Thursday, October 25, 2007

A Monkey Wrench in the Ratings Machine

Interesting things, facts. Stubborn at times, when they are reviewed, and apt to make most reasonable people change their minds about subjects if they are studied and accepted. Of course, they often tend to be ignored --- unfortunately, in the wonderful world of Modern American Medicine™, the latter situation often prevails.

A case in point is the headlong rush to rate physicians' quality of care almost solely upon the volume of a specific procedure they happen to perform. It's a simple concept, really --- it would seem to make sense that the more frequently a surgeon performs a given procedure, the better their outcomes should be. That case has been frequently made, particularly on the part of large academic medical centers, for a whole variety of procedures -- sort of a Good Housekeeping Seal for surgery. These include pancreatic resection, esophagectomy, coronary bypass surgery, laparoscopic gastric bypass surgery, and carotid endarterectomy. There is a push for "centers of excellence" to be created for these procedures, with gastric bypass surgery centers of excellence already established. There are reasonable statistics to back up this idea, but very little investigation has been undertaken to evaluate the opposite proposition ---- what if some surgeons actually have good outcomes with a given procedure, despite performing that procedure at a low volume than has been arbitrarily picked as a threshold?

I would like to give kudos to a few surgeons at the University of Vermont who have decided to buck the trend and look a bit differently at their own data. Their study, entitled Credentialling for Laparoscopic Bowel Operation: There Is No Substitute for Knowing the Outcomes was published in the October edition of the JACS. Basically, they acknowledge that case volume has been utilized as a reasonable estimate for granting surgical privileges --- a point that I agree with completely --- but that it also has the potential to prevent some surgeons for gaining privileges. Bowel resections performed by four surgeons at their institution were reviewed; one of the surgeons had completed fellowship training in advanced laparoscopy, and a second had recently completed a colorectal surgical fellowship --- so, each had a large amount of laparoscopic bowel surgical experience in their training. Let's call them the Young Turks. The other two had completed colorectal surgical training prior to the advent of advanced laparoscopic training; we'll call them the Old Farts. Out of a total of 112 laparoscopic bowel resections performed, the Old Farts held their own, despite lower volumes and the obvious difference in training:

Six hundred twenty-four bowel resections were performed during the study period, of which 112 were performed laparoscopically. Of the four study surgeons, the percentage of laparoscopic versus open cases ranged from 8% to 56%. Individual surgeon complication rates varied from 9% to 47%. Surgical volume and training had no notable relationship to incidence of complications (19% high volume/fellowship training versus 10% low volume/no fellowship, p = 0.25). An inflammatory indication was a strong predictor of technical complications on univariate (p = 0.02) and multivariate (p = 0.01) analysis.
Well, looky there. The Old Farts actually had fewer complications than the Young Turks, though statistical significance was not established. Wouldn't you have liked to be sitting in on the faculty conference when this data was presented!

Well, what does this teach us? The most important take-home lesson for surgeons in the present-day world where hospitals, insurance corporations, health-rating companies, and Uncle Sam (or Aunt Hillary) want to rate, regulate, and limit surgical privileges based upon volume is:
KEEP YOUR OWN STATISTICS!
Unfortunately, that's kind of hard --- it is time consuming, requires a lot of data collection and entry, and I can tell you from personal experience is not easily accomplished with presently available programs (including the one offered by the American College of Surgeons).

What this also may tell us is that there is something to be said for experience. I feel, and I pray that I am right, that I am a better clinician and a better surgeon today than when I first came out of training ---- despite the fact that that training was long, intensive, included a laparoscopic fellowship, and involved a whole lotta operating. Maybe we could say that physicians, like musicians, get better with age, experience, and practice. Don't believe me? Well, who would you rather see in concert:
this guy
or this one?

I know how I would answer that question, but I am an Old Fart, with an emphasis on the "Old" part of the description. Pharmaceutical enhancements aside, I think anyone who listens to the young Clapton and compares him to today's version understands that the man has learned a few tricks along the way.

Lest I be condemned for advocating continued practice by surgeons far beyond their prime in reasoning and physical skill, I admit that there is a point beyond which a physician loses skills necessary to good practice. It is impossible to tell when exactly that happens, and in the ideal world every surgeon would be able to recognize a diminution in his or her ability to adequately care for patients, and back off. And once again, we can turn to the world of music for a comparison. Who would you rather hear play:

this guy, on top of his game

or this over the hill, ridden-hard-and-put-away-wet guitarist who can't remember the notes?

