Again?

"Would you do it again?'

That was a frequent question this weekend at my medical school reunion. The answers were, surprisingly, a pretty uniform "yes." Everybody had a qualifying "but" to add, but affirmed their initial decision to go to medical school in the long run.


Which leads me to the next question --- why? Why go to medical school back in the late 80s, knowing what we know now, with the future of medicine not looking terribly bright? I think a clue came from listening to the fond memories we shared of our time at The Best Medical School in the Country®. It was fun. It was like sipping a fine wine with friends --- if you like to sip your wine from a fire hose.

College, for me, was like sipping a glass of wine, or drinking a cup of tea on a nice sunny morning. Relaxing, enjoyable, with the time to savor the experience. Medical school? Oh, it was a wee bit more involved. The increase in workload over college was pretty substantial, with a torrent of information to get through, absorb, understand, and have on hand to regurgitate on a moment's notice. As a result, there was no time to savor the experience --- we were all furiously drinking as much as possible from a fire hose, knowing all the while that every time we stopped to take a breath massive quantities of important information blew right by us, never to be seen again.

What made that seemingly impossible situation fun was that we were all in it together. A shared experience with like-minded folks under pretty intense pressure tends to bring out the best in people, be it their humor, humility, graciousness, or interest in helping others. I have closer friends from those 4 years than from any other part of my life, people who I can (and have) see once every decade and enjoy their company as if we had just seen each other yesterday.

So, yeah, I'd do it again. In a heartbeat.

Besides, you really wouldn't want to be reading a blog called "Aggravated CarSalesman."

We Don't Speak the Same Lingo

Hello. I'm a Hospital Administrator.













I'm a Doc.

A what? You aren't wearing your photo ID badge --- that's a JCAHO violation! What exactly do you do here?

You know, doctor stuff. Take care of patients, that sort of thing.













Uh, anyway, dude, I haven't met you before --- how long have you been here?













Oh. I just got here 6 months ago myself. Straight from my last 3 year stint at another hospital. Who exactly are you again?













Aggravated DocSurg. I'm a surgeon. I've been here for 15 years, taking care of a big chunk of your patients. Surely you've at least heard of my partners and I since you came here.












........













OK. What is it that you do?














I maximize profit! I integrate the system! I public-key zero administration functionalities! I help develop the innovative dedicated matrix!












Dude?

By utilizing adaptive encompassing functionalities, I hope to develop a business-focused tertiary local area network consisting of a team of associates and providers!

Associates? You mean you are bringing in other hospital systems to work together?













Ho, ho! That's a good one! No, silly, "associates" is a euphemism for employees! We think it makes them feel more valued. Everybody is an associate -- nurses, CNAs, techs, etc. Well, everybody but us. We're administrators. We, well, administrate!









And providers are.....?











You! Don't you feel valued now, Dr. .....?











Billroth, Theodor. Come on, dude. How about this --- I'll feel "valued" if perhaps we can discuss ways to make patient care better here. You know, spend a little dough on things like improving staffing, buy a few new sets of OR instruments, that sort of thing. Maybe even we could talk about how to streamline patient processing, so it doesn't take 2 hours to get someone registered for outpatient surgery and another 2 to get them discharged. That way, I'm happy, the staff is happy, and the patients are happy --- and then you should be happy.

Uh, well, see, that's not what our consultants told us to do. The consultants told us that we needed to focus on improving our food. And that we need to buy another robot. We value their input, Dr. ..... er, what did you say your name was?










DeBakey, Michael E. You know, another robot isn't going to help you with the majority of your patients. How about adding a few new ORs and increasing the number of staff in Admitting to help get folks registered ---- you even had some consultants tell you that!










Well, that's what last year's consultants told us! Ha, what a hoot! You don't expect me to go by last year's consultant report! I just got here 6 months ago!

No offense, but, that's sort of silly. Why spend the money on consultants just to ignore their advice?

So that we can keep hiring them! That way, I'm eventually assured of a job with a consulting firm!

Ooh. Strike that. Wasn't prudent to say, Dr. ......










Halsted, William Stewart. OK. Let's try talking about something else. I think it would be good for the morale of the staff --- sorry, associates --- if they actually saw administrators around in the evenings and weekends every once in a while. You really can't appreciate how hard certain arbitrary rules can make things on the associates until you see the tornado effect of a major trauma in the ED and OR, for example. While I certainly don't claim to be an administrator, I do have some insight into your world from the meetings I attend with you.






