Life is hard

I shouldn't have gone through the Yellow Pages® yesterday counting up all the malpractice attorneys in the area. The practice of medicine is too uncertain, and combined with seeing yet another article reminding us of the huge increases in malpractice insurance premiums, it can quickly generate a panic attack.

Just over the past week, I've had to deal with areas of tremendous uncertainty. An elderly woman is dying and none of the seven doctors on the case are quite sure why. We do know that the end is near and that the family needs to come to grips with end-of-life issues. Some of the family believe that if they just had smarter, better doctors, she just might stand a chance of recovery. Could they turn around and sue us?

Another patient had a post-polypectomy bleed. When we remove a growth with a colonoscope, we cauterize where the polyp was in order to prevent bleeding. The literature quotes about a 1/300 chance of a delayed bleed from the site; for reasons which may simply be blind, dumb luck, my own rate has been closer to 1/2000. That 1 out of 2000 came into the hospital last week, requiring blood transfusions before the bleeding finally stopped. Could she turn around and sue me?

I don't do high-risk cases these days, but a young gentleman requires some tricky work, and no one else will do it, and the parents are very nice, and doc won't you please make an exception just this once? I did the procedure today, and now I await notification from the nurses that the patient is having some gruesome side effect for which I'll get sued, even though the procedure went without a hitch and I have no reason to believe that they'll need to call.

Thank goodness for Krispy Kreme donuts! Two or three of those and life once again is good.

So many lawyers, so little time

My disclaimer is that I have of course changed enough details of the occurrences to maintain confidentiality, but not enough so that the basic truth of the occurrences is obscured. In the finest tradition of northeast mainstream media journalism, you might say that these stories are "fake but accurate".

I live in a community which is large enough to be considered a city but small enough not to have any major-league sports teams. As an exercise in pain and penance, I went through the "Attorney" section of the Yellow Pages and marked every lawyer or firm that advertises that they handle medical malpractice cases. There were 53.

Most of the advertisements were fairly tasteful, but there were a few featuring angry looking people who would not rest until the victims had recovered every last nickel they were due. One had a rather flippant "Injured? Call A.K., he'll make them PAY". I wondered if I could sue someone if I stroked out reading this stuff.

Once upon a time I was referred a young man with chest pain. He noted that his chest only hurt when he drank, and when he drank he would down a six-pack in a sitting.

I performed endoscopy on the gentleman and noted that he has some minor changes of inflammation in his esophagus. He also had a small warty growth called a 'squamous papilloma'. These are almost always benign but I removed it to be sure. Subsequent biopsies confirmed my impression.

I met afterwards with the patient and his mother. "I really think you need to cool it with the alcohol", said I. "If I drank as much as you do, my chest would be hurting, too".

There are some days I can get away with this remark, days when I'm radiating warmth and goodness, or when I've been humbled and speak as one pilgrim to another. This was not one of those days. I have no doubt that my demeanor was one of "Gimme a break, it shouldn't take a doctor to tell you that habitually drinking six packs is bad for you; where is your brain?" They meekly considered my council.

Five months later I received a very nice note from his mother. "Would you be willing to write off the balance of my son's bill? He was diagnosed with Hodgkin's Disease and it's almost impossible to pay all his bills".

I gave the note to my billing and collections lady, telling her that as long as it wasn't violating some law it was fine with me. It seemed a good Christian thing to do.

As I reflected on this case, I struck me: of course! A rare but classic presentation of Hodgkins Disease is pain of the lymph glands that occurs whenever the patient drinks. I had heard about this symptom back in 1976 as a medical student, but hadn't ever seen a case. His chest must have been full of diseased glands, and everytime he drank they all hurt. Why didn't I think of that?

Five months after that I received a call from the patient's family doctor. In the letter I had sent to him I had meant to say "The patient has a squamous papilloma, a completely benign lesion with no malignant potential". I missed a one letter typo, and the letter read like this instead: "The patient has a squamous papilloma, a completely benign lesion with a malignant potential". The family had a copy of the records and stumbled upon that sentence.

"Doc, the family is furious with you. They're convinced that you knew he had cancer and just flubbed up the communication out of maliciousness".

