Dave Weigel is a libertarian, right-leaning blogger who had been writing for the Washington Post. Although his politics veer right of center, he has no tolerance for the radical, wacky wing of the Republican Party (think Tea Partiers, Glenn Beck, Sean Hannity, etc.) Weigel was a member of the liberal-leaning listserv called JournoList (a private, by-invitation-only email group comprised of professional journalists and bloggers). JournoList provided a forum for these guys to exchange ideas with one another in an off the record fashion. Weigel, this week, in a moment of reckless writing, posted a thread on JournoList implying that the world would be a better place if Matt Drudge suddenly decided to self immolate.
Someone read the post and decided to break protocol. Ultimately, several of his off the record email posts were published for the general public on both the Daily Caller and FishbowlDC. Weigel subsequently resigned his position as a writer/blogger for the Washington Post.
The embroglio got me thinking social media and professionalism, in general. On places like Facebook and private blogs and Twitter accounts, people often present a far different characterization of themselves than the one they perhaps proffer in the office, at the hospital etc. Perhaps we sometimes trust too much that these two versions of ourselves do not overlap, that our secret rebellious, outgoing selves are secure behind passwords and restricted access walls. (This is why I don't do Twitter or Facebook--- Buckeye Surgeon is the sole source of learning about Dr Parks; no contradictions or duplicity. As long as I keep writing honestly, I don't feel any need to worry about reprisals.)
Sermo is a social network restricted to physicians (you have to give a verifiable medical license number in order to join). It's a great resource for docs. I've run cases by strangers on Sermo in real time while trying to decide upon an appropriate treatment plan for a difficult patient and have been aided immeasurably by the advice and comments I've received. But there are also posts about the political aspects of medicine and complaints about other specialties and rants about difficult patients and malpractice claims. And not everyone on Sermo chooses to be anonymous.
What if someone obtained access to Sermo for nefarious purposes? Perhaps a physician-turned-hospital administrator who went looking for dirt on a trouble-making internist. Or a malpractice attorney who used his brother-in-law's log-on ID to troll for cases.
Dave Weigel lost his job over a careless post on what he thought was a secure, private listserv. You figure it's not a question of if, but when, something similar will occur to casually flippant doc on a site like Sermo....
Monday, October 18, 2010
Compromise
Glenn Greenwald has done a bang up job of exposing the cozy, compromising relationships that the elite press corps has developed with the very Washington DC politicians and insiders they are ostensibly supposed to be covering. In this era of blogging and open source media, the public doesn't necessarily have to seek political news and opinions from the old guard of mainstream media. The elites no longer have a monopoly on defining what is news and how the news ought to be interpreted. So they cling to the one thing that the bloggers will never be able to touch---their sources, connections, and inside contacts.
As a result we get travesties like the Joe Biden party where reporters engage in squirt gun fights with the Vice President and other White House staffers. You get Chris Wallace "interviewing" Dick Cheney without asking a single uncomfortable question about torture and waterboarding. You get Sarah Palin running for Vice President without having to endure a single unscripted press conference. The presentation of "news" becomes merely a propaganda show where journalists and reporters subserviently regurgitate what the politician wants them to say, unchallenged. Because if they don't, guess what? No more access! No more "private sit down" sessions with Mr. VIP! And so the journalist/reporter simply stops doing the job he/she was hired for, i.e. holding governmental persons in postions of power accountable. Getting at the truth isn't so important as maintaining an open relationship.
Similarly, in medicine we often compromise ourselves for nefarious purposes, especially financial. We bitch and moan about tort reform and the insidious malpractice situation but we refuse to hold one another accountable. When another doctor makes an error, no one says anything. It's "too awkward" to say anything or "it creates an antagonistic environment" will be the explanations you hear. And of course this is true to some extent. But a larger reason has to do with the way private practice is constructed. Referral patterns are based on relationships and habit. You refer to a certain surgeon because he seems nice and the patients like him. You refer to a certain endocrinologist because she went to your medical school. Rare does it have anything to do with the quality of care delivered. And as these referral patterns and relationships ossify, it becomes harder and harder to change them. One thing that will change a referral pattern mighty quick would be "tattling" on a referring doctor for providing substandard care. Or receiving a notice in the mail from your QA committee that another physician has submitted several examples of cases where you delayed an intervention.
We specialists don't want to disrupt our profitable and essential referral patterns. So we don't say anything when an internist puts a patient on full strength lovenox 24 hours after a colon surgery. At most we perhaps off-handedly mention to the physician that maybe it would be a better idea to allow the surgeon to decide when to re start anticoagulation. The GI doc doesn't report the surgeon who always calls him for his all too frequent post-lap chole bile leaks. We don't report the internist to QA who prescribes massive doses of IV steroids to a patient with a rash (probably from morphine reaction) who was admitted with diverticulitis, who then decompensates and becomes septic with peritonitis. We just kinda, sorta mention that altering the patient's immunity with corticosteroids maybe wasn't such a great idea. Or maybe we don't say anything at all. Because it would just create an awkward situation.
As a result we get travesties like the Joe Biden party where reporters engage in squirt gun fights with the Vice President and other White House staffers. You get Chris Wallace "interviewing" Dick Cheney without asking a single uncomfortable question about torture and waterboarding. You get Sarah Palin running for Vice President without having to endure a single unscripted press conference. The presentation of "news" becomes merely a propaganda show where journalists and reporters subserviently regurgitate what the politician wants them to say, unchallenged. Because if they don't, guess what? No more access! No more "private sit down" sessions with Mr. VIP! And so the journalist/reporter simply stops doing the job he/she was hired for, i.e. holding governmental persons in postions of power accountable. Getting at the truth isn't so important as maintaining an open relationship.
Similarly, in medicine we often compromise ourselves for nefarious purposes, especially financial. We bitch and moan about tort reform and the insidious malpractice situation but we refuse to hold one another accountable. When another doctor makes an error, no one says anything. It's "too awkward" to say anything or "it creates an antagonistic environment" will be the explanations you hear. And of course this is true to some extent. But a larger reason has to do with the way private practice is constructed. Referral patterns are based on relationships and habit. You refer to a certain surgeon because he seems nice and the patients like him. You refer to a certain endocrinologist because she went to your medical school. Rare does it have anything to do with the quality of care delivered. And as these referral patterns and relationships ossify, it becomes harder and harder to change them. One thing that will change a referral pattern mighty quick would be "tattling" on a referring doctor for providing substandard care. Or receiving a notice in the mail from your QA committee that another physician has submitted several examples of cases where you delayed an intervention.
We specialists don't want to disrupt our profitable and essential referral patterns. So we don't say anything when an internist puts a patient on full strength lovenox 24 hours after a colon surgery. At most we perhaps off-handedly mention to the physician that maybe it would be a better idea to allow the surgeon to decide when to re start anticoagulation. The GI doc doesn't report the surgeon who always calls him for his all too frequent post-lap chole bile leaks. We don't report the internist to QA who prescribes massive doses of IV steroids to a patient with a rash (probably from morphine reaction) who was admitted with diverticulitis, who then decompensates and becomes septic with peritonitis. We just kinda, sorta mention that altering the patient's immunity with corticosteroids maybe wasn't such a great idea. Or maybe we don't say anything at all. Because it would just create an awkward situation.
The Increasingly Unacceptable Negative Appendectomy
When I was a medical student (really, not that long ago), we were taught on our surgical rotations that one can expect to take out a significant number of normal appendixes during a career. Specifically, a 15-20% negative appendectomy rate was considered appropriate, if not the standard of care. The rationale went like this: you don't want to miss appendicitis, delayed diagnosis leads to complicated outcomes, therefore, it's worth the morbidity of an operation to remove a few normal worms along the way.
This dogma dominated surgical thought right up until the Era of the Ubiquitous CT Scan came into being. Today's scanners are quick and highly sensitive for intra-abdominal pathology. An inflamed appendix rarely eludes its watchful eye. As a result, given the highly litigious environment of 21st century medicine, it's rare for a patient presenting to an ER with belly pain to go home without a scan. Personally, I like the CT scan, even in the so-called no-brainer cases (20 year old male with focal RLQ abdominal pain). For one thing, it helps me plan the surgery better--- is there an abscess in the pelvis needing drained, is it retrocecal, should I place my ports in a certain configuration, etc. For another, I'm a self-described ace when it comes to reading a scan for appendicitis. If I don't see the hallmarks of appendicitis while scrolling through the images, then I'm pretty hesitant to rush the patient to the OR. Finally, I just hate the concept of doing a surgery for no reason. Taking out a normal appendix is a highly unsatisfying endeavor. The only two truly negative appendectomies I've done in my career so far were on pregnant patients who chose not to undergo pre-operative CT scanning but had suggestive clinical histories.
It's funny, in the recent past, a surgeon with such a low negative appendectomy rate would raise suspicions from his local QA committee. It suggested that he/she was "not being aggressive enough" in treating ER patients in abdominal pain. The tide has turned however. A recent article from Radiology demonstrates a decrease in negative appies from 23% to 1.7% over the past 18 years, again directly attributable to the old CT scan. Also, from Surgery, a group at a New York hospital describes a decrease in negative appendectomy rates to around 5%. And that sounds about right to me.
Nowadays, a surgeon who regularly takes out normal appendices is going to come under fire. On one of my QA committees, we "keep an eye on" surgeons who have negative appy rates over 15%. With modern CT scanners, it's hard to justify the old dogma. Of course, someone will probably write up some groundbreaking finding about how all these CT scans lead irrevocably to a higher incidence of cancer---- which will reverse the tide again and we'll be once more teaching residents the value of "laying on of hands" and clinical judgement.