Ho, ho! Another good one. You really are a laugh a minute, ...... er, what was your name?











Schweitzer, Albert. Let's try a few simple questions. Why do I and all of your associates have to change our computer passwords every other Thursday and whenever the cafeteria serves pasta for lunch?










JCAHO.












And why are there 6 different versions of the surgical consent form in the hospital, dating back to 1978?











JCAHO.













OK. What is the reasoning behind hiring two new nursing administrators for the ED and GI lab, but decreasing staffing by 15% in the same areas?













JCAHO.













What day is it?













JCAHO. HIPAA. JCAHO. HIPAA. JCAHO. HIPAA. JCAHO. HIPAA. JCAHO. HIPAA. JCAHO. HIPAA. JCAHO. HIPAA. JCAHO. HIPAA. JCAHO. HIPAA. JCAHO. HIPAA. JCAHO. HIPAA. JCAHO. HIPAA. JCAHO. HIPAA. JCAHO. HIPAA. JCAHO. HIPAA. JCAHO. HIPAA. JCAHO. HIPAA. JCAHO. HIPAA. JCAHO. HIPAA. JCAHO. HIPAA. JCAHO. HIPAA.








Gotcha. Loud and clear. Let me turn on my Bullshit generator and see if it helps......Accelerated policy solutions! Synergize mission-critical networks! Orchestrate enterprise partnerships! Did that help?

Whoo! Thanks! Nothing like a good jolt of industry buzzwords to get me back to myself! JCAHO and HIPAA on the brain, dont' ya know, 24 - 7.











I think it's pretty clear we don't speak the same lingo, 24 - 7. But I'll try one more time. How about a martini?












Gotcha. Loud and clear. Are you buying?

A good way to start a day on call....

Created by OnePlusYou

The Five People You Don't Meet in the Hospital

Quick --- name the five types of people you meet in a hospital! Almost everybody comes up with the same answers:

• doctors
• nurses
• nurses' aides
• the folks doing the paperwork
• "techs" -- respiratory techs, X-ray techs, lab techs, etc.

Well, I'm going to let you see a little bit more of the hospital. Let me introduce you to The Five People You Don't Meet in the Hospital®, the people who work (hard) behind the scenes to make sure things go well for you in ways that are not always apparent.

• The dietary staff --- cooks, dishwashers, dietitians, etc. These are the folks in charge of getting you that much maligned hospital food. Green Jello! What a treat! In reality, they do the best with what they have, and are usually the most cheerful crew in the hospital.

• The pharmacists --- miracle centers need to have miracle drugs, and these guys are in charge of purchasing, measuring, mixing, and delivering said miracles. They are there 'round the clock, and their responsibilities include double checking folks like me to ensure my patients get the right doses of the right meds at the right time. In. Di. Spensable.


• The Medical Records staff --- let's say you take Granny to the ED at 10PM, and Granny has been in the hospital 3 times in the past few years, and she takes enough medications to clog a downspout. But, let's be honest, you really aren't sure whether she had a cardiac catheterization or an echocardiogram last fall, and those medications are all in her medicine cabinet. How is a hard-working ED physician or nurse to figger that stuff out? The send out an SOS to Medical Records, and some poor soul has to search through a warehouse of charts that could swallow a blue whale and come up with the right one. Voila! And for my next trick, I shall pull a rabbit out of zee insurance executive's nether regions! And, please, don't harbor the illusion that electronic medical record systems are on their way to eliminating these folks -- that's a pipe dream smoked mainly by politicians.


• OR Techs/Scrub Nurses --- I have a soft spot for the members of the operating room crew, which should come as no surprise given my line of work. However, I'm not only the President of the Surgery Club for Men, I'm also a customer! To date, I have had sharp instruments plunged into my body 6 times, so I am acutely aware of the need for a competent group of folks helping with surgery. Having surgery early in the morning? Late afternoon? Middle of the night? These guys are there and ready. This is generally, without a doubt, the most fun group of hospital employees with which to "hang" (sorry, ED crew -- you're way overexposed on TV anyway).
  


• Last but certainly not least, the Housekeeping and Maintenance crew --- without a doubt, the least appreciated members of the staff, they tend also to be the most quiet, unobtrusive, and efficient group as well. The hospitals and EDs in my town are chronically overcrowded --- as quickly as one patient leaves another needs the same slot, putting pressure on the housekeepers to get the rooms cleaned and ready to be used as rapidly as possible. The hospital is nothing if not a high traffic area --- it often reminds me of DFW airport --- and does not have the luxury of having areas or equipment that is not usable, so the maintenance crew is constantly busy. Both groups deserve our thanks and kudos for a job well done.