"Over a one letter typo concerning a lesion that has absolutely nothing to do with Hodgkins Disease? Have them give me a call and we'll set up a meeting so I can disabuse them of this nonsense".

That's when the requests for records started to come. First was from a midlevel malpractice attorney with a nurse reviewing these records.

The only positive thing I could think of was that the statute of limitations for malpractice in my state is one year, so they had to serve me papers or forget about it forever. Didn't I really foul up? I could have diagnosed Hodgkins Disease when he saw me if only I had remembered that weird symptom. The fact that it wouldn't have affected his outcome didn't make any difference. It never does: what matters is whether the plaintiff can look pitiful in front of a jury and if he has a lawyer clever enough to convince them that it was all my fault.

Five weeks later I get another request for records, this time from one of the most successful and meanest malpractice attorneys in the city. Once again I have the records sent off. This time I was glad that my billing and insurance lady had put the mother's request for a write-off in the patient's chart. I wouldn't seem like such an ogre in front of the jury.

Three more weeks came and went, and no papers were served. Perhaps the mother's letter was enough to scare the sharks away. The only thing I experienced was seven months of feeling dumb and two months of feeling evil. No harm done.

The lawyers would cite this case as a victory of the System. After all, no suit was ever filed, thanks to the conscientious work of the malpractice attorneys. But I wonder just who gave these poor souls the idea of vengeance for profit.

My once-a-week daily reading

As I limp downstairs, preparing to brew some Starbucks and lecture the cats about their poor language skills, I see my son watching "Fear Factor" on TV. If you've not seen the show before, don't bother. It's one of those insufferable 'reality TV' shows that features greedy camera-hungry morons doing all sorts of unspeakably gross stuff on a dare. The prize for being the one willing to do the most absolutely vile things the longest is $50,000. I imagine that the sum will cover the cost of the "winner"'s therapy for the post traumatic stress syndrome they must surely get from this foolish enterprise.

My own 'fear factor', as with so many of us, is holding up a mirror to our soul and looking carefully and deeply at who we are. I feel safest doing this by reading. If the subject matter gets too uncomfortable, I can set the book down and go play video games or something. I can even 'lose' the book and postpone having to read it for months or even years. From the time I purchased a book on workaholism to the time I actually read it was about eighteen months. I had just forgotten where I put the darn thing.

If there is a book that I should be reading daily but pick up only once a week, then I know that either the book is boring or that it is hitting too close to home. So goes it with my reading of Chip Dodd's The Voice of the Heart. This gentleman speaks the truth and I don't much care for it at times. This week, rather than read it, I've poured my energy into this blog, of all things. I'm not sure that's all bad, but I recognize it as an evasive maneuver.

Let me share with you some passages I found insightful:

We are people with heart pains and heart problems which require heart solutions. Howver, we attempt to solve heart problems with intellect, willpower, and morality, which are no more effective for solving heart problems than a shovel is for cutting a board...

...[W]e begin by feeling our feelings and exposing our hearts, thereby awakening our emotional and spiritual needs, desires, longings, and hope...

There was a time when I thought, and had even been tutored to believe, that feelings are neither good nor bad; they just are. That is not true. All eight feelings are good...It's my behavior or planned behavior that is good or bad; feelings themselves are good--each feeling is a gift from God.

Each feeling has its own specific purpose in helping us live life fully.

Hurt leads to healing.

Loneliness moves us to intimacy.

Sadness expresses value and honor.

Anger hungers for life.

Fear awakens us to danger and begins wisdom.

Shame maintains humility and mercy.

Guilt brings forgiveness.

Gladness proves hope of the heart to be true.

This is all news to me, and news I don't necessarily want to hear.

Of kittyblogs and bloggerel

Could it be? Have I learned to make imbedded links? I think courtesy of The Complete Idiot's Guide to Creating a Web Page & Blog I may just have!

Well, well, well.

The author introduces me to two new (to me) terms: kittyblog, one of those dreary personal blogs that inevitably includes pictures of the bloggers cats, and bloggerel, those blogs that feature the bloggers poetry.

Frankly, yesterday's entry left me exhausted; something about writing all that out opened up the proverbial floodgates, a cleansing enema for the soul, as a gastroenterologist might say. So today I'll join the ranks of the kittybloggers and bloggerelers and make my deposits on the lawn of the terra bloga. (Note to younger daughter: you brought this on yourself).