This dogma dominated surgical thought right up until the Era of the Ubiquitous CT Scan came into being. Today's scanners are quick and highly sensitive for intra-abdominal pathology. An inflamed appendix rarely eludes its watchful eye. As a result, given the highly litigious environment of 21st century medicine, it's rare for a patient presenting to an ER with belly pain to go home without a scan. Personally, I like the CT scan, even in the so-called no-brainer cases (20 year old male with focal RLQ abdominal pain). For one thing, it helps me plan the surgery better--- is there an abscess in the pelvis needing drained, is it retrocecal, should I place my ports in a certain configuration, etc. For another, I'm a self-described ace when it comes to reading a scan for appendicitis. If I don't see the hallmarks of appendicitis while scrolling through the images, then I'm pretty hesitant to rush the patient to the OR. Finally, I just hate the concept of doing a surgery for no reason. Taking out a normal appendix is a highly unsatisfying endeavor. The only two truly negative appendectomies I've done in my career so far were on pregnant patients who chose not to undergo pre-operative CT scanning but had suggestive clinical histories.
It's funny, in the recent past, a surgeon with such a low negative appendectomy rate would raise suspicions from his local QA committee. It suggested that he/she was "not being aggressive enough" in treating ER patients in abdominal pain. The tide has turned however. A recent article from Radiology demonstrates a decrease in negative appies from 23% to 1.7% over the past 18 years, again directly attributable to the old CT scan. Also, from Surgery, a group at a New York hospital describes a decrease in negative appendectomy rates to around 5%. And that sounds about right to me.
Nowadays, a surgeon who regularly takes out normal appendices is going to come under fire. On one of my QA committees, we "keep an eye on" surgeons who have negative appy rates over 15%. With modern CT scanners, it's hard to justify the old dogma. Of course, someone will probably write up some groundbreaking finding about how all these CT scans lead irrevocably to a higher incidence of cancer---- which will reverse the tide again and we'll be once more teaching residents the value of "laying on of hands" and clinical judgement.
Doctors or Technicians?
Interesting article recently from Health Affairs (via WSJ blog) about the clinical equivalence between the care provided by anesthesiologists and CRNAs. The article concludes by advocating that CRNAs be given permission to practice anethesiology without physician supervision. It's more cost effective. And there is no compromise to the quality of care delivered to patients.
We recommend CMS return to its original intention of allowing nurse anesthetists to work independently of surgeon or anesthesiologist supervision without requiring state governments to formally petition for an exemption,” they conclude. “This would free surgeons from the legal responsibilities for anesthesia services provided by other professionals. It would also lead to more cost-effective care as the solo practice of certified registered nurse anesthetists increases.” The study was funded by the American Association of Nurse Anesthetists.
A couple of caveats. One, the study was conducted by the American Association for Nurse Anesthetists (sort of like a study claiming that Jeff Parks is the smartest man on earth being conducted by "friends and family and hired sycophants of Dr. Parks"). Also, the study admits that CRNA's tend to work on less complex cases than MD anesthesiologists.
The main thrust of papers like this is to delve into the essence of what it means to be a "doctor". Are all doctors alike? Is the orthopod who replaces 350 knees a year the same as the internist cranking through 30 patients a day with complex medical problems? Is it fair or unfair to further categorize the various specialities according to some sort of intellectual hierarchy? Do some specialties verge perilously close to being mere technicians, thereby inviting the sort of turf war salvo sounded by the above referenced paper?
In reality, I think it goes beyond anesthesiology (although anesthesiologists are an arguably easier target). Most of the work done by a family practitioner can probably be adequately performed by a NP or PA without adverse effects. If you trained a physically gifted person to take out gallbladders and that's all he did, day after day, I bet you would be able to find a paper demonstrating that the non-MD surgeon has a similar complication rate as a formally trained general surgeon. But then what is that automaton going to do when he encounters a cholecysto-colonic fistula or when the cholangiogram shows he has cut the common bile duct? What is the NP going to do when she has to manage a patient with diabetes, heart disease, peripheral vascular disease, and obesity who comes into the office with abdominal pain? Would any CRNA accept the responsibility and stress of running a CABG solo?
The bottom line is, most of the time you don't need a doctor until you really need one. But you never know when that day is going to be. You never know when that seemingly normal patient who walks into the ER ends up turning into a complete disaster. My advice to these non-doctors seeking legitimacy and complete autonomy: be careful of what you wish for.
We recommend CMS return to its original intention of allowing nurse anesthetists to work independently of surgeon or anesthesiologist supervision without requiring state governments to formally petition for an exemption,” they conclude. “This would free surgeons from the legal responsibilities for anesthesia services provided by other professionals. It would also lead to more cost-effective care as the solo practice of certified registered nurse anesthetists increases.” The study was funded by the American Association of Nurse Anesthetists.
A couple of caveats. One, the study was conducted by the American Association for Nurse Anesthetists (sort of like a study claiming that Jeff Parks is the smartest man on earth being conducted by "friends and family and hired sycophants of Dr. Parks"). Also, the study admits that CRNA's tend to work on less complex cases than MD anesthesiologists.
The main thrust of papers like this is to delve into the essence of what it means to be a "doctor". Are all doctors alike? Is the orthopod who replaces 350 knees a year the same as the internist cranking through 30 patients a day with complex medical problems? Is it fair or unfair to further categorize the various specialities according to some sort of intellectual hierarchy? Do some specialties verge perilously close to being mere technicians, thereby inviting the sort of turf war salvo sounded by the above referenced paper?
In reality, I think it goes beyond anesthesiology (although anesthesiologists are an arguably easier target). Most of the work done by a family practitioner can probably be adequately performed by a NP or PA without adverse effects. If you trained a physically gifted person to take out gallbladders and that's all he did, day after day, I bet you would be able to find a paper demonstrating that the non-MD surgeon has a similar complication rate as a formally trained general surgeon. But then what is that automaton going to do when he encounters a cholecysto-colonic fistula or when the cholangiogram shows he has cut the common bile duct? What is the NP going to do when she has to manage a patient with diabetes, heart disease, peripheral vascular disease, and obesity who comes into the office with abdominal pain? Would any CRNA accept the responsibility and stress of running a CABG solo?
The bottom line is, most of the time you don't need a doctor until you really need one. But you never know when that day is going to be. You never know when that seemingly normal patient who walks into the ER ends up turning into a complete disaster. My advice to these non-doctors seeking legitimacy and complete autonomy: be careful of what you wish for.
Horseshoe Abscess
These cases are sometimes a little tricky. The patient had been suffering from severe butt pain for over a week. He couldn't even sit upright in a chair. He was feverish and had an elevated WBC count upon arrival in the ER. But on exam, you couldn't actually see any of the typical findings of perianal sepsis---no erythema, induration, or fluctuance. But it hurt him like hell when you tried to do a rectal exam. So we got the pelvic scan as seen above to help clarify the diagnosis.
What you see is a circumferential abscess/phlegmon, ringing the low rectum. You can't just lance these things at bedside like you can most abscesses. So I took him to the OR and made a couple of counter incisions to help effectuate complete drainage of the deeper pelvic sepsis. Then I like to leave a Penrose drain in situ, connecting the two incisions. It comes out in the office usually in a week.
Surgical Warranties
The mathematics and specific details of this article from Archives elude me to a certain (substantial) extent, but the main gist of it is this:
Complications and costs of care can be indexed to quality performing hospitals. Warranties for surgical care can reward effective and efficient care and preclude the need for additional payments for complications.
What that means, I think, is that those providers and hospitals that perform colon surgery with a lower overall incidence of complications set the bar in terms of bundled payment reimbursements. Those hospitals with higher complication rates, and therefore accrue higher costs, will find that much of the cost of this additional care and treatment will go un-reimbursed; thereby financially incentivizing them to either do a better job taking out colons or to get out of the colectomy business altogether.
I don't have much of a problem with this, to the exent that it is implemented fairly. A small hospital that recruits a colorectal surgeon isn't going to have the numbers to compete with the big tertiary care centers. As a result, complications that occur in the initial couple of years are going to statistically stand out as blaring clarion calls to cut reimbursements to that small hospital.
And the giant referral centers, teeming with surgical subspecialists clamoring for every square inch of operable human flesh will like that just fine.
Complications and costs of care can be indexed to quality performing hospitals. Warranties for surgical care can reward effective and efficient care and preclude the need for additional payments for complications.
What that means, I think, is that those providers and hospitals that perform colon surgery with a lower overall incidence of complications set the bar in terms of bundled payment reimbursements. Those hospitals with higher complication rates, and therefore accrue higher costs, will find that much of the cost of this additional care and treatment will go un-reimbursed; thereby financially incentivizing them to either do a better job taking out colons or to get out of the colectomy business altogether.
I don't have much of a problem with this, to the exent that it is implemented fairly. A small hospital that recruits a colorectal surgeon isn't going to have the numbers to compete with the big tertiary care centers. As a result, complications that occur in the initial couple of years are going to statistically stand out as blaring clarion calls to cut reimbursements to that small hospital.
And the giant referral centers, teeming with surgical subspecialists clamoring for every square inch of operable human flesh will like that just fine.
First, Do Nothing
(From the New York Times)
The New England Journal Of Medicine has published an astounding randomized controlled trial this month. 151 patients with metastatic, terminal non-small cell lung cancer were randomized to either receiving experimental chemotherapy alone versus chemotherapy plus palliative care. The group introduced to a palliative care specialist early in the diagnosis experienced a higher overall quality of life as the clock ran down. This part of the study shouldn't be surprising. The benefits of early involvement of an end of life specialist have been known for a while. Patients get better pain control, feel more in control of their lives as the disease unfolds, and are able to address end of life issues more honestly and openly with a professional. The psychological and emotional benefits are simply incalcuable.