Several years ago, working late on a weekend night, one of the private practice surgeons involved with our training program remarked that he felt that his closest friends in the hospital were not the other doctors, they were the folks listed above. Those of us who spend our waking (and often sleeping) hours in the hospital should do our best to earn their respect.

Mark Twain and Bikinis

Statistics are funny things. They can be manipulated, to be sure, in a manner not unlike an impressionist painting -- to give an impression of the facts, without an accurate rendition of the same. For the artist, this allows a wide range of expression and resultant interpretation on the part of the viewer. For the person generating statistics, it allows all sorts of shenanigans, whether intentional or not, that can result in dissemination of "facts" that are a bit shady. Unfortunately, we see this from a variety of sources in medicine today, with reams of data being mined, folded, twisted and mutilated to generate a given data set to support a particular position....or particular advertisement. A couple of recent articles may help illustrate this dilemma.

What Constitutes a "High-Volume" Hospital for Pancreatic Resection is a study from Johns Hopkins, itself an excellent facility with a very high volume of pancreatic surgery for malignancy. Basically, these folks looked at a five year collection of data from the Nationwide Inpatient Sample (itself a sampling of 20% of hospital discharges) to evaluate mortality rates for pancreatic resection --- with an eye towards determining some threshold below which mortality increased. The results (from the abstract):

Based on analysis of 7,558 patients who underwent pancreatic resection, median annual institution resection volume was 15 (range 1 to 254), and overall in-hospital mortality was 7.6%. The best model of “high-volume” centers was an annual institution resection volume of 19 or more, as determined by goodness of fit (r² of 5.29%). But there was little difference in data variance explained between this best model and other “high-volume” models. The model without any volume variable had a goodness-of-fit r² of 3.57%, suggesting that volume explains less than 2% of data variance in perioperative death after pancreatic resection.

Let me repeat. "(surgical) volume explains less than 2% of the data variance in perioperative death after pancreatic resection." The best model that fits with the data is defining "high volume" centers as those that perform 19 or more pancreatic resections per year --- hardly what an outside observer would The conclusions of the authors :

Very little difference was observed in the explanatory powers of models of “high-volume” centers. Although volume has an important impact on mortality, volume cut-off is necessary but insufficient for defining centers of excellence. Volume appears to function as an imperfect surrogate for other variables, which may better define centers of excellence.

Hmm. For the last several years, we have been treated to a variety of articles and policy proposals aimed at creating "centers of excellence" based upon the idea, and some supporting data, that higher volumes of certain surgical procedures leads to better outcomes. But when trying to retrospectively identify the threshold for what is "high enough," the data here don't match up well with the preconceived notion. Oops. As much as I suspect this same result might be seen if we looked at other procedures proposed to be regionalized into high volume centers, I don't expect the captains in charge of this ship to change course. My translation of this study's conclusions would read a bit differently --- we can't show that there is a volume threshold, but we still think it's important, so we'll find something else to focus on to prove our point.

OK. Bear with me. More statistics, but I promise not to have a quiz at the end. The next article is actually my favorite kind of journal piece -- it validates common sense and sticks it in the eye of folks who manipulate statistics inappropriately. Entitled The Zero Mortality Paradox in Surgery, it addresses the way data can be carved out to create a favorable impression of an institution.

Every surgeon knows that their next potential complication is only an operation away. Every surgeon has also seen journal articles touting things such as "2,000 consecutive whole body-ectomies without a mortality" --- which basically mean that the authors identified their two most recent deaths with a particular operation and counted the patients in between. Well, hospitals play that game too, and tout their successes with zero mortality in certain procedures in given years. These authors went a step further, and looked at such institutions in the years following a run of zero mortality for certain operations (from the abstract):

We obtained national Medicare data on five operations with high operative mortality (> 4.0%): coronary artery bypass grafting, abdominal aortic aneurysm repair, and resections for colon, lung, and pancreatic cancer. For each procedure, we defined zero mortality hospitals as those with no inpatient or 30-day deaths during the 3-year period 1997 to 1999. To determine whether these hospitals actually have lower mortality than other hospitals, we compared their mortality during the next year (2000) with the mortality at all other hospitals.