I guess the trick for patients is to not let Keith Richards operate on you.

Friday, October 19, 2007

Indiana Jones and the Cult of the Consultant

There's a great IBM commercial out right now in which a man opens a door on a darkened room, discovering a slew of fellow workers lying in the dark, heads on pillows, doing absolutely nothing productive.

ideate from ax09001h on Vimeo.

What are they doing? They are ideating!! Innovating!! Changing how things are done!! Only, they haven't "ideated" just how they expect to accomplish these grand plans. This is a fabulous depiction of a company that has swallowed way too many glasses of Consultant Kool-Aid®. They are more interested in catching the next management fad than they are trusting their own observations and instincts in running a successful enterprise. The health care system is not immune from this particular form of indulgence --- in my experience, hospital corporations tend to imbibe Consultant Kool-Aid® with the gusto of a Hollywood pop tart just released from rehab.

Starting with est, it seems to me that the baby boomer generation ushered in a penchant for latter day gnosticism that has never gotten a proper smackdown --- there is no corporate or culture icon willing to call bullshit on the never-ending stream of business management fads. Large group awareness training (bullshit), neuro-lingustic programming (bullshit), Myers-Briggs (give me a break!), "team building" exercises (B.S.), personality typing based on "color wheels," ......... c'mon, let's be honest. This stuff is pure, unadulterated BS dressed up like the earnest, sweet homecoming queen from Tulia, Texas, but carrying the hidden costs and hangover of a Las Vegas marriage to a gold-digger from Highland Park (sorry, ladies, it just slipped out!).

This is, with apologies to Orac, corporate woo, or to put it in other words, the Cult of the Consultant. Unlike Indiana Jones, however, there is no self-respecting corporate leader willing to drop the whip, pull out the gun and put a bullet through its heart. I have unfortunately seen intelligent, well-meaning folks do everything short of sing Kum Ba Yah while holding hands in the name of "team building." Otherwise independent people reduced to sharing their most sheltered traumas feelings with co-workers so that "barriers can be broken down," notwithstanding the normal human need to share those experiences with only their closest companions. Adults -- ADULTS!!! -- reduced to acting like 9-year-olds on a soccer team when they are given a replica Topps® card with their name and picture on it after spending a day as "team members" of a local sports team (as if the pro teams don't already make enough dough, now they are cashing in on the management consulting BS machine). Wheeeeeeee! I have then had the opportunity to hear these very intelligent, motivated people return to the hospital, spouting whatever catchphrase happened to be en vogue at the most recent management retreat.

Perhaps in the spirit of helpfulness that is the sine qua non of the Aggravated DocSurg, it is time for me to start my own consulting firm. No, I won't butt in on the lucrative business of fleecing corporate America, I'll simply focus my energies on fleecing gullible hospital systems with my very own brand of merde du DocSurg, with a particular aim at getting as much cash as possible by putting on mandatory seminars requiring participants to sign up for Nigerian banking scams. In return, they will each get a 27 ¢ desk pen and pencil set emblazoned with one of those great motivational phrases seen on posters in cheesy mall stores: "ADVERSITY. That which does not kill me leaves me brain damaged and with one kidney." The money will fly from the corporate coffers with each new consultant phrase that comes so easily to the "scruple-challenged."

Or, I could be more altruistic, and speak the truth. It's not flashy, fancy, or anything to get excited about. But it is the truth. Most corporations --- hospitals included --- would do much better spending the grain silos full of greenbacks they now so generously pour onto new age consultant gurus on their employees and products. At the end of the day, a happy employee will be your best ambassador --- and that is particularly true in the hospital. Nurses, respiratory therapists, radiology techs, and an army of other folks interact with the customers --- i.e., patients --- of a hospital and influence their opinions to a far greater degree than any advertising campaign or feel-good management style fad ever can. Talk to them. More importantly, listen to them. And for goodness sakes, make sure they are on board with any new management scheme that you come up with. And the doctors? Treat them like business partners, not bratty third graders that need a new rule thrown at them on a weekly basis; act like you want their business, and they will return the favor.

As Edith Ann would say, "and that's the truth!"