The surprising part of the study was that the patients in the chemo/palliative care group lived an average of3 months longer than the chemo alone group. This, despite the fact that the patients in the palliative care group often decided to forgo additional aggressive treaments as they deteriorated.
What does this mean? Can we attribute the small, but significant, benefit simply to the effectiveness of palliative care? Or can we extrapolate further? What if patients who deferred chemotherapy altogether or only underwent an abbreviated course of treament had a survival advantage? Wouldn't it be reasonable to conclude that the chemotherapy itself was the determining variable?
Let's be honest. The literature on salvage chemotherapy in stage IV cancers is pretty weak. Survival "benefits" are quoted in terms of weeks or months. This stuff is basically poison blasted into your veins, in the hope that maybe, possibly, hopefully you will live a couple months longer than the guy who buys a ticket to Costa Rica and sits on a beach drinking Pina Coladas until he dies.
I've always been uncomfortable with the entire rationale behind "medical oncology" in stage IV, terminal disease. Many of these guys are peddling pipedreams and exploiting a very vulnerable patient population for financial and academic gain. It's good to see an RCT paper like this one to help tilt the perception back toward a "less is more" mentality.
The New England Journal Of Medicine has published an astounding randomized controlled trial this month. 151 patients with metastatic, terminal non-small cell lung cancer were randomized to either receiving experimental chemotherapy alone versus chemotherapy plus palliative care. The group introduced to a palliative care specialist early in the diagnosis experienced a higher overall quality of life as the clock ran down. This part of the study shouldn't be surprising. The benefits of early involvement of an end of life specialist have been known for a while. Patients get better pain control, feel more in control of their lives as the disease unfolds, and are able to address end of life issues more honestly and openly with a professional. The psychological and emotional benefits are simply incalcuable.
The surprising part of the study was that the patients in the chemo/palliative care group lived an average of3 months longer than the chemo alone group. This, despite the fact that the patients in the palliative care group often decided to forgo additional aggressive treaments as they deteriorated.
What does this mean? Can we attribute the small, but significant, benefit simply to the effectiveness of palliative care? Or can we extrapolate further? What if patients who deferred chemotherapy altogether or only underwent an abbreviated course of treament had a survival advantage? Wouldn't it be reasonable to conclude that the chemotherapy itself was the determining variable?
Let's be honest. The literature on salvage chemotherapy in stage IV cancers is pretty weak. Survival "benefits" are quoted in terms of weeks or months. This stuff is basically poison blasted into your veins, in the hope that maybe, possibly, hopefully you will live a couple months longer than the guy who buys a ticket to Costa Rica and sits on a beach drinking Pina Coladas until he dies.
I've always been uncomfortable with the entire rationale behind "medical oncology" in stage IV, terminal disease. Many of these guys are peddling pipedreams and exploiting a very vulnerable patient population for financial and academic gain. It's good to see an RCT paper like this one to help tilt the perception back toward a "less is more" mentality.
Making it Easier to Sue!
Rumors abound of a plan to revise the federal tax code in such a way that will benefit those poor, struggling plaintiff's attorneys. A bill introduced by Arlen Specter, currently being bandied about Congress, would allow personal injury lawyers to deduct costs accrued during the pre-trial and trial phases of a claim.
Previously, in contingency cases, attorneys would have to front the costs of a major case themselves, and then hope to recoup that investment with a jackpot jury award. This risk assumed by the personal injury lawyer acted to curb the number of frivolous lawsuits submitted. Allowing the lawyers to deduct these costs shifts the financial burden onto the federal government to some extent. Moral hazard is enjoined.
From the Washington Legal Foundation's Walter Schwartz:
If Senator Specter’s proposed modification of the Internal Revenue Code succeeds, the federal government will, for all intents and purposes, share in the cost and risk of bringing the initial litigation. Under current and certainly potential future tax laws, this could be as much as 40% of the cost of bringing litigation.
That's just fantastic.
Previously, in contingency cases, attorneys would have to front the costs of a major case themselves, and then hope to recoup that investment with a jackpot jury award. This risk assumed by the personal injury lawyer acted to curb the number of frivolous lawsuits submitted. Allowing the lawyers to deduct these costs shifts the financial burden onto the federal government to some extent. Moral hazard is enjoined.
From the Washington Legal Foundation's Walter Schwartz:
If Senator Specter’s proposed modification of the Internal Revenue Code succeeds, the federal government will, for all intents and purposes, share in the cost and risk of bringing the initial litigation. Under current and certainly potential future tax laws, this could be as much as 40% of the cost of bringing litigation.
That's just fantastic.
A poorly kept secret amongst recent med school grads is the fact that the last year of medical school is a complete joke and waste of time. Most 4th years will do rotations in July and August in the specialty they hope to match in, for the purpose of cozying up to attendings for recommendation letters. But after that, it's a 6 month vacation until match day. I did a surgical ICU rotation in July and then followed that up with a stint on cardiothoracic surgery. I spent the rest of the year half assing my way through rotations like radiology, anesthesiology, and pathology case studies. Most days I got to the gym around noon for a 4 hour session of pick up hoops. And oh yeah, I borrowed about $35,000 to finance that lifestyle.
There are two main reasons to reorganize medical school education along the lines of a three year program. One, it's a waste of loan money and squanders a year of earning potential. Two, it just may be a contributing factor in driving more students out of internal medicine, primary care, and general surgery.
Let me explain. If you eliminated the fourth year, students wouldn't have the oportunity to rotate through subspecialties like dermatology and radiology and cardiology and orthopedics. Hence, less chance to be brainwashed into thinking that general medicine and surgery were beneath them. The third year curriculum would expand the exposure to internal medicine and general surgery and family practice. Someone who really really wanted to do a cardiology rotation could do so, but would have to eliminate either OB/gyn or psychiatry. As it is now, the entire fourth year is built around the idea of winning praise from subspecialist academic physicians. Is it any wonder that medical students look down upon the "mere generalist" professions?
There are two main reasons to reorganize medical school education along the lines of a three year program. One, it's a waste of loan money and squanders a year of earning potential. Two, it just may be a contributing factor in driving more students out of internal medicine, primary care, and general surgery.
Let me explain. If you eliminated the fourth year, students wouldn't have the oportunity to rotate through subspecialties like dermatology and radiology and cardiology and orthopedics. Hence, less chance to be brainwashed into thinking that general medicine and surgery were beneath them. The third year curriculum would expand the exposure to internal medicine and general surgery and family practice. Someone who really really wanted to do a cardiology rotation could do so, but would have to eliminate either OB/gyn or psychiatry. As it is now, the entire fourth year is built around the idea of winning praise from subspecialist academic physicians. Is it any wonder that medical students look down upon the "mere generalist" professions?
A Customer Emotion Dashboard
A Customer Emotion Dashboard
The job of a CIO is filled with challenges. There's a delicate balance in constant flux among:
*Short term urgencies
*Long term strategies
*Ever changing compliance/regulatory requirements
*Day to day operations
*Budgets
What's the right objective measure of success?
Uptime?
On time, on budget project performance?
Positive feedback from your Governance groups?
All of these can look rosy but customers can still be unhappy. The juggling of IT supply and customer demand means than not all projects can be done. The complexity of IT work means that projects will take longer than customers expect. All communications plans, no matter how comprehensive will still miss some stakeholders. The end result of all of this is customer dissatisfaction.
A CIO can never achieve 100% customer satisfaction. In fact, if only 10% of my customers dislike me on a given day, then I've achieved a stellar approval rating.
By human nature, we want to make everyone happy and avoid conflict. When I lecture about my top 10 leadership principles for surviving as a CIO:
10. Select your change and what not to change
9. Identify those who will lose
8. Acknowledge their loss
7. Over Communicate
6. Be Honest and Consistent
5. Consensus is not essential
4. Embrace conflict
3. Focus on your detractors
2. The last two minutes of the meeting are the most important
1. You cannot please everyone
#1 is that you cannot please everyone. There will never be enough budget, enough staff, or enough governance to ensure everything is perfect.
Normally, the naysaying can be addressed through focused customer service, planning, and conversation.
However, it's getting harder now that the economy is challenging and expectations of technology support are escalating i.e. "I just bought a new smartphone yesterday, how come you do not provide application support for it?'
The level of tension in every sector is increasing. Civility is diminishing.
This means that I must carefully monitor the pulse of all my customers.
I've emailed my staff that at our next leadership meeting, I'd like to develop a new type of scorecard for each major stakeholder group. I will empower my staff to rate the emotional trajectory of each group as red/yellow/green. With such a scorecard, I'll be able to anticipate growing discontent before it escalates and then focus my time and energy on detractors, embracing conflict to proactively change strategy and tactics before it's too late to change.
A customer dashboard based on the trajectory of stakeholder emotion rather than budgets, projects and timelines - I have a feeling that it will be very effective in directing my management focus, especially in trying times.
I'll let you know how it works by the end of 2010.
The job of a CIO is filled with challenges. There's a delicate balance in constant flux among:
*Short term urgencies
*Long term strategies
*Ever changing compliance/regulatory requirements
*Day to day operations
*Budgets
What's the right objective measure of success?
Uptime?
On time, on budget project performance?
Positive feedback from your Governance groups?
