Man does not live by blogs alone

I am blissfully heading to points south for a weeklong vacation. My wife and I are participating in a marriage seminar sponsored by our church. It is a law of nature that the week just before and just after a vacation are chaotic at best. This week has been no exception, hence the blogging has been at a minimum. Thank you for the kind comments.

My daughter tells me that the blog was much better when it was warm and fuzzy and before I started ragging on the lawyers. Perhaps. I just like ragging on lawyers. It is good for the soul.

Mission statement

This is the best medical mission statement around:

"It becomes every man who purposes to give himself to the care of others, seriously to consider the four following things:

First, that he must one day give an account to the Supreme Judge of all the lives entrusted to his care.

Secondly, that all his skills and knowledge, and energy as they have been given him by God, so they should be exercised for His glory, and the good of mankind, and not for mere gain or ambition.

Thirdly, and not more beautifully than truly, let him reflect that he has undertaken the care of no mean creature, for, in order that he may estimate the value, the greatness of the human race, the only begotten Son of God became himself a man, and thus ennobled it with His divine dignity, and far more than this, died to redeem it.

And fourthly, that the doctor being himself a mortal man, should be diligent and tender in relieving his suffering patients, inasmuch as he himself must one day be a like sufferer."

Thomas Sydenham (1642-1689)

This is the second best:

"We're all on earth to help others. What on earth the others are here for, we don't know."--W.H. Auden

Standard of care

Back in the early 90's if we found a colon polyp we would do a follow-up colonoscopy in one year, then repeat the exam in three years. A few years ago the guidelines were changed: after the initial colonoscopy we now wait five years before updating the examination, with occasional exception.

A recent study in the Annals of Internal Medicine asserted that we do too many colonoscopies. Physicians just can't let go of the old guidelines, it seems, and the result is unnecesary scopes. This study received a lot of flak on scientific grounds, and no doubt will remain a source of controversy for quite some time.

My response is not so scientific: studies like this really chap my hide.

If a patient requests a colonoscopy and you don't perform one because it doesn't adhere to existing guidelines, God help you if the patient ends up having colon cancer. If the patient requests ANY test and you don't order it because in your judgment it isn't necessary, God help you if the patient ends up with a serious disease that could have been diagnosed with the "unnecessary" test.

Lawyers think this is a good thing. "When it comes to my health," my lawyer intoned, "I want you guys to practice defensive medicine. I don't want you to miss anything at all, even if it's rare and requires lots of expensive tests to diagnose."

Whether we like it or even acknowledge it, the "leave no stone unturned and damn the expense" has become the standard of care for American medicine.

Which is why I got sued in 2000.

To be continued.

Puppies and doctors

My favorite doctor joke:

Q: What's the difference between puppies and doctors?

A: Puppies stop whining when they grow up.

My corollary:

Never, ever hang around the doctors lounge when you are already depressed.

Which is exactly the mistake I made this weekend.

The whining now has taken on a sense of desperation and anger. Doctors are small business owners and we've seen the health insurance rates for our employees (which we pay) go up 20% a year. The same insurance companies have cut our reimbursements as much as 30% over the past two years. When we read about the CEO of one of our major health insurance companies getting a $42 million yearly bonus, our mood is not dissimilar to the peasants before they rose up and got rid of the Czar.

Which is also why many American doctors are thinking the unthinkable: socialized medicine. Traditionally we would hope to be in a single party payer system as much as we would hope to come down with gonorrhea. Those days are coming to an end.

In the lounge a neurosurgeon assumes the role of the Oracle. "I came to America because I could never get any OR time in Canada", he says. "I was always having my cases cancelled at the last minute because of some emergency coming in through the ER. But now I can't afford to make the malpractice payments of $150,000 a year unless I work so hard I never see my family. Now if I were in Canada and had my cases cancelled, I'd just go home early that day. In fact, if it wasn't for the 55% tax bracket they have back in Canada, I'd be gone in a heartbeat".

Memorial

As a member of the Christian Medical & Dental Associations I have access to the Medical Malpractice Ministry.The ministry is headed by a very kind woman who prays for you and all parties involved with the occurrence. She also puts you on a waiting list for a tape series about "How to Survive Malpractice Suits".

Over the past few years the waiting list for the tapes has been pretty long. It took me three or four weeks to receive the material, such is the demand for it.

The tapes do not let the listener indulge in self-pity; it challenges us to take responsibility for our own actions and to forgive the actions of others against us.