Thursday, October 18, 2007

Domo Arigato (Mr. Roboto)

(With apologies to Styx fans)

Thank you very much, Mr. Roboto
Until the day we meet again
Thank you very much, Mr. Roboto
I want to know your secret
I want to know your secret too, Mr. Roboto, and I think I have discovered at least a part of it.

There is a tremendous amount of interest, excitement, and speculation revolving around the da Vinci surgical system. It is a fascinating piece of engineering, designed to allow minimally invasive approaches to a variety of surgical procedures. Predominantly, the use of "the robot" has been limited to cardiac and prostate surgeries, though a whole host of bright surgeons are trying to expand its applications. Plus, it looks cool --- sort of like the ED-209 with longer arms.











Separated at Birth?

I have had the opportunity to watch robot-assisted laparoscopic prostatectomy and mitral valve surgery (you can view a video on their web site), and the technology is truly impressive. Well, I'm no technophobe, so what role might Mr. Roboto play in general surgery? Will I get to play with this cool ~$1.5 million device? I'm not so sure.

A little background is in order. Laparoscopic, minimally invasive general surgery procedures have gradually gained traction in the past 15-20 years. Initially limited to simple surgeries such as cholecystectomy and appendectomy, we have seen significant advances in instumentation that now allow general surgeons to perform more complex procedures --- my practice includes laparoscopic colectomy, gastric bypass, splenectomy, Nissen fundoplication, and Heller myotomy, along with the less complex procedures noted previously. Better instruments that allow safe dissection and division of tissues, such as the Harmonic Scalpel and LigaSure, along with better endoscopic stapling devices have make most of this possible. Additionally, it is critical to be facile with laparoscopic suturing; what we routinely perform in an "open" procedure can be tedious and difficult with long instruments and a 2-dimensional video system.

The robotic system allows a surgeon to have instruments that mimic their hand movements to a very great degree. This permits the surgeon to replicate open surgery techniques using minimal access, particularly with suturing. There are some procedures that are "suture-intense," in a fashion, that have been performed with good success using the robot --- prostatectomy and mitral valve surgery are good examples --- that were not generally feasible with conventional laparoscopic instruments.

For most general surgical procedures, however, our current instruments are more than up to the task, and adding the setup time and complexity of the robot may not provide significant improvements in the things that matter most --- outcomes, OR time, and cost. This has been shown in a number of articles, including two in the most recent volume of Surgical Endoscopy. The first, entitled Robotic versus laparoscopic colectomy, comes from the Univ. of Illinois and compared 30 consecutive robotic and 27 consecutive non-robotic laparoscopic colon resections (emphasis is mine):

Conclusions The comparison groups were similar. The robotic cases were significantly longer for right colectomies because of the intracorporeal anastomosis instead of the extracorporeal anastomosis performed in the laparoscopy cases. Every cost category was higher for the robotic cases. The right colectomies showed significant increases in total OR cost, OR personnel cost, OR supply cost, and OR time cost. The sigmoid colectomies had significant increases in OR personnel cost and OR supply cost. The total hospital cost was higher for the robotic groups, but the difference was not statistically significant.
Additionally, though the difference was not statistically significant, the robotic cases averaged about 35 minutes longer --- however, the authors did not factor the lengthy robot set-up time in this analysis, which is critical when multiple procedures need to be performed in an OR on a given day.

The second study, while more favorable in some ways to the robotic approach, reached a similar conclusion. Entitled Robot-assisted versus conventional laparoscopic fundoplication: short-term outcome of a pilot randomized trial, this Romanian study compared forty patients randomized between the two approaches. Interestingly, their robot set-up time was fairly short, compared to an average of 30-45 minutes in other studies, but their operative time was shorter with the robot. Despite a trend towards a slightly faster procedure, using the robot was more expensive and no differences in outcome were found:
Conclusion In comparison with CLF, operative time can be shorter for RALF if performed by an experienced team. However, costs are higher and short-term outcome is similar. Thus, RALF can not be favoured over CLF regarding perioperative outcome.
Well crap! A cool new toy, here at my hospital, and I can't find a good reason to play with it! Why aren't the results any better in general surgery, like they are in cardiac and urologic surgery? There are a two fairly obvious reasons.
[1] We are already pretty efficient at minimally invasive general surgical procedures, with good outcomes, so a huge change would be needed to see significant improvement
[2] The robot excels at procedures requiring a large amount of suturing. We already have great laparoscopic stapling devices that have eliminated the need for extensive laparoscopic suturing. Even in a laparoscopic fundoplication, I will only be placing and tying about 6-7 sutures.
We also need to be aware of the dollars and cents --- these are expensive toys, and hospitals are unlikely to have several of them laying around for every surgical specialty to use. It makes the most sense to me for them to be utilized for those patients who will gain the maximal potential benefit from them. For now, that appears to be certain cardiac surgery and prostatectomy patients.