All of these can look rosy but customers can still be unhappy. The juggling of IT supply and customer demand means than not all projects can be done. The complexity of IT work means that projects will take longer than customers expect. All communications plans, no matter how comprehensive will still miss some stakeholders. The end result of all of this is customer dissatisfaction.
A CIO can never achieve 100% customer satisfaction. In fact, if only 10% of my customers dislike me on a given day, then I've achieved a stellar approval rating.
By human nature, we want to make everyone happy and avoid conflict. When I lecture about my top 10 leadership principles for surviving as a CIO:
10. Select your change and what not to change
9. Identify those who will lose
8. Acknowledge their loss
7. Over Communicate
6. Be Honest and Consistent
5. Consensus is not essential
4. Embrace conflict
3. Focus on your detractors
2. The last two minutes of the meeting are the most important
1. You cannot please everyone
#1 is that you cannot please everyone. There will never be enough budget, enough staff, or enough governance to ensure everything is perfect.
Normally, the naysaying can be addressed through focused customer service, planning, and conversation.
However, it's getting harder now that the economy is challenging and expectations of technology support are escalating i.e. "I just bought a new smartphone yesterday, how come you do not provide application support for it?'
The level of tension in every sector is increasing. Civility is diminishing.
This means that I must carefully monitor the pulse of all my customers.
I've emailed my staff that at our next leadership meeting, I'd like to develop a new type of scorecard for each major stakeholder group. I will empower my staff to rate the emotional trajectory of each group as red/yellow/green. With such a scorecard, I'll be able to anticipate growing discontent before it escalates and then focus my time and energy on detractors, embracing conflict to proactively change strategy and tactics before it's too late to change.
A customer dashboard based on the trajectory of stakeholder emotion rather than budgets, projects and timelines - I have a feeling that it will be very effective in directing my management focus, especially in trying times.
I'll let you know how it works by the end of 2010.
S Military Pursues Patient Engagement
I had an amazing experience last Thursday. I encountered some of the smartest, fastest-thinking, most motivated healthcare transformation thinkers I've ever seen. The ideas were flying so fast it was like transformation popcorn. And this was in an organization I'd never heard discussed as health leaders: a U.S. Army "Physician Champions" meeting in Boston.
The people I met with have a particularly passionate commitment to effective care: having chosen the military themselves (not the world's best working conditions), they're distinctively committed to their patients. They have a long-running EMR system (electronic medical record), so that any "doc" who encounters a patient can see what previous providers have entered. And because of frontline military circumstances (at the front, a medic is the one you call "doc"), the records are used by all tiers of providers. In these conditions the value of accurate information is acutely apparent - as are the challenges of system usability and workflow.
The event leaders who invited me to speak were as passionate about patient engagement as anyone I've met anywhere. I spoke about participatory medicine, and heard discussions of real-world workflow issues and best practices for working with the system to get the job done. It was concrete and practical.
I had a strong sense that U.S. hospitals will have lots of meetings like this in the next few years as they implement EMRs.
I wondered why in all our civilian discussions of EMR I haven't heard of this group of change leaders. Sure, I've heard about the DOD's long-standing use of their medical record, and I know about the VA's system (which is not the same as DOD's). But I had no idea there was a group aggressively advocating for patient engagement in the military.
And to me that makes a ton of sense, because for the most part, when soldiers leave the service their medical record will no longer be visible to their new providers. They'll need to be engaged in their care.
My gratitude to Dr Bob Walker from the Europe Army Medical Command in Heidelberg and his team for introducing me to this special operation. Great
The people I met with have a particularly passionate commitment to effective care: having chosen the military themselves (not the world's best working conditions), they're distinctively committed to their patients. They have a long-running EMR system (electronic medical record), so that any "doc" who encounters a patient can see what previous providers have entered. And because of frontline military circumstances (at the front, a medic is the one you call "doc"), the records are used by all tiers of providers. In these conditions the value of accurate information is acutely apparent - as are the challenges of system usability and workflow.
The event leaders who invited me to speak were as passionate about patient engagement as anyone I've met anywhere. I spoke about participatory medicine, and heard discussions of real-world workflow issues and best practices for working with the system to get the job done. It was concrete and practical.
I had a strong sense that U.S. hospitals will have lots of meetings like this in the next few years as they implement EMRs.
I wondered why in all our civilian discussions of EMR I haven't heard of this group of change leaders. Sure, I've heard about the DOD's long-standing use of their medical record, and I know about the VA's system (which is not the same as DOD's). But I had no idea there was a group aggressively advocating for patient engagement in the military.
And to me that makes a ton of sense, because for the most part, when soldiers leave the service their medical record will no longer be visible to their new providers. They'll need to be engaged in their care.
My gratitude to Dr Bob Walker from the Europe Army Medical Command in Heidelberg and his team for introducing me to this special operation. Great
No country for old men
I'm probably going out my realm of expertise here, but it's just something I have to try to articulate. The wife and I saw the movie "No Country for Old Men" this past Friday. Now, judging by the nearly unanimous rave reviews the movie has received from expert movie critics, you'd think that this was the second coming of Citizen Kane or the Sistine Chapel or something. Phrases like "work of art", "darkly poetic", "modern masterpiece", "cathartic", and "flawless" can be lifted from literally hundreds of positive reviews. I admit, I was excited to see it. I hadn't read the Cormac McCarthy novel of the same name, but I enjoyed his latest offering (The Road) quite a bit. When it was over, however, I walked out of the theater feeling completely empty, detached from what I had just witnessed. I wasn't moved. I didn't feel anything. Nothing. It was like going out to a highly recommended restaurant and having them serve a plate of thin air. A strange sensation to have after watching, ostensibly, "one of the great American movies of the decade", indeed. And that bothered me. Why was I feeling nothing when the rest of the country was apparently swept up in rapturous delight?
Was it a bad movie? No. It was actually entertaining and extremely well made. The acting was top notch. Javier Bardem just nails the role of the remorseless sociopath. Nails it. But when the credits rolled, I stood up and left without a pause. Within 2 minutes my wife and I moved on to other conversational topics. Isn't a "work of art", a "masterpiece" supposed to ingrain itself into your psyche just a wee bit longer? What was my problem? I liked the movie; don't get me wrong. The scene where Bardem makes a poor gas station clerk call heads or tails to determine whether or not he lives is a masterful combination of humor and horror. I just don't get why critics are falling over themselves with praise and adoration, as if the Coen brothers have contributed to the aggrandizement of the collective human mind.
For one thing, I think there's an important distinction between "technical excellence" and "art". No Country for Old Men is certainly flawless in its construction. The scenes are taut and steely. The dialogue crackles. The characters are developed with a minimum of exposition. The cinematography is occasionally breathtaking. No denying the superiority of the film in these regards. But is it art? Did it force me to look deep within, to acknowledge a truth that perhaps I hadn't realized? Was there a hidden human beauty, carefully delineated, that became steadily more manifest as the film reached its conclusion? What edifying idea was transmitted?
The film is about a bizarrely hilarious psychopath, Anton Chigurh, who spends the bulk of his time on screen mercilessly gunning down innocents with a compressed air gun, usually used to subdue cattle prior to slaughter. Chigurh's inexorable, inevitable killing rampage is conducted on a barren, craggy south Texas landscape almost completely devoid of anything soft or gentle. Tommy Lee Jones as the aged lawman with lines in his face like a dry, cracked riverbed, can only follow the carnage, always showing up a little late, helpless to stop it. Josh Brolin is the everyman, suddenly thrust into the crosshairs, who decides to challenge the ineluctability of his own death, unable to overcome the temptation of easy money. In the end, evil triumphs. The last twenty minutes elapse quickly in retrospect. The violence, so meticulously portrayed in all its gory detail in the frst half of the film, is elided at the end, the Coen brothers leaving to our imagination the senseless concluding butchery. I suppose that was nice of them.
We like our violence in America, I get that. We also love our psychopaths. But just because talented filmmakers are able to package that recipe into a well-made movie, that doesn't necessarily mean that ripples have been made in the river of historical aesthetics. Maybe I'm a little biased, given what I do for a living, but I see plenty of suffering and needless pain almost every day. It's very clear that the 45 year old woman with stage IV breast cancer didn't do anything to deserve her plight. Or the guy who comes in with perforated diverticulitis. Or the elderly lady with a massive myocardial infarction. I don't need to watch a goofy looking sadist leave a trail of horror for two hours to illustrate the vicissitudes and randomness of the human condition. Most of the beauty of art isn't in the actual work itself, but rather in the discussion and soul searching and enlightenment that the work of art triggers in each individual and the subsequent sharing of such insight. It's sad commentary that in this modern age, it takes someone like an Anton Chigurh to rouse us from our cruise control ennui and complacency. It shouldn't have to be like that. Suffering is all around us. In our neighborhoods, within the walls of our own homes. Even when we look in the mirror. No Country for Old Men is merely well made escapist fare with cool characters (a la Pulp Fiction)that satisfies our national fetish for violence. That isn't art. So let's all get down from our cultural purveyor thrones (I mean you Roger Ebert, AO Scott, Peter Travers, etc), wipe the blood from our lips, and save the awards for something a little more ennobling.
Was it a bad movie? No. It was actually entertaining and extremely well made. The acting was top notch. Javier Bardem just nails the role of the remorseless sociopath. Nails it. But when the credits rolled, I stood up and left without a pause. Within 2 minutes my wife and I moved on to other conversational topics. Isn't a "work of art", a "masterpiece" supposed to ingrain itself into your psyche just a wee bit longer? What was my problem? I liked the movie; don't get me wrong. The scene where Bardem makes a poor gas station clerk call heads or tails to determine whether or not he lives is a masterful combination of humor and horror. I just don't get why critics are falling over themselves with praise and adoration, as if the Coen brothers have contributed to the aggrandizement of the collective human mind.