I have no pictures of my cats, but I'll share a sign I had posted over the kitty litter box:

ATTENTION CATS!
I’m tired of changing your kitty litter.
You are hereby limited to 3 leaks and
1 poop a day.
No exceptions!

It has yet to yield the intended results.

I have lots of poetry, all of which is horrid. To try to give these at least a thin veneer of erudition, I have taken the first two lines of each of these Shakespearean love sonnets and, well, reworked them a bit.

When forty winters has besieged thy brow
And dug deep trenches in thy beauty’s field,
And make-up smeared by layers with a trowel
Will not thy youthful glow ever to yield,
How will thy loveliness come back to thee?
Take heart! For yes, there surely is a way.
But know thee that this path is not for free.
A surgeon thou must be prepared to pay.
Furrows and frown lines hence are rejected
And beauty will yet hearken to thy locks
If thy brow is skillfully injected
With collagen and bountiful Botox.
And on that day when Death shall visit thee
No need for embalming thy face shall be.



****

When my love swears that she is made of truth
I do believe her, though I know she lies.
And though she try to plow me with vermouth
A Lexus she’ll not get for all her sighs.
And as she tries to sway me with her charms
And tells me that my writing’s like the Bard’s,
My deepest soul is filled thus with alarms
When gropes she for my worn-out credit cards.
No flattery’s too vain for her to use;
Her designs have the clarity of mud
When deigns my worldly wealth she to abuse
And says, “Honey, I think you’re such a stud!”
My fate’s sealed as if by divine decree,
For with the last sentence I do agree.

Footnote

A couple of posts back I used some references to Monty Python's Flying Circus that I did not link because I still don't know how. Here's an excerpt from their famous "dead parrot sketch":

C: 'E's not pinin'! 'E's passed on! This parrot is no more! He has ceased to be! 'E's expired and gone to meet 'is maker!
'E's a stiff! Bereft of life, 'e rests in peace! If you hadn't nailed 'im to the perch 'e'd be pushing up the daisies!'Is metabolic processes are now 'istory! 'E's off the twig!'E's kicked the bucket, 'e's shuffled off 'is mortal coil, run down the curtain and joined the bleedin' choir invisibile!!
THIS IS AN EX-PARROT!!

I think it's one of the funniest sketches ever made.

The Launching Pad

1980 was the year of my junior residency: the year of training right after internship, when we're just a little older if not a whole lot wiser. I trained in a hospital that was built in the 1930's: large open wards where patients lived and died in full view of about thirty other patients and anyone else wandering in and out.

In November, as the days grew short and my Seasonal Affective Disorder resumed its annual siege upon my well-being, I was assigned to the Cancer Ward for two months. Few trainees liked this rotation, and one way we coped with it was to descend into a very Dark Humor. The open ward had a private room attached to it that we called the "Launching Pad". This room was reserved for folks dying in such miserable fashion that it would have been inhumane to leave them out on the ward. No patient assigned to the Launching Pad ever walked out of the hospital that I know of.

One day we admitted a particularly sad case. A young woman, in the sixth month of her pregancy with her third child, visited her obstetrician and told him that she had a little breast lump.

"Don't worry about it", he said. "We see this all the time in pregnancy, and it almost always goes away after you deliver. If its still there, remind me to take a look at it".

After the delivery it didn't go away. In fact, it expanded so rapidly that literally the entire breast was replaced by a rock hard mass. Biopsies revealed "inflammatory breast cancer", an unusually virulent form of the disease which seems to double in size about every thirty days. It also metastasizes early and often.

Our attending, fresh from his own training in cancer medicine at M.D. Anderson, assured the patient, her handsome young husband, and three small children that this kind of thing often responds really well to therapy, as long as the special protocols from M.D. Anderson are used.

On her first day on the Ward she was given the special protocol.

On the third day she was reassigned to the Launching Pad.

On the fourth day she died.

My intern and I withdrew to our tiny little office to indulge in another moment of Dark Humor: the Scoreboard. The two teams of doctors on the Cancer Ward kept track of every death that occurs on their team, a weirdly competitive way to deaden the pain. We mark her up.

