are "rich". We represent some sort of elite class of Americans who send their kids to private schools, drive Lexuses and Audis, join country clubs, and spend summers in the Hamptons. It's absurd, of course, as the majority of docs in the trenches can attest. But perception is king. Therefore, it seems that meaningful tort reform is unlikely until we do something to alter that perception. I have no problem with decreased salaries and lowered reimbursements. But the reason physicians make what they do in this country goes way beyond malpractice insurance. You want to transform the physician class into civil servants, fine. But do something about the exorbitant cost of medical school. Address the threats of frivolous lawsuits. Ease the burdens of running an office by subsidizing EMR. It's a package deal. As physicians we need to be a little more flexible. The roar from the primary care sector comes off sometimes as a whiny demand for more money (take it from the specialists if you have to!) and less work. And the more lucrative specialties (neurosurgeons/dermatologists) need to consider a world in the very near future where they earn 50-70% of what they make now. But it has to be a two way street. The social contract in the United States has always been tilted in favor of the entrepreneur, the capital man, the Wall St trader. We don't compensate individuals in this country based on the moral value they provide to a community. Few would argue that teachers and firemen and pediatricians and social workers are paid commensurate with the effect they have on local citizens. And we're fine with that. We're a country that has thrown in its lot with free enterprise and open market capitalism. That will never change. Doctors are now finding themselves marginalized financially in much the same way as the kindergarten teacher, the social worker at the battered women's shelter. I see the inevitability of it. But there has to be a reasonable compromise. You can't ask doctors of the future to earn less and work more without subsidizing the training and schooling, without addressing the med mal crisis. I'm willing to sit down at the bargaining table. But as the recent attempts at HCR demonstrate (no mention of tort reform or medical school subsidization in either bill), too often no one is willing to sit down across from us to negotiate....

Wednesday, February 10, 2010

Senator Murtha Dies Following Gallbladder Surgery

First of all, condolences to the family of Senator John Murtha who died recently following complications of gallbladder surgery. My thoughts are also with the surgeon in Maryland who performed the laparoscopic cholecystectomy. The death of a patient following routine elective surgery represents every surgeon's worst nightmare. The fact that it happened to a prominent American politician just exacerbates the stress and despair that the surgeon is probably feeling right now.

But I wanted to respond to a clip I watched earlier today from ABC News. In the video, Diane Sawyer (I know, you're supposed to say the lovely Diane Sawyer) interviews the ABC medical correspondent Richard Bessler, MD (trained as a pediatrician) about the possible causes of Senator Murtha's unfortunate outcome. Based on his explanations, she may as well have asked a 1st year medical student. According to Dr Bessler:

"to do this surgery, to remove the gallbladder, you need to separate it from the large intestine.....what may have happened, there may have been a small nick in the large intestine"

Now, what I think Dr Bessler is describing is an entity called a cholecysto-colonic fistula, which is very rare. For one thing, there are no natural attachments between the gallbladder and the large intestine. Certainly in cases of acute inflammation it is possible that an abnormal adhesion may form between the colon and gallbladder but these adhesions are typically very flimsy and easily divided; development of an actual connection between gallbladder and colon only occurs in cases of chronic inflammation over years and years. The likelihood that Murtha died from an injury to the colon is extremely low, statistically.

Most likely, Senator Murtha developed some sort of bile leak, either from the cystic duct stump or an actual injury to the common bile duct itself. Uncontained bile leakage throughout the abdominal cavity can lead to peritonitis, systemic inflammatory response syndrome (SIRS) and subsequent multiple organ failure/death. If there was a bowel injury, the most common source would be either the duodenum (often adherent to the neck of the gallbladder during the acute phase) or else small bowel adherent to the abdominal wall down by the umbilical port site (in placing the intial port, one can sometimes unwittingly cut into intestine that is stuck to the abdominal wall). Injury to the hepatic flexure of the colon would be much lower on my differential of possible causes.

I'm irritated because these are obvious points I'm making (from a surgical perspective). And here we have ABC News relying on the "expert testimony" of a pediatrician who works for the CDC. Dr Bessler, bless his heart, is obviously trying. You can tell that he looked at a human atlas and saw that the colon seems to be pretty close to the gallbladder. But his hypothesis is detached from any semblance of statistical likelihood. Why didn't ABC News ask, I don't know, maybe a SURGEON what the likely causes of Murtha's demise were? Is that asking too much? I know the guy is good looking and seems to handle himself well in front of the camera, but doesn't a news organization as influential as ABC News have an obligation to get their basic facts straight?

On another note.....posting has obviously been light. Probably will stay that way. Busy work and a crawling baby force a guy to have to eliminate certain indulgements.