Oh, well, maybe I can find something else to toy around with in the OR. I wonder if they'll let me play with the Midas Rex....?

Friday, October 12, 2007

The First Day as an Aggravated MedStudent

It was a hot August morning, the first day of classes at the country's best medical school. There were about 200 of us alphabetically arranged in our seats in a semicircular lecture hall, fidgety, nervous, looking around for a recognizable face somewhere in the crowd. There were a number of Longhorns -- poor bastards -- that obviously knew each other well from their pre-med classes, but I was sort of lost. I knew that one of my college classmates was there, and finally spotted him. Thank goodness, I thought, at least I will have someone here that I can talk to. But soon I spied another familiar face. Frank! A high school classmate! What a relief.....oh shit! He is probably the smartest guy I know! He put poor Fr. Schwing through his paces in calculus, so there's no question that medical school will be a breeze for him. What the hell am I doing here?

As I sat there waiting for the Dean of Students to arrive, that question raced around my head like a greyhound chasing a mechanical rabbit. What the hell am I doing here? Everyone in this room looks so smart, so capable, so sure of themselves. Not only will I fail out, I'll probably do so before Halloween. And then, just like a kid being told to take off his Halloween mask, they will know really who I am. They will all know --- that I am a fake, that I didn't really deserve to make the cut for medical school, that somehow I slipped through the cracks and there was a colossal screwup in the admissions office.

Just as I was worked up enough to just get up and leave, in walked the dean of student affairs --- probably the most easy going, supportive person around, Dr. Bryan Williams. In a gravelly Texas drawl straight out of east Texas, he welcomed us and then did something I found to be quite amazing -- he congratulated us, and told us to be excited that each and every one of us would get our M.D. degree in four years. "Sit back and relax! You are going to be just fine," he said, and really meant it.

Dr. Williams then proceeded to run down a list of emotions that each and every one of us in the room were feeling --- that everyone else in this room looked so smart, so capable, so sure of themselves. That everyone else would succeed, and that we ourselves were fakes, waiting to be unmasked by the first difficult anatomy test. That somehow we slipped through the cracks and there was a colossal screwup in the admissions office. And then he said "Hell, that's all bullshit. We didn't accept you just to let you fail. So relax, learn something, and quit worrying. You are all going to graduate from medical school." And so we laughed, more with relief than anything else, realizing that all of us had been fidgeting, all of us felt like we had somehow made it past the admissions process purely by accident, and all of us had the same fear of being exposed as a "fake."

What about Frank? True to form, he aced everything that came his way, and now is a successful neurosurgeon. But then again, everyone that started with me that August day, save one, graduated with me four years later. I have always felt that the little speech that Dr. Williams gave is a reason for that kind of success.

Tuesday, October 09, 2007

And I Thank You

With apologies to Isaac Hayes & David Porter, who wrote it, and Sam and Dave, who first popularized it, I have to go with ZZ Top's version of "I Thank You"as the version I like the best. Maybe that's because I heard it at an ear-splitting decibel level in the old Dallas County Convention Center (now reduced to rubble) during their Deguello tour. And that's the song that always comes to mind whenever I get a "thank you" note in the mail from a patient. It doesn't happen all that often, but it never fails to make me feel pretty danged humble.

I keep a file of these notes dating back to 1994, when I first started private practice. It's a nice reminder that at one time or another, somebody took the time to write a few kind words of thanks in recognition of something that I did for them or for their family member. Sometimes, all I provided was an opinion, sometimes elective surgery, and sometimes emergent surgery. Like every other scenario in life, the outcomes were not always the best --- and when those patients or families choose to say "thanks" it means even more to me.