Now, to be sure, these are good institutions with an admirable track record --- lower than expected operative mortality for some pretty major operations. However, they soon came back down to earth :

For four procedures, operative mortality in zero mortality hospitals in the subsequent year was no different than that in other hospitals: abdominal aortic aneurysm repair (6.3% zero mortality hospitals versus 5.8% other hospitals; (adjusted relative risk [RR]=1.09; 95% CI 0.92 to 1.29); lobectomy for lung cancer (5.1% versus 5.3%; RR=0.96; 95% CI 0.80 to 1.15); colon cancer resection (6.0% versus 6.6%; RR=0.91; 95% CI 0.80 to 1.03); and coronary artery bypass surgery (4.0% versus 5.0%; RR=0.81; 95% CI 0.61 to 1.04). In the case of pancreatic cancer resection, zero mortality hospitals had substantially higher mortality than other hospitals (11.2% versus 8.7%; RR=1.29; 95% CI 1.04 to 1.59).

What goes up, must come down. Every run of good luck comes to an end. Use whatever cliché you'd like, but a zero mortality rate for these types of procedures is a laudable but impossible goal to achieve. Or, as my stock broker likes to say, past results are not necessarily indicative of future performance.

OK. I lied --- it's quiz time!

Question: What did we learn with this little dip into the statistics whirlpool?
Answer: Statistics are like bikinis. What they reveal is suggestive, but what they conceal is vital.

Question: So, how is the unsuspecting public supposed to interpret these kinds of studies?
Answer: With a jaundiced eye. As Mr. Clemens famously stated, there are "lies, damned lies, and statistics." The trick is to ensure you know as much about the data being presented as you can in order to interpret the results.

Question: Does all of this mean that we shouldn't believe data in medical journals?
Answer: Absolutely not. It is important to accurately assess things such as morbidity and mortality, and honestly look at data that show where we can improve. However, creating public policy or planning advertising campaigns based upon such data can prove to be a bit of a problem, because future data can turn around and bite you in the rear.

Give Me Twenty (-twenty hindsight)

Twenty years is a mere blink to the elderly, a sizeable chunk of time to the middle-aged, and an unfathomable span to the young. As of the end of May, it it also represents the length of time I will have been able to write "M.D." after my name. In a few weeks, I'll travel to Dallas to attend my 20 year reunion with classmates at The Best Medical School in the Country. We'll probably end up sitting around a table with a bunch of margaritas, bitching about what ails "Medicine" presently, complaining that the young whippersnappers being trained today don't have any appreciation of how hard we had it in our day, and generally starting to look and sound like the old farts we are becoming.

Twenty years after graduating from medical school, I'll be 46 years old, and I'll probably be looking at another 20 years in practice (unless I miss my bet and the government doesn't take over health care in this country, in which case I might be able to retire at around 62). So, let's call this the halfway point of my career, which means that I am legally allowed by The Society of Disagreeable Olde Men to start giving the type of advice that can only be gained by the use of a complicated instrument, the retrospectoscope.

The retrospectoscope is a curious device, made available only to us older types, and is mainly used by the male of the species. It allows us to say things like "Trust me, I've made that mistake before;" "Don't do it! You'll regret it;" and "You'll put your eye out" with a straight face. So, now that you know that this represents the beginning of the end of my mental faculties, let the Aggravated DocSurg Twentieth Reunion Hindsight Advice Delivery begin:

• Listen -- listen to your parents, to your teachers, to your friends' parents, to anybody that is giving you any type of information or advice. You never know when it will come in handy or be comforting.
• Smile -- it puts people off guard.
• Read -- as much as you can.
• If you are married, give thanks every day that she has the patience to stay with you.
• If you have children, give thanks every day that no matter how bad you think you've screwed up, they are the best part of you.
• Thank your parents. Often.
  
• If you are a doctor (this is a medical blog, after all), be nicer to your patients than to hospital administrators or insurance folks. They are why we went to medical school in the first place.

That's it. That's the sum total of what I have learned as a surgeon in the past 20 years that can be put into little soundbites. I only hope I can put a bit of it into action in the next 20.

Oh, and one more little thing. I happened to get married just before I graduated. SWIMBO may be in the mood for an anniversary present, and I've been advised that a gray flannel nightgown is, well, not the best option. Suggestions are, therefore, most welcome.

Marching Orders

Well. I've been promoted. Given a raise in pay grade. Get to wear a fancy uniform (great way to get chicks, BTW). Rodger (The Real King of France) has named me Surgeon General of the Barn Army. If you don't quite get what the Barn Army is, check it out.