For one thing, I think there's an important distinction between "technical excellence" and "art". No Country for Old Men is certainly flawless in its construction. The scenes are taut and steely. The dialogue crackles. The characters are developed with a minimum of exposition. The cinematography is occasionally breathtaking. No denying the superiority of the film in these regards. But is it art? Did it force me to look deep within, to acknowledge a truth that perhaps I hadn't realized? Was there a hidden human beauty, carefully delineated, that became steadily more manifest as the film reached its conclusion? What edifying idea was transmitted?
The film is about a bizarrely hilarious psychopath, Anton Chigurh, who spends the bulk of his time on screen mercilessly gunning down innocents with a compressed air gun, usually used to subdue cattle prior to slaughter. Chigurh's inexorable, inevitable killing rampage is conducted on a barren, craggy south Texas landscape almost completely devoid of anything soft or gentle. Tommy Lee Jones as the aged lawman with lines in his face like a dry, cracked riverbed, can only follow the carnage, always showing up a little late, helpless to stop it. Josh Brolin is the everyman, suddenly thrust into the crosshairs, who decides to challenge the ineluctability of his own death, unable to overcome the temptation of easy money. In the end, evil triumphs. The last twenty minutes elapse quickly in retrospect. The violence, so meticulously portrayed in all its gory detail in the frst half of the film, is elided at the end, the Coen brothers leaving to our imagination the senseless concluding butchery. I suppose that was nice of them.
We like our violence in America, I get that. We also love our psychopaths. But just because talented filmmakers are able to package that recipe into a well-made movie, that doesn't necessarily mean that ripples have been made in the river of historical aesthetics. Maybe I'm a little biased, given what I do for a living, but I see plenty of suffering and needless pain almost every day. It's very clear that the 45 year old woman with stage IV breast cancer didn't do anything to deserve her plight. Or the guy who comes in with perforated diverticulitis. Or the elderly lady with a massive myocardial infarction. I don't need to watch a goofy looking sadist leave a trail of horror for two hours to illustrate the vicissitudes and randomness of the human condition. Most of the beauty of art isn't in the actual work itself, but rather in the discussion and soul searching and enlightenment that the work of art triggers in each individual and the subsequent sharing of such insight. It's sad commentary that in this modern age, it takes someone like an Anton Chigurh to rouse us from our cruise control ennui and complacency. It shouldn't have to be like that. Suffering is all around us. In our neighborhoods, within the walls of our own homes. Even when we look in the mirror. No Country for Old Men is merely well made escapist fare with cool characters (a la Pulp Fiction)that satisfies our national fetish for violence. That isn't art. So let's all get down from our cultural purveyor thrones (I mean you Roger Ebert, AO Scott, Peter Travers, etc), wipe the blood from our lips, and save the awards for something a little more ennobling.
Sick
Physicians have a different conception of what the word "sick" means. It's different than the meaning an eight year old boy gives it when he tells his mommy he feels "sick". Different than what a college kid means when he relates how "sick" he got after shot-gunning six beers. For a physician, deeming someone "sick" is a declaration of war, of sorts. It means the patient isn't doing well. It means death lurks around the corner. Usually the patient is in an ICU, hooked up to a ventilator, on multiple antibiotics, vasopressors, swollen and distorted, fluids seeping out the vascular system. I was closing the fascia on a guy yesterday who had perforated his cecum. This guy's going to be sick, I kept thinking. Sick patients keep you on edge. There's no relaxing. You can't miss anything. The degree of vigilance has to be ramped up ten fold. They give me an ulcer sometimes. So how do you know if someone's really "sick"? What are the best indicators? How can you predict the ones who are likely to struggle? Here's a top five list of clinical indicators that a lot of docs use:
5. White blood cell count: I'm not a fan of this one. Sure, leukocytosis is usually associated with severe infection/inflammation but I've seen planty of patients on death's door with normal WBC counts.
4. Lactate levels: When tissues aren't being perfused, the cells undergo anaerobic metabolism. Thus, lactate will be elevated. I don't use this one very often. It always takes the lab too long to run it and lactatemia doesn't usually manifest until the patient is already starting to decompensate. So it just confirms what you already know.
3. Heartrate: An old school surgeon from my Chicago residency used to call us in the middle of the night for updates on his post op whipples. I'd ramble off streams of data; urine output, CVP, blood pressure, etc. Stop, he'd say. What's the pulse? That's all he wanted to know. Tachycardia is the first response mechanism to stress. All tachycardia ought to be investigated. Post op tachycardia should make you very very nervous. Find out why it's so fast.
2. Bandemia: I like this one. Bands are immature WBC. In the face of severe infection/iinflammation, the bone marrow will mount a massive leukocytosis. Initially, this won't show up on the CBC. Always look at the differential. Bandemia and left shifts are early indicators of something drasticly wrong.
1. Base Deficit: This is my favorite. Cells that aren't getting enough oxygen will undergo anaerobic metabolism. Lactic acid then builds up in the blood stream, lowering the pH. The body has an amazing buffering capacity, but when it gets overloaded, the pH will drop anyway. Base defict is a way of measuring one's relative buffering capacity. A high base deficit is suggestive of a body being overrun by a catastrophic event.
1a. Gestalt: How does the patient look? If they look like shit, trust your hunch. It's like that Malcolm Gladwell book Blink; sometimes your intial, subconscious perception is right on. Be very afraid of patients with a sense of impending doom, telling you they feel like they're about to die. They probably are.
On a brighter note, Happy Thanksgiving.
5. White blood cell count: I'm not a fan of this one. Sure, leukocytosis is usually associated with severe infection/inflammation but I've seen planty of patients on death's door with normal WBC counts.
4. Lactate levels: When tissues aren't being perfused, the cells undergo anaerobic metabolism. Thus, lactate will be elevated. I don't use this one very often. It always takes the lab too long to run it and lactatemia doesn't usually manifest until the patient is already starting to decompensate. So it just confirms what you already know.
3. Heartrate: An old school surgeon from my Chicago residency used to call us in the middle of the night for updates on his post op whipples. I'd ramble off streams of data; urine output, CVP, blood pressure, etc. Stop, he'd say. What's the pulse? That's all he wanted to know. Tachycardia is the first response mechanism to stress. All tachycardia ought to be investigated. Post op tachycardia should make you very very nervous. Find out why it's so fast.
2. Bandemia: I like this one. Bands are immature WBC. In the face of severe infection/iinflammation, the bone marrow will mount a massive leukocytosis. Initially, this won't show up on the CBC. Always look at the differential. Bandemia and left shifts are early indicators of something drasticly wrong.
1. Base Deficit: This is my favorite. Cells that aren't getting enough oxygen will undergo anaerobic metabolism. Lactic acid then builds up in the blood stream, lowering the pH. The body has an amazing buffering capacity, but when it gets overloaded, the pH will drop anyway. Base defict is a way of measuring one's relative buffering capacity. A high base deficit is suggestive of a body being overrun by a catastrophic event.
1a. Gestalt: How does the patient look? If they look like shit, trust your hunch. It's like that Malcolm Gladwell book Blink; sometimes your intial, subconscious perception is right on. Be very afraid of patients with a sense of impending doom, telling you they feel like they're about to die. They probably are.
On a brighter note, Happy Thanksgiving.
Rushing
There's this old guy with dementia/chf etc who came in with SOB and a dislodged gastrostomy tube. He isn't one of those quiet/gorked-out type of demented guys either. You walk in his room and he starts rambling incessantly. "Doctor, let me ask you a question..." and then he trails off, mumbles or else "Doctor, dont leave, I have to know something...." whenever I try to leave, but he never completes a thought. He never actually asks me anything. It's annoying I'll admit. I don't usually spend a lot of time in his room. I just want to get in, get out, make sure the new tube is working properly and sign off the case as soon as I can. Well the last day I went in and his wife was there. She's this small, frail, soft-voiced old lady who sat quietly in the corner in the shadows when I was examining him. I didn't notice her at first. As I pulled up his covers and made to leave, he started his usual demented rambling. "Doctor I have to ask you.." And his little wife shot up out of the chair in a flash and was holding his hand saying Joe, Joe what is it you want to ask the doctor and his eyes looked scared and she said Im here Joe Im here Joe just tell me what you want to ask the doctor. And then he went silent. He just stared at her. He looked terrified and lost. And then she started crying I know Joe it's ok it's ok Joe and kept holding his hand and she looked at me and I felt like the biggest asshole for wanting to rush through things and sign off the case. I'm sorry I said, hoping she would understand everything I meant by that and I stood there and rubbed his damn shoulder or something like that for a while and then I left...
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.
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.
The meaning of life
The Happy Hospitalist took aim at my post from last week on the spry 92 year old lady with metastatic breast cancer who needed a Mediport for her adjuvant chemotherapy. As anyone who reads the Happy Ho would expect, he comes down hard on the decision of myself, the patient, and the oncologist to proceed with aggressive chemotherapy on someone obviously in the twilight of life. He writes:
So I have to ask the question. Does this 92 year old have the right to consume the resources used to treat an incurable, fatal and futile disease if it means we wont have the money required to treat another disease that is neither incurable, neither fatal and neither futile?
Unsurprisingly, HHO treats this case as yet another flagrant example of the profligate waste we see in everyday medical practice in America. Health care dollars and resources are a limited commodity (like oil and soybeans?), he avers---we cannot afford to waste them on the extreme elderly.