"You know", the intern says, "one of these days I'm going to have a good long cry about this, but we have twenty other patients on the service, and if I cry about this now, there ain't no way I'm going to be able to go out there and face the rest of them".

I agree. Too many patients, too much misery, not enough time. I'll cry about it some other time.

I'm still waiting for the day.

The Voice of the Heart, author Chip Dodd

Providence Publishing: The Voice of the Heart

I still haven't figured out how to do imbeded links, but when I do, I'll be able to link to this site a little more gracefully.

Sued by a (reputed) cat-killer

My disclaimer is that I have of course changed enough details of the occurrences to maintain confidentiality, but not enough so that the basic truth of the occurrences is obscured. In the finest tradition of northeast mainstream media journalism, you might say that these stories are "fake but accurate".

I used to believe that malpractice lawsuits were handled like traffic tickets. Just keep your record clean for five years and it will be removed from your record.

Silly me. The liability carriers take a "once-sued always-sued" approach; that is, each and every lawsuit, no matter how frivolous, stays on your record until you shuffle off the mortal coil and join the Choir Invisible.

I was sued in the early 90's for a complication that arose from one of my procedures. The bare-bones story is very straight-forward. A referring physician sent me a patient for an ERCP, a specialty test used to define the anatomy of the bile ducts and pancreas. This poor soul had been through almost every other test imaginable and was sent to me for the study more or less out of desperation.

"There is some chance that this test will help us figure what the problem is", I explained, "but there is also a chance you could experience several complications from this study. The worst of these is pancreatitis, which could land you in the hospital and even result in death".

"No problem," replies the patient. "I need answers and I'm not getting any. When is it scheduled?"

I perform the procedure without any obvious glitches. Unfortunately I get a call later in the day from the ER: the patient has returned with what looks like acute pancreatitis. The poor soul is admitted into the hospital in my name.

Three days later this soul has one of the worst episodes of DT's that I've ever seen. And he stays in the hospital for a long time. After going through hell and highwater he survives.

I was not terribly surprised when I got sued by this soul, although my office note had outlined very clearly (whew!) our conversation about the risks and benefits of the procedure, and the procedure was performed in a competent manner.

After two years of maneuvering and delays the case goes to trial. It starts on Monday and goes to noontime Friday, when the closing arguments are completed. The jury breaks for lunch and returns with the verdict: all twelve of the jurors find me not-guilty.

I imagine that winning a lawsuit like this is the scaled-down version of surviving combat: you're glad you didn't get killed but you don't really feel good about the whole thing. I grouse about this for months.

While wandering aimlessly about a mall one day, I'm approached by a vaguely familiar woman. "Hi, Doc!" she says. "I sat in on your trial a few months back. I got to tell you what happened. In the hour we were deliberating, we took five minutes to find you not-guilty, twenty-five minutes to eat lunch, and the rest of the hour discussing how (dung)-eating cases like yours tie up the courts".

I guess I felt better about it still when someone tangentially related to the suit came up to me with this story: "I wouldn't feel so bad about getting sued by the guy and yadayadayada" he says. "That guy had a very eccentric friend who owned six cats. The friend died and willed to him all six of the cats and $50,000 to take care of them in the manner to which they were accustomed. The guy had the cats put to sleep and spent the money. When the family found out about it, they sued his (fanny) and made him pay the entire sum back".

This case will hang around my neck until I'm pushing up the daisies.

Salieri undergoes colonoscopy

About ten or twenty years ago the New England Journal of Medicine published an article written by an anonymous Midwestern family physician. In this article the author reviewed what he regarded as the biggest mistakes and professional blunders of his career. Sharing this type of information almost never happens in medicine, not your worst nightmares with your very best friend (who just might turn out to be a referring physician). The author clearly wanted to perform a very public mea culpa and clear his conscience of cases that had haunted him. The cases he described weren't the wanton negligent "Oops, I amputated the wrong leg because I operated when I was slobbering drunk" type of thing. What happened in all these cases was he either didn't know about something or he didn't recognize it. I thought it was a very noble gesture.