One quote startled me: "For every malpractice suit one receives, he's probably guilty of ten to twelve occurrences that could have led to a suit but didn't". That means I've been guilty of as many as thirty-six instances of malpractice. That's a lot.

To my knowledge I've never committed a Res Ipsa Loquitur, such as removing the wrong body part. We've all had cases where we look back and ask, "Man, what were you thinking?", situations where we made poor judgments, overlooked clinical clues, and the like.

I once missed the diagnosis of acute mesenteric ischemia. Although the patient's presentation was confusing and other doctors were fooled as well, I hold myself to the highest standards of practice. It's not clear the patient would have survived (he probably wouldn't have), but without an accurate diagnosis he had no chance at all.

About a week after the patient's demise I met with the patient's family. I explained about the cause of death, our failure to make the diagnosis prior to death, and my opinion that it may not have made much difference under the circumstances. The family appreciated my candor.

As penance I shut myself in the hospital library for one afternoon, reading everything I could get hold of regarding acute mesenteric ischemia. I resolved that I would never miss another.

Since that time I've seen other presentations of acute mesenteric ischemia, presentations that had baffled every other doctor. I've never again missed the diagnosis. I'm proud of it. But remembering just how I acquired this expertise is always bittersweet, my perpetual memorial to the patient who died that I might develop good judgment.

Self-pity

More from Chip Dodd:

Self-pity is a way to escape the pain of sadness by trying to make others feel sadness for us.

Surrounded by experts

In the 80's I served as a gastroenterologist in Another City for two years. The high point of my week was Thursday morning, when I would travel a few miles to St. Elsewhere to attend GI Grand Rounds.

Grand rounds were hosted by the GI Department of the Major University. During the rounds various topics of GI interest were presented, usually by physicians in training under the very watchful eyes of the professors. The presentations were always state-of-the-art, and were very informative. Plus, just outside the lecture hall you could purchase a cup of cappuccino and a cinnamon roll the size of a manhole lid for only $2.00. If I wasn't excited about the topic I could count on a massive caffeine/sugar rush.

When patients can't swallow it is often due to an esophageal stricture. We then stretch or expand the passage way by means of a dilator. The initial dilators were long candlesticks that were shoved down a patient's gullet.

Instead of candlesticks we now use Maloney dilators, which are soft rubber tubes filled with tungsten. These are much safer and work quite nicely, unless the stricture is tight or very rigid. Then we need to use a dilator that is stiffer and has more leverage.

In my earliest years we used Eder-Puestow dilators, demonic devices in which metal olives were mounted on steel rods. In order to keep the dilator from being ramrodded into the tissues, they were always passed over a guidewire. As long as the guidewire was in place, you could push as hard as you needed to and the dilator itself would stay on the straight and narrow.

During that time, Savary dilators hit the market. These nifty instruments were made of stiff-yet-flexible plastic. They were a big improvement over the older dilators but you had to be careful with them. They could easily penetrate tissues, so you still had to pass them over a guidewire. I purchased a set and liked them so much I pitched the Eder-Puestow dilators.

One day at Grand Rounds the professors at the Major University held a symposium on the new Savary dilators. Since they purchased them, they had had several perforations, occurrences where the dilator drilled through the wall of the esophagus and into the chest.

As I cringed in my seat, they presented a careful review of the world's medical literature and reached the startling conclusion that these dilators should probably be passed over a guidewire instead of just being shoved down the gullet. I have no idea if they contacted the injured parties and shared this research with them.

I thought they could have saved a lot of time and research if they had just read the instruction flier that came with the instruments.

Expert witness

I've finished up ahead of time at the hospital, and now have a choice between bloging a little or going back to the office to do administrative work. Tough choice.

In a lawsuit the plaintiff's lawyer lines up the Expert Witness, someone who can testifiy that whatever you did was negligent. If the case is weak, ie. not worth a lot of money to the lawyer, or if the lawyer if low-rent, the Expert is someone listed in a publication of hired guns. If the case is worth a lot and if the lawyer is well-funded and willing to invest the money, the Expert is a National Authority from a Major University or Teaching Center.

The Expert Witness, even the National Authority, doesn't necessarily have to be a very good clinician. It's probably a hindrance for him to be any clinician at all, as patient care diverts the Authority from his research time to things not helpful at all to his career, ie. counseling patients and families, answering phone calls in the middle of the night, and other drudgery. That's what the trainees under him are for.