Now I think his heart is in the right place. Happy isn't a preternaturally evil person. Most of what he writes is at least reasonable. Besides, when you are an anonymous blogger, sometimes you write things you don't necessarily mean, with a stridency that you wouldn't normally use in everyday discourse. Who knows, maybe in real life HHO is a giant softy, one of those docs who brings his patients warm blankets and a cup of hot tea every morning. But on this particular topic, I think he's way off the mark and a little out of his depth.
I'm going to veer of course for bit, if that's OK. Notice first the ponderous, pretentious title of this post--- "the meaning of life". What the hell is that all about? Is this going to be another rant about Baudrillard or Kundera or DFW, you ask? Well, sort of. Just bear with me. Much of what happens to us in life is unimportant and ultimately forgettable. The traffic jam on the way home from work. Saying hi to people you pass in the hall. Pumping gas. Watching television. Reading the sports section. The lost moments of time that slip through our fingers every day. But every once in a while moments arise that demand our attention. These are the moments that either force us to step up and make good on the ideal conception of the sort of person we think we are (adversity, ethical quandaries, etc) or force us to stop and re-evaluate the very foundations of our notion of being. No matter who you are, it's important to accept these challenges when they present themselves; otherwise life is a random, arbitrary mess that ends much too quickly. My 92 year old breast cancer patient was, for me, such a moment. As a physician, and this may come off as a bit arrogant, I think I am thrust into situations that demand this sort of introspection more often than the average Joe. This is both a privilege and a burden.
A physician's raison d'etre is arguably to alleviate suffering, to improve a patient's quality of life, and to, in some cases, work to extend the duration of the life of an ill patient. Life is the common denominator. Our purpose, our meaning is driven by the concept of "life"--- making it better, richer, less intolerable. If we admit this, then we are obligated to define what we mean by "life", because that is the fulcrum upon which we operate. What is life? What is it exactly that we are trying to save, to alleviate, to improve?
Now this is purely my take and I'm just some yahoo like all the rest of you so don't get too upset if you disagree. I see our temporal time on Earth as having two distinct components. On the one hand is our contingent, a priori self that thrusts itself upon us, the part that deprives us of our autonomy. I was born in the late 20th century. I could not choose my parents. My genome is unalterable. I was raised a certain way by my mother. This is our contingent life. It didn't have to be like it is, but it is, and there isn't anything we can do about it. And it doesn't end at birth. The contingencies of life continue until we die. Events occur beyond our control that exert pressures upon our being. Wars. Economic depressions. Pestilence. The tragic untimely death of a loved one. A car that runs a redlight as you drive home from your daughter's wedding. We cannot control them. There is no escape from the weight that they bring to bear. But we are not condemned to let contingency define us. There is another side of Life, the side of free choice and alterability. Jean-Paul Sartre wrote about the being for itself (etre pour soi) that exists fleetingly in the instantaneous moment when we are free to decide, to choose to be, to push back against the weight of our contingencies, to create ourselves, fresh and new. Heidegger's dasein (being in time)is a similar concept. We aren't always doomed to serve out the sentences of our contingencies; every moment in time brings with it an opportunity to change, to rectify, to make better. We don't have to accept defeat. Those moments that interminably rush toward us with each waking second of consciousness afford us the chance to get back up off the canvas. And this is the aspect of Life that I find far more interesting.
Going back to my old lady with breast cancer. Her situation is fraught with contingency. She has incurable cancer. The chemotherapy may do more harm than good. She's old as hell. She's seemingly crushed by the cold hard weight of pure contingency. And she knows it. She knows she is going to die, that the cancer will ultimately vanquish her. But in that dark moment of impending, irrevocable mortality, she exercises her right to push back against death for the sake of her unmarried grandchildren and whatever else--- one more spring bloom, one more Thanksgiving, one last morning snow in December. Who are we to deny her that possibility?
This goes beyond charges of ageism. It's far more important than that. What we're talking about is a woman's dignity and free will. This was an intelligent, lucent, fully informed woman who has decided etre pour soi to mount one last counterattack against the ravages of time and human fallibility. It's as simple as that. To me, the succor of life is in those moments that challenge our preconceptions of who we really are, that force us to re-assess whom we wish to become. The full life, the life bursting at the seams with effervescence, is the one where one continues to make those big decisions as long as one can, independently, without meekly capitulating to the forces of time and contingency. To see it in a 92 year old woman is not grounds for condemnation; it's a reason to celebrate. To want to live so much, to have such appreciation for the rising of another sun, to thirst so much for the chance to make it all last just a little bit longer.... man it's just beautiful. The minute we start to ration care based simply on someone's age or some other convoluted bureaucratic formula, we start to lose something indispensable about what it means to be a human being, let alone for what it means to be a doctor.
Happy says: "Being 92 and functional is, in my opinion, not a good enough reason to abuse patients in their last few months of life, while we choose to ignore the economic realities all around us."
I feel bad for the guy. He's missing something crucial about being a physician. The "economic realities" of society will plague civilations long after we've all shuffled off this mortal coil. But if we cede the terms of our existence to pure contingency and ignore that powerful force of dasein that lurks deep within us all, then we might as well close up shop now because that's not the sort of world I want my grandchildren to live in.
Anyway, that's what a scrappy 92 year old lady, who will probably be dead this time next year no matter what she does, taught me last week....
So I have to ask the question. Does this 92 year old have the right to consume the resources used to treat an incurable, fatal and futile disease if it means we wont have the money required to treat another disease that is neither incurable, neither fatal and neither futile?
Unsurprisingly, HHO treats this case as yet another flagrant example of the profligate waste we see in everyday medical practice in America. Health care dollars and resources are a limited commodity (like oil and soybeans?), he avers---we cannot afford to waste them on the extreme elderly.
Now I think his heart is in the right place. Happy isn't a preternaturally evil person. Most of what he writes is at least reasonable. Besides, when you are an anonymous blogger, sometimes you write things you don't necessarily mean, with a stridency that you wouldn't normally use in everyday discourse. Who knows, maybe in real life HHO is a giant softy, one of those docs who brings his patients warm blankets and a cup of hot tea every morning. But on this particular topic, I think he's way off the mark and a little out of his depth.
I'm going to veer of course for bit, if that's OK. Notice first the ponderous, pretentious title of this post--- "the meaning of life". What the hell is that all about? Is this going to be another rant about Baudrillard or Kundera or DFW, you ask? Well, sort of. Just bear with me. Much of what happens to us in life is unimportant and ultimately forgettable. The traffic jam on the way home from work. Saying hi to people you pass in the hall. Pumping gas. Watching television. Reading the sports section. The lost moments of time that slip through our fingers every day. But every once in a while moments arise that demand our attention. These are the moments that either force us to step up and make good on the ideal conception of the sort of person we think we are (adversity, ethical quandaries, etc) or force us to stop and re-evaluate the very foundations of our notion of being. No matter who you are, it's important to accept these challenges when they present themselves; otherwise life is a random, arbitrary mess that ends much too quickly. My 92 year old breast cancer patient was, for me, such a moment. As a physician, and this may come off as a bit arrogant, I think I am thrust into situations that demand this sort of introspection more often than the average Joe. This is both a privilege and a burden.
A physician's raison d'etre is arguably to alleviate suffering, to improve a patient's quality of life, and to, in some cases, work to extend the duration of the life of an ill patient. Life is the common denominator. Our purpose, our meaning is driven by the concept of "life"--- making it better, richer, less intolerable. If we admit this, then we are obligated to define what we mean by "life", because that is the fulcrum upon which we operate. What is life? What is it exactly that we are trying to save, to alleviate, to improve?
Now this is purely my take and I'm just some yahoo like all the rest of you so don't get too upset if you disagree. I see our temporal time on Earth as having two distinct components. On the one hand is our contingent, a priori self that thrusts itself upon us, the part that deprives us of our autonomy. I was born in the late 20th century. I could not choose my parents. My genome is unalterable. I was raised a certain way by my mother. This is our contingent life. It didn't have to be like it is, but it is, and there isn't anything we can do about it. And it doesn't end at birth. The contingencies of life continue until we die. Events occur beyond our control that exert pressures upon our being. Wars. Economic depressions. Pestilence. The tragic untimely death of a loved one. A car that runs a redlight as you drive home from your daughter's wedding. We cannot control them. There is no escape from the weight that they bring to bear. But we are not condemned to let contingency define us. There is another side of Life, the side of free choice and alterability. Jean-Paul Sartre wrote about the being for itself (etre pour soi) that exists fleetingly in the instantaneous moment when we are free to decide, to choose to be, to push back against the weight of our contingencies, to create ourselves, fresh and new. Heidegger's dasein (being in time)is a similar concept. We aren't always doomed to serve out the sentences of our contingencies; every moment in time brings with it an opportunity to change, to rectify, to make better. We don't have to accept defeat. Those moments that interminably rush toward us with each waking second of consciousness afford us the chance to get back up off the canvas. And this is the aspect of Life that I find far more interesting.
Going back to my old lady with breast cancer. Her situation is fraught with contingency. She has incurable cancer. The chemotherapy may do more harm than good. She's old as hell. She's seemingly crushed by the cold hard weight of pure contingency. And she knows it. She knows she is going to die, that the cancer will ultimately vanquish her. But in that dark moment of impending, irrevocable mortality, she exercises her right to push back against death for the sake of her unmarried grandchildren and whatever else--- one more spring bloom, one more Thanksgiving, one last morning snow in December. Who are we to deny her that possibility?