While taking care of the actual wounded is what I do best, my barebones psychiatric skills may come in handy with this bunch. Best advice I can usually hand out in a psychiatric emergency is "take two martinis and call me in the morning." However, this newly minted position does give me the interesting capability of giving a few marching orders, so here goes:

• Quit whining.
• If you're over 50, get a colonoscopy --- and quit whining about it!
• Work hard -- nothing good ever came from laziness -- and quit whining about it!
• If you aren't going to take your prescribed medications or follow a physician's recommendations, at least be up front about it --- and don't whine if you have problems because of it!
• Smile, at everybody. It'll lower your blood pressure, and make everyone else feel better. Those that it doesn't make feel better are probably a little off kilter, so it gives you an idea of who to avoid.
  

There ya have it. The first in a series of edicts, to be followed strictly and taken with a large helping of NaCl.
At ease. (That means you, too, Richter).

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.

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....

Top 10 Doctor Movies

The lovely and talented SWIMBO convinced me to watch the Oscars last night. Sort of interesting, because the last time I watched, Daniel Day-Lewis won for Best Actor. Anyways, it got me to thinking --- with all of the "top ten" lists wandering around in cyberspace, there doesn't seem to be one for doctor movies. So, without further ado, here is The Aggravated DocSurg Top 10 list of movies about or otherwise concerning doctors:

10. Master and Commander -- Paul Bettany was cast well as the ship's physician in this well done movie which didn't get as much praise as I thought it deserved. There's a gruesome amputation scene and another where the surgeon must operate on himself --- that's enough to put it on the list in my book.

9. The Last King of Scotland -- This movie won Forest Whitaker an Oscar for Best Actor (deservedly), but James McAvoy's portrayal of a young, idealistic yet opportunistic personal physician to Idi Amin is superb.

8. The Hospital -- This movie does not hold up well, unless you are terminally trapped in an early '70s mindset, but George C. Scott's performance is magnificent. It's worth watching just to remember what a great actor he was.

7. The Andromeda Strain -- Written by a doctor (Michael Crichton), with a "medical" theme that is well done and certainly better than many of its imitators. While not as good, another sci-fi flick from the same era that merits mention is Fantastic Voyage --- if only for the fact that it has Raquel Welch prominently displayed in a wet suit.

6. Alien -- technically, since he's not human, I suppose Ian Holm's character "Ash" isn't a doctor, but he certainly is the ship's medical officer. Besides, it's a great depiction of parasitology -- so good, that one of my professors at the country's best medical school , an infectious disease specialist, used its now-familiar scene to introduce his lecture on parasites.

5. Malice -- This movie has over the top acting, a confusing plot at times, and one of my least favorite actors on the planet. It also contains the only scene in any movie that made SWIMBO almost cough up her popcorn --- when, in a ridiculously darkened OR, the nurses clap (CLAP!) after the surgeon finishes a difficult case. But it has a devilishly good streak of revenge, and one simply cannot go wrong spending two hours gazing at Nicole Kidman.

4. The Painted Veil -- I thoroughly enjoyed this movie; a bit of a tear jerker, to be sure, but a beautifully filmed story of love and loss, with the background of an English bacteriologist dealing with cholera in Shanghai. Great acting, beautiful scenery, and a good story.

3. M*A*S*H --- what, you think I'd leave off the list the most irreverent look at surgeons ever put on film? Great, if dated flick, with at times a pretty fair depiction of "surgical humor." And lines like these are classic:

Capt. Peterson: What are you two HOODLUMS doing in this hospital?
Hawkeye: Ma'am, we are surgeons and we are here to operate. We just waiting for a starting time. That's all.
Capt. Peterson: You can't even go near a patient until Col. Merrill says its ok and he's still out to lunch.
Trapper John: Look, mother, I want to go to work in one hour. We are the Pros from Dover and we figure to crack this kid's chest and get out to golf course before it gets dark. So you go find the gas-passer and you have him pre-medicate this patient. Then bring me the latest pictures on him. The ones we saw must be 48 hours old by now. Then call the kitchen and have them rustle us up some lunch.
[turns to Hakweye]
Trapper John: Ham and eggs will all right.
[turns back to Capt. Peterson]
Trapper John: Steak would be even better. And then give me at least ONE nurse who knows how to work in close without getting her tits in my way.

Try saying that in a hospital today! Somehow, I suspect you'd be on your way faster than you could say "incoming!"

2. The Doctor -- this movie had me sold on it in the first few minutes, as William Hurt waltzed from OR to OR, being serenaded by Jimmy Buffett on the stereo. Been there, done that. And, unquestionably, there are times I have been just as self-assured and arrogant as he was at the start of the movie. This is a great movie, IMHO, for every physician to see.