Now it's my turn. Somebody took the wholly unexpected step of e-mailing me to ask if I would mind being interviewed for the Wall Street Journal Health Blog. My first reaction was "How the heck can e-mail get sent to the wrong person?" My second reaction was surprise --- I never thought that any of the three or four people who read this blog might actually enjoy it! Anyway, I had a great time talking with Scott Hensley of the WSJ Health Blog, who as it turns out happens to spend a fair amount of time reading medical blogs -- mine included. He was kind enough to write a very flattering post about this blog in particular, and I suspect he will be doing the same in the future for other doc bloggers. I would just like to say "thank you" to Mr. Hensley -- with a little video from that Little Ol' Band from Texas:

Friday, October 05, 2007

Medical Bottle Rocket Training


I'm old enough to have spent entire summers goofing off with my friends, running around the neighborhood on our bikes, laying waste to our parents' homes, and setting off fireworks with complete abandon --- all without having adults constantly warning us about one danger or another. A favorite sport was spending hours setting up a field of army men, and then wiping them out with a combination of Black Cats and rubber bands. Marty, my next door neighbor, and I destroyed enough plastic soldiers that a poorly written scrawl of "army men" in red crayon was often placed on my mother's grocery list. Of course, the battle would not be complete without firing up at least a few bottle rockets.

OK, I know I shouldn't romanticize playing with fireworks; heck, where would I be today if I didn't have all my fingers? Probably I'd be an orthopedist, but that's another story. But I often think back to my bottle rocket days when a high school or college student asks about the process of becoming a physician. Why compare medical training with bottle rockets? Why not choose the classic "hard work, followed by harder work" theme? Let me try to explain.

Step 1: Light the match. Traditionally, the vast majority of students who choose the pre-med route in college need to take a single-track-mind approach. There are fairly strict class requirements, with even stricter grade demands, in order to even start the medical school application process. Of course, just like some dud matches that won't strike, some kids wash out due to lack of interest or lack of adequate grades.

Step 2: Light the fuse. Acceptance to and then attending medical school is just about the most exciting thing that can happen to a young mind. The excitement burns bright and hot, just like the bottle rocket fuse.....and it needs to, in order to propel a student through long hours of study for two years followed by longer hours on hospital wards in the last two years of medical school. Of course, the fuse is really only a precursor to the big blastoff, but it can be so much fun that we lose sight of what is to come.

Step 3: Blastoff into residency. If someone told me I could take a ride in the nose capsule of the greatest bottle rocket ever made, I would think I had died and gone to heaven. Just like a conventional bottle rocket, it expends a tremendous amount of fuel to get going and lift off; a lot of that is wasted energy --- think "intern year." Then and then the action and learning is accelerated, coming fast and furious from every direction. And once again, this was at least for me so much fun that I had a hard time focusing on what would come once it was all over. Don't get me wrong, it was also pretty friggin' hard, especially on SWIMBO.

Step 4: BOOM! The bottle rocket tops out and explodes; pieces tumble everywhere. Residency is over and real life starts --- find a job, start a practice, buy malpractice insurance, take out loans, move, sometimes marry and start a family ("my biological clock is ticking!"), experience complications that are your very own, and try to remember to breathe.

Step 5: There is no step 5. The incredible joy of the bottle rocket ride is a one-time event. The rocket topped out and blew itself into a thousand unreconstructible pieces, blown away by the wind so quickly that all that is left to remember it by is the acrid aroma of gunpowder. And that fades rather quickly as well.

If that sounds bittersweet, well, that's because it is. Once the rocket ride is over, what is left is a lifetime of medical practice --- sort of a gradual drifting through space. There are no grades to study for, no accolades to garner, no "best resident" awards to hope for. Unlike our brothers and sisters and friends who are not in medicine, there is no corporate ladder with promotions to climb, no executive VP position to covet and achieve, no corner office to angle after. For some doctors, accustomed to a life of achieving one goal or another, that's not enough. Those are the physicians driven to start their own clinics, insurance products, new techniques and instruments, and the like. The rest of us --- myself included --- have to radically change our mindset and learn to get our jollies in a different way.

It took me several years to figure this out. Slow learner, sorry. While the rapid fire excitement of medical school and training is far behind me, I have learned to enjoy the simple pleasures of talking to new patients and listening to their symptoms, of putting the pieces together to make a diagnosis and a plan, of then carrying out that plan in the operating room. There are no teachers that praise one for this, no pats on the back, no grade reports; only the satisfaction that when the skin is closed, I know that my best work is hidden where it can't be seen. And that's OK, because then every day can be its own little "bottle rocket" for me.

