Sunday, March 30, 2008

Pucker

Having explored what attributes help make a successful surgeon, I thought I'd add a word on what makes a good general surgeon. And that word is pucker.

No, not the "pucker up" kind of pucker.

Not the "best brown-noser in the world" kind of pucker (for those of you in the corporate world, these do exist in the medical arena as well).

Not even the "I'm so strange I walk around looking like this" kind of Dali-esque pucker.

I'm talking about good old fashioned tight sphincter tone. Anal retentiveness. An absolute obsession with getting the details, and getting them right. Maybe for me this comes from an abnormally young exposure to Vonnegut's Breakfast of Champions, which prominently featured a crudely drawn picture of an anus. Or maybe, I'm just anal retentive.

Freud, who must have been rather obsessed with these sorts of things himself, described those with an "anal character" were meticulous, parsimonious, and obstinate. Those qualities, as detrimental as they may be in interaction with others generally, are of particular help to a general surgeon.

Now, some nurses and physicians reading this may have just spewed their coffee on their keyboards; e-mail me, and I'll see about getting you a replacement. General surgeons? Those guys who walk into a patient's room and poke on their bellies for 12.6 seconds on average, and then announce it's time to head to the OR? "Surely, DocSurg, you're joking!"

Well, Lucy, let me do some splainin'. You see, before I waltz into the room in my oh-so-comfortable shoes, I have

  • read the chart
  • read the old chart, if it exists
  • reviewed the x-rays
  • found the lab results
  • talked to the referring physician
  • had a few martinis cups of coffee
Making a decision to go to the operating room is often fairly easy. What can be hard -- and I mean truly taxing -- is trying to decide when not to go to the operating room. I know that sounds a bit backwards, but sometimes a decision to hold off on opening somebody's abdomen means there is a potential to miss something. So, it's important to get one's ducks in a row, and that means preparing with all of the available information.

Note that I said "available" information. Sometimes, there's a whole lotta missing data, and a decision must be made about how to manage a particular patient. This is where the sphincter starts to pucker a bit. Because sometimes, after going through everything and examining the patient, what to do remains somewhat cloudy. There is an expression that surgeons use from time to time to describe this situation: "I don't know if operating now is the right thing, but it is certainly not the wrong thing."

Throw in a few compounding factors and it starts to feel like your next BM will happen on a cold night in August. Sick patient. Anticoagulation. Bad heart. COPD. Morbid obesity. You get the picture. It is important to make sure that nothing is missed or forgotten in the evaluation of a patient, or you end up feeling like the guy staring at Popeye Doyle at the end of The French Connection. Oh, merde!

But, to be honest, that is really only the start of the puckering process. In the OR, no stone can go unturned, no potential problem left unexplored. This is true for routine, as well as complex and emergent surgeries. And then, for the truly ill patient, all sorts of things need to be tended to after surgery--- and a general surgeon must rely on his or her own self, not abdicating things like looking at all of the labs or X-rays to other consultants that may be involved. This is where the "meticulous, parsimonious, and obstinate" personality comes to the forefront. Because if you make the decision to operate on a patient, in a sense you "own" them and it is your responsibility to get them out of the hospital in better shape if at all possible.

Pucker. Attention to detail. Rechecking the anastomosis before closing. Calling to check on the sick postop patient, even though you are not on call and you know full well that your partner, who is on call, is perfectly capable of dealing with anything that arises. Answering pages. It all leads up to pucker, pucker, and more pucker. And since we deal with the "end" result of too much pucker (sorry about the bad pun), as much as I love my dog, I have to say that a general surgeon's best friend comes in a jar:
Think you have enough "pucker" to be an anal retentive general surgeon? Find out with these handy dandy quizzes.