A lot of other doctors didn't share my opinion. In the letters to the editor section in the next week's issue, one specialist after another sounded off on the family doctor's obvious incompetence. The orthopedic surgeon belittled him for misdiagnosing an anterior compartment syndrome; a cardiologist barraged him for mishandling an obvious case of torsades de pointes arrhythmia; the obstetrician condemned him for incorrectly calculating fetal viability and, in effect, performing an inadvertent abortion of a perfectly viable fetus.

It became clear the standard of care established by the letter writers required that the family doctor should be capable of passing virtually all the subspecialty board tests before it was safe to allow him to practice on the general public. I concluded that it was a pretty good idea not to share your misadventures with anyone but your wife and your priest (the added benefit is that neither of these parties can be legally questioned by the plaitiff's attorney).

It is in this context that I will try to share, in an impressionistic way, my experiences with the American medicolegal community. I hope to capture the conflict between at least three forces warring within the physician: the overwhelming sense of injustice that malpractice claims incite; the realization that life isn't fair, that's the way it is, don't take it personally, and get over it; and the nagging sense of dread that you really did screw up and that someone suffered grievously because of what you did or didn't do.

My disclaimer is that I have of course changed enough details of the occurrences to maintain confidentiality, but not enough so that the basic truth of the occurrences is obscured. In the finest tradition of northeast mainstream media journalism, you might say that these stories are "fake but accurate".

Proof of God's existence

The patient shifts uncomfortably in his seat as I enter the room. Glancing this way and that, he works up the nerve to pop the question: "Doc, why did you go into gastroenterology. I mean, sticking scopes up people's (you know) seems a little gross to me".

For a moment I thought he was going to hit me up for an Oxycontin prescription that would take care of him, his family and his friends for about three months (I never prescribe the stuff, by the way). Instead he just wants to know what kind of pervert I am.

Most of the time I just make something up, like "My grandpa had such horrible constipation and suffered so, so I dedicated myself at an early age to try to improve the bowel function of my community". Occasionally I tell the simple truth: when I was in college I loved pinball machines. And I was not just good, but was GREAT at them. My idea of quality entertainment was to spend 50 cents at the student union thrashing the machines there. Two quarters was all it took to get me through an entire evening, and given a few games to figure them out, I could win games on just about any of them.

After the patient gives me the "I thought you were a pervert but instead you're a nutcase" look, I then explain just what pinball machines and endoscopy have in common: its all about hand-eye coordination. Somehow we try to maneuver an inanimate Object about a maze of a colon without pushing too hard and setting off the TILT alarm. Really not much different in concept from a pinball game. Video games and modern endoscopy are very similar: we twist little knobs and dials and watch what happens on a monitor. I've been doing this for almost twenty years and I still think it's kind of cool.

Which is why I was thrilled at the release of a new study claiming that we medical proceduralists benefit from the routine playing of video games (link not provided because I was too lazy to hunt it down and haven't yet figured out how to imbed it into the text). Life is good. Only a beneficent God would allow me to have a profession where I can play Madden 2004 for hours on end and consider it continuing medical education.

Next entry: the first of my malpractice suits.

Crisis du jour

I received an urgent fax from the local medical society: "Attention all doctors! You are doomed!" It seems that the local medicare administrator either ran out of money or had a computer malfunction or was just flat-out in a bad mood. No one is getting any payments from medicare these days. I really hadn't noticed because I hadn't been getting payments from anyone lately and was attributing it all to the sluggish Holiday season. The third-party payors need time off, too, I suppose.

So there is an emergency meeting at the Medical Society later this week. I'll probably go to it. They are mighty entertaining. The older doctors are trained so that if they demand something with fire in their eyes, they will get it. The beancounters just sit there and listen and totally ignore the old docs, much to their frustration.

And it's sad. The oldest negotiation strategy in the book is for one side to make totally outlandish demands, all the while being prepared to concede them if they get what they're really after. The docs, on the other hand, go postal over the outrageous demands and struggle to get them changed, not realizing that in the end we make massive concessions concerning power and reimbursements.

I'll go to the meeting but I don't expect anything to be accomplished other than getting my blood pressure and pulse up a bit. Armed with the knowledge acquired in the meeting, I'll feel very comfortable confronting an organization with several billion dollars of assets with my demands for a 2% increase in my reimbursements. And as a solo doc, I'm confident of the results.