This goes beyond charges of ageism. It's far more important than that. What we're talking about is a woman's dignity and free will. This was an intelligent, lucent, fully informed woman who has decided etre pour soi to mount one last counterattack against the ravages of time and human fallibility. It's as simple as that. To me, the succor of life is in those moments that challenge our preconceptions of who we really are, that force us to re-assess whom we wish to become. The full life, the life bursting at the seams with effervescence, is the one where one continues to make those big decisions as long as one can, independently, without meekly capitulating to the forces of time and contingency. To see it in a 92 year old woman is not grounds for condemnation; it's a reason to celebrate. To want to live so much, to have such appreciation for the rising of another sun, to thirst so much for the chance to make it all last just a little bit longer.... man it's just beautiful. The minute we start to ration care based simply on someone's age or some other convoluted bureaucratic formula, we start to lose something indispensable about what it means to be a human being, let alone for what it means to be a doctor.
Happy says: "Being 92 and functional is, in my opinion, not a good enough reason to abuse patients in their last few months of life, while we choose to ignore the economic realities all around us."
I feel bad for the guy. He's missing something crucial about being a physician. The "economic realities" of society will plague civilations long after we've all shuffled off this mortal coil. But if we cede the terms of our existence to pure contingency and ignore that powerful force of dasein that lurks deep within us all, then we might as well close up shop now because that's not the sort of world I want my grandchildren to live in.
Anyway, that's what a scrappy 92 year old lady, who will probably be dead this time next year no matter what she does, taught me last week....
Forgotten Man
I recently finished Amity Shlaes' book on the Great Depression, The Forgotten Man. It's a compelling, swift read; I encourage all to check it out. The term "forgotten man" was originally coined by this guy named William Sumner in the 19th century. His formulation was as follows---- Suppose you have entities A and B who are in positions of economic and political power. Both realize that entity C is unfairly compromised and excluded from sharing in their bounty. A sense of shame and justice and perhaps humanitarianism prompts A and B (the federal government and the capitalistic Masters of the Universe, respectively) to get together to try and find a way to help C (the poor and needy). But instead of directly assisting C, A and B instead identify X--- the forgotten man, the man who grinds through life, earns his own way, pays his taxes, doesn't ask or require anything of the government--- but because X lacks political standing, A and B find it is easy to place the burden of philanthropic redistribution on him. FDR of course had his own formulation of the forgotten man. In FDR's scheme, the forgotten man is just C and it is up to A and B to provide for his welfare.
Anyway you define it, I'm drawn to this concept of forgotten men in American life. As a surgeon, I cross paths with the downtrodden and forgotten rather frequently. We meet in the middle of the night, often, in lonesome, half-lit emergency rooms. Usually I find them sprawled uncomfortably on rickety stretchers, a thin hospital sheet stretched across their torso and limbs, never long enough, yellowed toes, bony pale hairless shins exposed. They never remember me the next day. They lay in the stretcher writhing in pain. They ask for more morphine. They can't remember how they ended up here. It's been going on for days. It hurts. Doc, it hurts and they turn towards the wall, clutching their abdomens. I review the films and the lab work and I try to explain what is happening, the perforated viscus, the appendicitis, whatever the hell it is, but I can tell they don't care. Just make it better they say. But when I turn to look for family, for a loved one, there's no one there. There's no one to call either. They've come into my life seemingly all alone....
I had a guy not too long ago who presented with a perforated duodenal ulcer. It was 3AM but I didn't mind driving in, already awake from my baby crying. It's nice sometimes to drive with the windows down on a cool summer night while the rest of the world slumbers. The smell of the dew dampened trees and grass and the sounds of the nighttime insects. The ER was empty. It must have been a Monday or Tuesday night. According to the EMS runsheet, the patient had been found down at the Shell gas station where he worked. He had peritonitis and looked deathly ill. He was 48 years old. His teeth were bad and he had that look of a chronic alcoholic, thin and disheveled and beaten down. We rushed him upstairs to the OR. After washing out a couple of liters of bile and gastric acid from his abdominal cavity, I patched the ulcerated hole in his duodenum with a tongue of well vascularized omentum. It was a quick, efficient case. We got him to the ICU within the hour. The family waiting area afterwards was dark and empty. There were no phone numbers of loved ones on his chart. I showered, lay down for an hour and then started my rounds.
A few days later I was surprised to see an older woman in his room while he slept. She introduced herself as his aunt. He had been living with her for the past several months. She asked about his condition. I informed her he was improving. She rolled her eyes. Probably fell off the wagon again, she said. Actually, no, I said. His blood alcohol level was zero when he arrived. Well, I'm sure this little adventure will give him an excuse to start hitting the bottle again, she said dismissively. I don't know how the hell he's going to make his rent this month. And then she walked off. I never saw her again.
As the days went by, my patient made remarkable progress. He turned out to be a very gentle and genuinely nice man. He seemed ever grateful for the care he'd received. He shook my hand on rounds. He always smiled, even when it was obvious he was hurting. The nurses loved him. He worked hard every day, walked the halls, used his incentive spirometer. I had had him on a prophylactic alcohol withdrawal protocol but that turned out to be unnecessary. He had been dry for 8 months now. He was working 50 hours a week at the gas station, saving his money. By day 6 he was eating and we were able to discharge him home.
Two weeks later, I saw him in the office. I hardly recognized him. He had showered and shaved and was wearing a button down shirt with corduroy pants. You could tell the clothes were brand new, the packaging creases still prominent. His wound had healed beautifully. He was back to work already. His boss had been very kind, granting him some time off. After a quick exam we talked for a bit. He opened up about his life. He was moving out of his aunt's spare bedroom into his own apartment. He didn't like his aunt so much. But she was the only family member who hadn't completely rejected him. Admittedly, he hadn't always lived his life the way he would have liked. He had made mistakes. He had been selfish. There was a lot in his history he wasn't proud of. But things were different now. There was hope etched into the lines of his coarse, aged face. He was hoping to get a night manager's position at the gas station later in the summer. Things were better. He had met a woman. He had a daughter in Phoenix he hadn't seen in years he was hoping to visit in the fall. And he was categorically grateful for the second chance he'd been given to make his life better. I can't express how thankful I am you took care of me, he said. You saved my life. It's hard to know what to say or how to act when someone says stuff like that to you. You were just doing your job. It wasn't personal. I'm just happy you got well again. It doesn't become personal until later, once the patient has conclusively recovered. And then you allow for a bit of unadulterated emotion to seep into the doctor-patient relationship, like two old war buddies talking about old times over a beer years later. Actually, that's not exactly true. As doctors we become attached to many of our patients almost from the beginning. But we hold back, restrain the heartstrings from thrumming for the sake of clinical objectivity and professionalism. There will be time for letting down your guard later, after you've successfully led the patient through the morass of illness. Eventually he had to leave. I haven't seen him since. I hope things are still well. I hope he's still dry and made amends with his estranged daughter. Hopefully he got that night manager's job. As time elapses, it gets harder and harder to remember what he looks like, the haziness of time blurring the edges of his face.
There was another forgotten soul from this summer I've wanted to write about. He was a veteran of the Vietnam War who had been battling alcohol abuse for years. He had been bouncing around Cleveland for the past decade, intermittently homeless, sometimes living with a loyal brother, sometimes crashing with fellow bums in ramshackle abodes. About five years ago he had tried to kill himself. His employment record was spotty. He was basically eking out an existence on the periphery of the American Dream. One night, after a massive binge, he took a pistol, pointed it down at his abdomen, and pulled the trigger. I was on trauma call that night when he rolled into the resuscitation bay. He was this emaciated, broken heap of a man bleeding out from his self inflicted wound. We intubated him, stabilized him as much as possible and rushed him to the OR. The bullet had entered his abdomen just below his ribcage on the right side, tore through the left lobe of his liver, blasted through the tail of his pancreas, exploded the top half of his left kidney, finally coming to a rest in a muscle belly of his back, inches from his spine. I opened his abdomen and encountered 3 or 4 liters of blood. We moved quickly. You pack all four quadrants, maintain your cool, and then systematically explore. The liver injuries were controlled with pressure and some whipstitches. Half of his pancreas was unsalvageable so I had to do a distal pancreatectomy. The kidney looked like a grenade had gone off in it and it was actively spurting blood so I performed a quick total nephrectomy. Foprtunately his bowels had been spared. There was no fecal or enteric contamination. I put some drains in and closed up shop. Initially his course was a little stormy. He went into alcohol withdrawal. He was intubated for over a week. But he slowly got better. He developed a persistent yellowish/brown drainage from one of his Jackson-Pratt drains and the evaluation of the fluid revealed this to be evidence of a pancreatic fistula (a not uncommon complication of pancreatic resections, especially when performed under duress). He went to a rehab facility with his drain and has been seeing me every few weeks in the outpatient clinic. He has VA eligibility but he doesn't want to see anyone else. Every few weeks we review the daily drain output volumes that he has meticulously written down on a wrinkled shard of paper, sometimes even the back of a napkin. The outputs remain too high. The fistula may not close spontaneously. So I've had to make arrangements for him to see a GI specialist in the VA system for an ERCP and to make sure he gets approved for the pancreatic secretion-reducing medication octreotide. It adds a lot of work to my ledger. I guess it would be easier to just dump him onto a surgeon at the VA for management. But I dont. He doesn't want that. See you in a few weeks Dr. Parks, he says.