Monday, October 01, 2007

The Med List

There has been a tremendous amount of (frequently justified) criticism of physicians over the years for poor handwriting. Thankfully for you, I am typing this, rather than writing it out longhand, as I must admit that my own handwriting tends to get a trifle difficult to interpret as the day wears on. Prescriptions in particular seem to be a target of late, with many calling for wider use of computer generated faxes to pharmacies rather than hand written prescriptions. That's all well and good for the docs who never leave their offices and can do so, but at least half of the prescriptions I write are handed to patients in the hospital, ED, or outpatient surgery center. When I know I am having a particularly bad "hand" day, I try to print the whole thing. In 13+ years, I have been called only a handful of times by a pharmacist for clarification, but never for inability to read my writing. (hand firmly patting back)

There is, however, another side to this coin. As much as I don't mind letting people have fun at physicians' expense, I'd like to play devil's advocate and put you into my shoes for a few minutes. An important part of the information sheet that every patient fills out in my office includes a list of medications he or she is currently taking. Here's a peek at what I commonly encounter (yes, these have actually appeared in one chart or another):

Water Pill ?
Blood Pursure (sic) 60
Doxobonosin (sic) once
Breathing medicine when I need it
Aspurn (sic) every day
Diabetes ?
? ?


This is frequently preceded by a list of allergies that rivals the length of the Oxford English Dictionary, complete with a description of all the supposed allergic reactions to said medications scrawled along the edges of the paper --- "made me throw up;" "headache;" "dizzy;" "palpitations;" "didn't feel right" --- none of which can be reasonably described as a true allergy, but which will nonetheless get duly recorded as sacrosanct for all eternity in the patient's medical record.

OK. Based on what is listed, we can reasonably assume a few things. First of all, this patient has hypertension, possibly an element of congestive heart failure (although that is far from certain), COPD or asthma, and diabetes. In other words, the bases are loaded and the tying run is at bat. And I am the pitcher, who needs to throw strikes in the form of questions to keep this patient from hitting a grand slam --- which could be a potential fatal perioperative event.

So, what is one to do? A few options:

[1] Call the patient's primary care physician. This assumes that the patient actually has one, and that he or she sees them on a regular basis; not the case all too often. This also assumes that we can reach the PCP's office and get a real, live person on the phone who can send us some information. That would be, of course, the same information we requested 10 days ago when the patient made this appointment. But, as we all know, getting the phone answered between the hours of 11AM and 2PM is damn near impossible, and after 4PM maybe out of the question.

[2] Call the patient's pharmacy. Er, which one? The one around the corner from their home, the one in the hospital, the one across the street from the hospital and the local VA pharmacy are all potential suspects, and frequently patients utilize more than one.

[3] Ask what each pill is for. Unfortunately, this request can be met with nothing more than a recitation of "I take a little blue one in the morning, a white one and a purple one at noon, and then three more at night." Nice, but not helpful.

[3] Ask the patient to actually bring in their medications at the time of their next visit, which in my case is generally a preoperative visit. Be specific. Actually state "BRING IN THE BOTTLES" so that you will know what they are supposed to be taking. This is different than what many actually are taking. You will find that many of the bottles date back to the Carter administration, but the patient may state that they still take one of those little pills every once in a while.

[4] If you have opted for approach number three, there is one more important thing to do: pray. Pray that the patient is not on Coumadin, in which case you will need to cancel the planned operation and deal with anticoagulation issues. Pray that if he is prescribed Coumadin, he is actually taking it --- it's not handed out willy nilly. Pray that most of the bottles have the same physician's name on them, because polypharmacy is a can of worms that can take months to sort out.


While electronic medical record systems may help with this situation, they will never be a panacea. Different systems will not interface well at first, and everybody --- doctors' offices, clinics, hospitals, and every pharmacy --- will need to be able to access the same data set. Finally, as I've alluded to, not every patient is follows their prescriptions like a Marine following orders.

If you have gotten to the end of this without falling asleep, you may be wondering about the terribly sloppy physician handwriting samples above. The first came from the hand of a certain psychiatrist of some notoriety, and the second was written by the father of modern medicine. I suspect that were they around today, some clipboard-carrying JCAHO nurse would demand that they have their hospital privileges suspended for poor handwriting.