Reading list

One consequence of my putative ADHD is that I often read three or four books at a time, depending on where the book is located in my house: family room, bedroom, upstairs bathroom, donwstairs bathroom. As a gastroenterologist I do not recommend you read on the commode, but I digress.

Here is my current reading list. Have you been reading any of these? Feel free to share your thoughts about them.

Blog by Hugh Hewitt . On page 189 Hugh says

"[H]ere's the key: your blog will display you to the world. Understand what that means. Have fun with it, but do not indulge in crudity or viciousness, as other believers will have you thrown back in their faces as an example of Christian hypocracy. You can use cutting humor and the other weapons of argument, but be slow to do so because these are not easily mastered and can go very wrong. What you commit to your blog cannot be erased. It will follow you for as long as anyone cares to follow you, and significant people are followed very long indeed, especially by those they injure, whether rightfully or not".

Bummer. There goes all my nasty comments about lawyers and the Dallas Cowboys.

The Fortunes of War by Patrick O'Bryan.

The Voices of the Heart by Chip Dodd.

What Went Wrong? by Bernard Lewis.

The Imitation of Christ by Thomas a Kempis.

Financial disclosure

Yes, there has been quite a ruckus made over some of the more famous bloggers accepting money in order to promote an agenda or ideology. Let me make this clear: we all have a price, and mine is not all that high. Wire me some green over PayPal, or mail me a package stuffed with small denomination bills, and I'll sing like a canary.
After all, I've made precious little for writing anything at all. When I was in high school, I made some money as a paperboy for the Washington Post. They once had a writing contest for paperboys, something along the theme of "Tell us why you like waking up at 5AM so you can deliver our stinking rag" or something like that. I entered and won second place, which was worth $50. All I had to say was "I wouldn't be so sleepy if George Bush wasn't the president", and that's all it took to win the Washington Post over, even though no one had even heard about Bush back in the 60's except for an occasional email from disgruntled TANG officials.
Anyway, that's it. Everything else has been free, from my careful exposition on intestinal gas to my tearful confession about when I almost lost it in Romania while on a mission trip because a local restaurant ran out of cheeseburgers just as I was ready to place an order.
So dig deep darlings. Send me enough and I'll even say how much I love the Dallas Cowboys.

Scope it out!

No, this is not a blog written by an Airborne Ranger, although in my fondest fantasies...
In the Dark Ages, before the invention of the Internet, we writers who wished to rant on but did not haved the training/talent/opportunity to publish their thoughts in "legitimate" vehicles, would have to pay varying sums of money to 'vanity publishers' to see their material in print. I've seen these books, and they're not pretty. But now, spend a few minutes on the internet, enter a few password codes, and sign a service agreement without looking at it or having the slightest clue what it says, and voila, one is now a widely distributed if not widely read writer.
And so here I am. I have written for some local papers, such as "Kentuckiana Health and Fitness" and the "Southeast (Christian Church) Outlook", but have always felt a bit restrained in these publications. In a recent article about Irritable Bowel Syndrome, I interjected a subtle yet harsh rantette about the Lousville legal community, and my editor wisely but unceremoniously deleted it. And somehow I don't think a church newspaper would allow me to speculate about what a fine preacher Gilbert Godfry would make, nor would the editors there be amused by my posting the scores of the divisional playoffs of my fantasy team of Madden 2004.
But this is my blog and I get to write anything at all on it, regardless of whatever lack of insight, style or expertise I might have.
In this blog I will skillful weave together these themes: the practice of gastroenterology in the new millenium; contemplations upon one's Christian calling or vocation; whining about what a bunch of evil people plaintiff's lawyers are; what I would do if I were in charge of the American healthcare system, or the Christian Church, or the the entire universe; what it takes to win at Madden 2004 without using all those cheats; and why I think a church that had Gilbert Godfry as the preacher would excel; and whatever else emerges from my spells of OCD/ADHD/chronic melancholia.
So enjoy. Feel free to share your comments. And let me issue a challenge: nothing can be so temporarily satisfying as unleasing expletives on the 'Net (see my considerable restraint on the reference to lawyers above), but it is so terribly, well, declase. So clean it up, folks. No potty language here, although I might make an occasional exception in regards to lawyers or the Dallas Cowboys. And now, honey, will you get off that computer....