Heart Pounding Mountain Biking; Heart Stopping Falls

Sweat. Dirt. Rocks. Great scenery. What's not to like about mountain biking? But, it's important to get the right gear --- and, of course, look good in and on your gear. For example, this could be me:
Of course, the guy on the Gary Fisher HiFi is not a fat bastard with a 9 year old hard tail Specialized bike, but really, it could be me! The trauma surgeon in me makes a mental note of a few things that may not jump right out at the average person. First and foremost, this guy is wearing a helmet. I can't tell what brand it is, so let's say for the sake of argument it's a Giro Havoc.
Cool helmet. Stiff, wraps around the skull well. And, let's face it, it looks so good it could even make a fat bastard feel like he could ride Trail 401 in Crested Butte without sweating. Why, there is even one of these helmets at the DocSurg Pool Hall, Massage Parlor, Outpatient Brain Surgery Center and BBQ Joint.
The last time I saw this particular helmet was as I drove off to run a few errands with the lovely and talented Mrs. DocSurg. It was perched atop my son's head, strapped on tight, as he rode off up the hill on his way to race around in the dirt with a friend. In fact, he had insisted I buy this particular helmet, because he liked the way it covers the back of his head better than others he tried.

Look a bit closer, however, and you may see a few disturbing features.
The brim is not attached to the helmet in the way it should be. No big deal, that could happen if he dropped it. As long as the helmet is otherwise intact...




But, look a bit closer. There looks to be a little crack above the left ear. An inspection of the other side looks the same.

Er. Not good. The kid must have really dropped it, and now I get to drop another $64 for a new helmet. Better safe than sorry --- any break in the helmet renders it useless.


Except, that's not what really happened. The whole truth goes something like this. Imagine having a day off --- with all of the honey-dos and errands that entails, but starting it with a relaxing breakfast with SWIMBO at a nearby restaurant. The youngest surgling, who is such a mountain biking fanatic that he rides the neighborhood with weights on his legs to get stronger (honestly), has been dropped off up the hill with a friend for a few hours of bike riding. And then imagine that SWIMBO realizes her cell phone is dead as we pay the check, and plugs it in the charger once we get back in the SurgMobile. And it rings. Instantly.

Now imagine the heart-stopping words "Your son is being put into the ambulance right now."

Wait a minute. I know this stuff. Cold. I see trauma patients, I know what can be going on, and what is likely to have happened. But this is my son, and it's a bit hard to stay that analytical.

The EMTs that brought him to the ED handed me his helmet.
It's hard to get a perspective, but compare it to the side view of a similar helmet. The whole back is caved in. And that is exactly what is supposed to happen. That is, of course, if you happen to go flying head-first over your handlebars and smack the back of your head on the rocks. If you happen to like that sort of thing, which apparently Mr. Surgling does.

The most recent photo featuring this helmet comes from two days later, as he modeled it for his sisters.
You may notice a few bandages on his arm. They are hiding a few pieces of metal holding his radius in proper position, courtesy of one of my favorite hand surgeons. Just in case he wants to go riding again. Which he does, since we have arranged a biking trip in the Black Hills for late June. Which, of course, means that I'll be shelling out a few more dollars for a new helmet.

But this time, I'll do it with a smile, and not say a word when he asks for one with more protection.

Sunday, March 02, 2008

The "A's" Have It

Back in the Dark Ages (i.e., when I was in training) it was said that the most important attributes a surgeon could have in order to be successful were:

  1. Availability
  2. Affability
  3. Ability
Specifically, ability was felt to be the least important of the requirements for a referring physician to send a surgeon patients. Sort of sounds backwards, don't it? Well, let's ruminate a little.

AVAILABILITY -- from the adjective available (American Heritage Dictionary):
  1. Present and ready for use; at hand; accessible
  2. Capable of being gotten; obtainable
  3. Qualified and willing to serve or assist
In the surgeon's world of the past, this meant being readily on hand, reachable, and quick to respond when asked to see a patient. "Capable of being gotten" means keeping your beeper on -- and answering it. And, of course, being "qualified and willing to serve or assist" should be the hallmark of a good general surgeon.

AFFABILITY -- from the adjective affable:
  1. Pleasantly easy to approach and to talk to; friendly; cordial; warmly polite
  2. Showing warmth and friendliness; benign; pleasant
Hmm. "Showing warmth and friendliness." "Pleasantly easy to approach." Sort of a non sequitur with the words "Aggravated DocSurg " -- what am I supposed to be, a golden retriever? Well, let's be honest. These are not terms generally applied to most surgeons, but they are critically important. Let's face it, would you rather be operated on by an extremely capable jerk, or a capable and caring one? Most referring physicians certainly choose the latter. Being pleasant to referring physicians, nurses, and referring docs is not only good for everyone involved, it also makes plain old good bidness sense.