We never formally talked about why he ended up like this. We never directly addressed his suicide attempt. He saw a psychiatrist and all that and he denies any persistent suicidal ideations currently but I still worry about him. He hasn't had a drink since the accident and he seems to be somewhat hopeful about the future. But he also knows the score. He's 58 years old. He hasn't done a whole lot with his life. Other than his brother, he doesn't have much of a social support structure. He never married. He has no children. He's been in and out of trouble with the law in multiple states. Since the accident, though, he's lived a very simple life. He doesn't drink or brawl or stumble around in chaos anymore. He wakes, eats a little, empties his drain and records how much comes out. He walks the streets where his brother lives. He used to bowl but he doesn't do that anymore. Before bed he empties the drain again and writes down what comes out. I half hope that damn fistula never closes.
I don't care what formula you want to use for who the forgotten man is. A, B, C, or X. In real life, there are no equations or secret formulations for the downtrodden and forgotten. They're all around us. We get so caught up in our silly, post modernist American lives we don't notice them, or we choose not to notice. Lonesomeness is pervasive. Those forlorn blank faces that pass you on the street, sitting silently across from you on the bus, the gaunt and weary who disappear into the background tapestry of life. We don't see them. We choose not to. We fear the light they shine into our own souls, the precariousness and utter abandonment of it all. We turn our heads, afraid to see our own reflection mirrored in the forgotten shadows of their lives....
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Anyway you define it, I'm drawn to this concept of forgotten men in American life. As a surgeon, I cross paths with the downtrodden and forgotten rather frequently. We meet in the middle of the night, often, in lonesome, half-lit emergency rooms. Usually I find them sprawled uncomfortably on rickety stretchers, a thin hospital sheet stretched across their torso and limbs, never long enough, yellowed toes, bony pale hairless shins exposed. They never remember me the next day. They lay in the stretcher writhing in pain. They ask for more morphine. They can't remember how they ended up here. It's been going on for days. It hurts. Doc, it hurts and they turn towards the wall, clutching their abdomens. I review the films and the lab work and I try to explain what is happening, the perforated viscus, the appendicitis, whatever the hell it is, but I can tell they don't care. Just make it better they say. But when I turn to look for family, for a loved one, there's no one there. There's no one to call either. They've come into my life seemingly all alone....
I had a guy not too long ago who presented with a perforated duodenal ulcer. It was 3AM but I didn't mind driving in, already awake from my baby crying. It's nice sometimes to drive with the windows down on a cool summer night while the rest of the world slumbers. The smell of the dew dampened trees and grass and the sounds of the nighttime insects. The ER was empty. It must have been a Monday or Tuesday night. According to the EMS runsheet, the patient had been found down at the Shell gas station where he worked. He had peritonitis and looked deathly ill. He was 48 years old. His teeth were bad and he had that look of a chronic alcoholic, thin and disheveled and beaten down. We rushed him upstairs to the OR. After washing out a couple of liters of bile and gastric acid from his abdominal cavity, I patched the ulcerated hole in his duodenum with a tongue of well vascularized omentum. It was a quick, efficient case. We got him to the ICU within the hour. The family waiting area afterwards was dark and empty. There were no phone numbers of loved ones on his chart. I showered, lay down for an hour and then started my rounds.
A few days later I was surprised to see an older woman in his room while he slept. She introduced herself as his aunt. He had been living with her for the past several months. She asked about his condition. I informed her he was improving. She rolled her eyes. Probably fell off the wagon again, she said. Actually, no, I said. His blood alcohol level was zero when he arrived. Well, I'm sure this little adventure will give him an excuse to start hitting the bottle again, she said dismissively. I don't know how the hell he's going to make his rent this month. And then she walked off. I never saw her again.
As the days went by, my patient made remarkable progress. He turned out to be a very gentle and genuinely nice man. He seemed ever grateful for the care he'd received. He shook my hand on rounds. He always smiled, even when it was obvious he was hurting. The nurses loved him. He worked hard every day, walked the halls, used his incentive spirometer. I had had him on a prophylactic alcohol withdrawal protocol but that turned out to be unnecessary. He had been dry for 8 months now. He was working 50 hours a week at the gas station, saving his money. By day 6 he was eating and we were able to discharge him home.
Two weeks later, I saw him in the office. I hardly recognized him. He had showered and shaved and was wearing a button down shirt with corduroy pants. You could tell the clothes were brand new, the packaging creases still prominent. His wound had healed beautifully. He was back to work already. His boss had been very kind, granting him some time off. After a quick exam we talked for a bit. He opened up about his life. He was moving out of his aunt's spare bedroom into his own apartment. He didn't like his aunt so much. But she was the only family member who hadn't completely rejected him. Admittedly, he hadn't always lived his life the way he would have liked. He had made mistakes. He had been selfish. There was a lot in his history he wasn't proud of. But things were different now. There was hope etched into the lines of his coarse, aged face. He was hoping to get a night manager's position at the gas station later in the summer. Things were better. He had met a woman. He had a daughter in Phoenix he hadn't seen in years he was hoping to visit in the fall. And he was categorically grateful for the second chance he'd been given to make his life better. I can't express how thankful I am you took care of me, he said. You saved my life. It's hard to know what to say or how to act when someone says stuff like that to you. You were just doing your job. It wasn't personal. I'm just happy you got well again. It doesn't become personal until later, once the patient has conclusively recovered. And then you allow for a bit of unadulterated emotion to seep into the doctor-patient relationship, like two old war buddies talking about old times over a beer years later. Actually, that's not exactly true. As doctors we become attached to many of our patients almost from the beginning. But we hold back, restrain the heartstrings from thrumming for the sake of clinical objectivity and professionalism. There will be time for letting down your guard later, after you've successfully led the patient through the morass of illness. Eventually he had to leave. I haven't seen him since. I hope things are still well. I hope he's still dry and made amends with his estranged daughter. Hopefully he got that night manager's job. As time elapses, it gets harder and harder to remember what he looks like, the haziness of time blurring the edges of his face.
There was another forgotten soul from this summer I've wanted to write about. He was a veteran of the Vietnam War who had been battling alcohol abuse for years. He had been bouncing around Cleveland for the past decade, intermittently homeless, sometimes living with a loyal brother, sometimes crashing with fellow bums in ramshackle abodes. About five years ago he had tried to kill himself. His employment record was spotty. He was basically eking out an existence on the periphery of the American Dream. One night, after a massive binge, he took a pistol, pointed it down at his abdomen, and pulled the trigger. I was on trauma call that night when he rolled into the resuscitation bay. He was this emaciated, broken heap of a man bleeding out from his self inflicted wound. We intubated him, stabilized him as much as possible and rushed him to the OR. The bullet had entered his abdomen just below his ribcage on the right side, tore through the left lobe of his liver, blasted through the tail of his pancreas, exploded the top half of his left kidney, finally coming to a rest in a muscle belly of his back, inches from his spine. I opened his abdomen and encountered 3 or 4 liters of blood. We moved quickly. You pack all four quadrants, maintain your cool, and then systematically explore. The liver injuries were controlled with pressure and some whipstitches. Half of his pancreas was unsalvageable so I had to do a distal pancreatectomy. The kidney looked like a grenade had gone off in it and it was actively spurting blood so I performed a quick total nephrectomy. Foprtunately his bowels had been spared. There was no fecal or enteric contamination. I put some drains in and closed up shop. Initially his course was a little stormy. He went into alcohol withdrawal. He was intubated for over a week. But he slowly got better. He developed a persistent yellowish/brown drainage from one of his Jackson-Pratt drains and the evaluation of the fluid revealed this to be evidence of a pancreatic fistula (a not uncommon complication of pancreatic resections, especially when performed under duress). He went to a rehab facility with his drain and has been seeing me every few weeks in the outpatient clinic. He has VA eligibility but he doesn't want to see anyone else. Every few weeks we review the daily drain output volumes that he has meticulously written down on a wrinkled shard of paper, sometimes even the back of a napkin. The outputs remain too high. The fistula may not close spontaneously. So I've had to make arrangements for him to see a GI specialist in the VA system for an ERCP and to make sure he gets approved for the pancreatic secretion-reducing medication octreotide. It adds a lot of work to my ledger. I guess it would be easier to just dump him onto a surgeon at the VA for management. But I dont. He doesn't want that. See you in a few weeks Dr. Parks, he says.
We never formally talked about why he ended up like this. We never directly addressed his suicide attempt. He saw a psychiatrist and all that and he denies any persistent suicidal ideations currently but I still worry about him. He hasn't had a drink since the accident and he seems to be somewhat hopeful about the future. But he also knows the score. He's 58 years old. He hasn't done a whole lot with his life. Other than his brother, he doesn't have much of a social support structure. He never married. He has no children. He's been in and out of trouble with the law in multiple states. Since the accident, though, he's lived a very simple life. He doesn't drink or brawl or stumble around in chaos anymore. He wakes, eats a little, empties his drain and records how much comes out. He walks the streets where his brother lives. He used to bowl but he doesn't do that anymore. Before bed he empties the drain again and writes down what comes out. I half hope that damn fistula never closes.
I don't care what formula you want to use for who the forgotten man is. A, B, C, or X. In real life, there are no equations or secret formulations for the downtrodden and forgotten. They're all around us. We get so caught up in our silly, post modernist American lives we don't notice them, or we choose not to notice. Lonesomeness is pervasive. Those forlorn blank faces that pass you on the street, sitting silently across from you on the bus, the gaunt and weary who disappear into the background tapestry of life. We don't see them. We choose not to. We fear the light they shine into our own souls, the precariousness and utter abandonment of it all. We turn our heads, afraid to see our own reflection mirrored in the forgotten shadows of their lives....
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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....
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....
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....
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....
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