Now, of course, comes the moment you have been waiting for..... the Aggravated DocSurg's number one doctor movie:

1. Doctor Zhivago -- what!? Look, it's one of the top 10 movies ever made, in my opinion, and, well, he is a doctor! Plus, it has that most important "Aggravated DocSurg ingredient" -- Julie Christie! I grew up watching this movie every year on TV, and never tired of looking at her eyes.

So, what have we learned here? Not much, except that I fully admit I can't take my eyes off Julie Christie or Nicole Kidman. There is a simple reason for that:

SWIMBO

(And I am a lucky man)

Any movies I missed? And, please, do not add Patch Adams to the list!

The Michelin Man, The Balloon, and the Harpoon

You know how some folks get when they see a pile of bubble wrap? They are drawn to it like Odysseus was drawn to the Sirens, can't keep their hands off it....pop, pop, pop, pop, pop.....Such is the case with subcutaneous emphysema.

SQ emphysema is kinda cool, unless you are the one with the problem. Basically, it occurs when air escapes from some portion of the respiratory tract and instead of staying within the chest cavity, it works its way into the subcutaneous tissues. I see this most frequently with blunt trauma to the chest, which causes a tear in the lung or even part of the bronchial tree. The air can track along the chest wall, into the neck, and even down along the abdomen or up into the face. With each breath, more air can escape, and in some cases the patient starts to look like Bibendum.

So, what's the deal with bubble wrap? Well, pressing on the area of SQ emphysema yields a crunchy but soft sensation .... sort of like popping bubble wrap. It can be for some sort of irresistible; since we don't see it every day, all of the students or young staff in the area wants to see what it feels like. The technical name for this is popping sensation is crepitus, but that term covers a wide variety of other processes that generate a vibratory and auditory sensation under the skin. (Image from Learning Radiology)

As dramatic as SQ emphysema in a trauma patient sounds, in many cases it can be an indicator that the patient's respiratory status will be OK, at least for a short while, without an immediate chest tube insertion. This is because the air that is leaking is making it's way out of the chest cavity. When air leaks from the lung or bronchial tree into the chest, and the leak persists with each new breath, then we've got a problem. In that situation, the air that escapes has nowhere to go, and starts taking up so much space that the lung has no place to expand into.....more air leaks with each breath, taking up more space with more built-up pressure, making the lung collapse further, and so on, and so on, etc.

And so on, up to a point where the lung is completely collapsed, the pressure in that half of the chest cavity is pretty great, and it starts to push the heart aside. This then prevents the heart from filling with blood (remember, the return of blood to the heart occurs via a low pressure system). Voila! You now have a perfect recipe for a cause of rapid death in a trauma patient: a tension pneumothorax. It's sort of like an over-filled balloon that needs to be popped.

Treatment for a tension pneumothorax, or a patient with SQ emphysema who has an associated pneumothorax (most often the case) is pretty simple and one of the most gratifying procedures in a surgeon's toolbox: put in a chest tube. It can be done quickly, and can be a life-saving maneuver. In the case of a tension pneumothorax, the amount of pressure present can be surprising, and I have had my hair blown back on more than one occasion upon getting into the pleural cavity. You sort of feel like a whaler, throwing a harpoon to finally put down Moby Dick, with the exhilaration of the chase and the wind in your hair raising your heart rate more than a few beats per minute.

Now, I know that most of you will (fortunately) never get the opportunity to harpoon a tension pneumothorax or pop the bubble wrap of SQ emphysema. But, here's a little substitute if you'd like to live vicariously through the trauma team. Have fun!

Oh, cr*p

As the state of Colorado returned to single party rule -- the party in the pocket of the trial lawyers -- my first prediction was that the malpractice caps that have been in place for many years would soon be flushed like used toilet paper. I hate being right.

There's simply no reason to continue to rehash the arguments against such a boneheaded move --- those who believe that an unfettered right to sue anybody, at any time, for anything, with no repercussions rarely are willing to have any type of discussion on the matter. Given the tone of those pushing this legislation, however, it does appear that we're headed back to the 70's....higher taxes, a trial lawyer lobby in complete control of the statehouse, etc. To quote the that staple of '70s radio, the Carpenters, what they are telling the physicians (and taxpayers) of Colorado is that "we've only just begun."

Crap. Maybe I need to get a license application from a more physician friendly state. Or, I could just call it a day