ABILITY -- the least important of the "3 A's":
  1. Power or capacity to do or act physically, mentally, legally, morally, financially, etc.
  2. Competence in an activity or occupation because of one's skill, training, or other qualification
  3. Abilities, talents; special skills or aptitudes
"Capacity." "Competence." "Special skills" -- sort of like the kind Napoleon Dynamite wanted. In short, you gotta be able to operate your way out of a paper bag, or you are in the wrong field!

OK. All three of the "3 A's" are important, and are likely to remain so for the foreseeable future. In exactly the same order.

"WHAT!!??? I'm shocked! Why DocSurg," you ask, "with the overwhelming push to measure patient outcomes, evaluate complication data, and compare costs generated by physicians are the "3 A's" likely to stay in the same order?" One would expect that a surgeon's ability -- his skill in caring for patients, his cost-effectiveness, his shorter-than-average length of stay, or whatever yardstick with which one chooses to measure -- would inevitably rise to the top of the list. In fact, one could argue that ability should already be numero uno, and for goodness sakes, why hasn't Ms. Hillary already made it so?

Sit back and let the Aggravated One explain it all to you. The reason that availability is so important to referring physicians is that when they need the assistance of a surgeon --- right away --- the guy that will answer the call ASAP will be the answer to their prayers. A busy internist, family practitioner, or gastroenterologist doesn't have the time or patience to try to track down a surgeon; this is especially true today, when these docs are busting their humps with a huge load of patients in the office just to make a living. Traditionally, being available for emergencies, "curbside consults," or questions was subsequently rewarded with elective surgical business. Think about it this way --- ever had a major leak in your house? The plumber that answers the call and comes quickly to help is the guy you are going to call when you need a new water heater or sinks replaced when your wife decides it's time to redo the bathroom.

Affability? Using our plumber analogy, if the "emergency plumber" turns out to be rude and obnoxious, you're probably going to go back to the Yellow Pages next time.

What about ability? This is the trickiest to explain. I know a little about plumbing, but I'm no plumber. If my favorite plumber does some work at my house, and it looks good, I'm going to trust that he did a pretty good job. And if what he is working on started out as a disaster, and there are a few problems along the way, I'll pretty much feel the same. I could say the same about a cardiologist or a neurosurgeon. That's the way it is for most busy internists and FPs, especially now that few of them come to the hospital any more.

"But! But! But DocSurg, Ms. Hillary and Mr. Obama and Mr. Stark and Mr. Grassley and Mr. McCain and all of the yahoos that run insurance companies promised! They promised you would be graded, evaluated, measured, probed, and rated at each and every turn! Surely, ability will soon be at the top of the heap!"

Er, no. Not really. Because of the fourth "A" --- adaptability:
  1. The ability to change (or be changed) to fit changed circumstances
You see, the successful surgeon of the future --- nay, the successful physician of the future --- must be imminently adaptable. Quick on their feet to make sure that they are fully compliant with every mandate passed by Congress and any other Borg-like regulatory agencies. Nimble enough to dance to the tune of a slew of paper-pushing high school graduates who will churn the numbers of a myriad of physician "quality measurements" (trust me, they are not going to hire a fleet of high priced CPAs, economists, or even math majors to evaluate your physician's care). And ready and willing to keep their own statistics, to ensure that any perceived deviation from local, national or regional arbitrarily determined standards can be demonstrated to be false.

Adaptability will last, for a while, at the top of the list, with "ability" relegated to fourth place. But, I'm sad to say that with a continual loss of market forces, of which only a pittance remain, any emphasis on quality of care will be in name only. We are driving down a road which now has almost no exits left, where I suspect ability, availability and affability will soon be sacrificed to the ultimate "A":
AFFORDABILITY

And then we are all, well you get the picture....