My most recent lawsuit was complex and potentially worth a lot of money, so both sides lined up experts with national reputations. The plaintiff's expert had an imposing resume, with well over fifty publications listed on his CV. My expert was a gentleman I had seen at lectures and was well-known for his clinical expertise.

My expert's opinion of the Plaintiff's expert was interesting indeed. "Aw hell", he scoffed. "I know this guy. He hasn't seen a patient in at least five years. He's only a researcher".

This comment was not lost upon my attorney. At deposition the plaintiff's expert acknowledged that he saw patients one afternoon every six weeks, only after they had been screened by the doctors in training.

That's one of the strengths of the American tort system: the right to trial by your peers.

To be continued.

You'll be hearing from our lawyers!

These posts sometimes cause me anxiety. I think it's because I live a fairly subterranean life and am uncomfortable sharing things with anyone, to say nothing of the millions of people who have access to this blog.

Yesterday's post left me feeling very uncomfortable. I have images of some lawyer reading it and muttering "He can't get away with that! Threatening to take out a contract on us, is he? Maybe the FBI should know about this".

"You're not paranoid if they really are out to get you". As silly as it sounds, lawyers have been known to do stuff like that. Last month a lawyer had two men arrested for for telling lawyer jokes (hat tip: Free Republic).

No threat is implied by the last post, needless to say. Then again, after reading the news item about the men getting arrested for telling lawyer jokes, my anxiety remains.

The Oracle

In each doctors' lounge resides an Oracle: an old physician who longs for the day when his Very Pronouncements were received reverently (I don't mean to sound sexist but I've never seen or even heard of a female Oracle). In my younger days if I found one of the rants interesting, I would listen politely and attentively. This only encouraged him. Many a lunch hour has been wasted as the Wisdom of the Oracle was dumped on me.

Now I'm more clever about it. I've trained myself to keep my eyes focused on the Wall Street Journal®, no matter how interesting the Oracle's rant might be. Otherwise the eye contact will doom you.

The Oracle was once holding forth about the malpractice crisis. Keeping my eyes fixed on the Journal, I could not believe what I was hearing.

"This situation has gotten out of hand and yada yada" said the Oracle. "I'll tell you what would put an end to this crap in one big hurry. One of my patients is a member of the local Underworld scene. He's told me that his organization would be more than happy to pay some of the plaintiffs and their lawyers a visit and convince them of the error of their ways".

Absolutely none of the physicians expressed the slightest interest in this approach to tort reform, and the subject was dropped. No mention of this was every made again, at least not within my hearing.

We all have dark moments, moments when we've been cut off by some road pig, moments when we imagine a wire-guided missle mounted on the roof of our car, moments when the pig's car is sighted and the trigger is pulled and the rocket speeds unerrantly and in one massive explosion it vanishes. The destruction is so complete there isn't any wreckage to move to the side of the road. The only reactions amongst the onlookers are admiration and just a bit of envy for not having a TOW missle of their own.

In my very darkest moments I contemplate the Oracle's approach to tort reform. So the plaintiff's lawyer is an evil bitch, is she? So she badgered me for seven flipping hours during my deposition, doing her best to paint me as an incompetent moron, did she? The Oracle's friends will take care of that. It would only take one well-publicized Unfortunate Event to serve notice to the rest of the sharks, like mounting the head of a traitor on a post on London Bridge as a warning to all the others. The rest of them would quickly look for other opportunities to defend the Public Trust. Suing McDonalds® and Wendys® should provide them sufficient income to finance their boat payments and beach houses.

I reflect on Chip Dodd's assurance that all emotions are good and that the anger that makes my hands tremble as I type this out will somehow lead to life. It arouses only rage.

With every ounce of energy I review what others are trying to teach me:

• If hurt leads to healing, then healing can't come if I don't admit how bad it's hurting.
• If others are hurting so badly, then what sense does it make to keep my own pain in hiding?
• I've been involved in enough end-of-life issues that I know that I will not move on until I grieve over my losses.
• I must admit that I have no idea how anger can lead to life, and must be willing to turn to others for instruction.
• I must confront my fear of extinction instead of escaping into mindless pursuits.
• I must also accept my shame as God's gift to prepare me to minister to others.
• What guilt I feel must lead me to forgiving the guilt of others.
• If I experience the slightest bit of gladness out of this sorry dung-heap, I'll surely recognize it as the Hand of God.

Opium for the people

I've not heard this put so elegantly:

“Religion, opium for the people. To those suffering pain, humiliation, illness, and serfdom, it promised a reward in an afterlife. And now we are witnessing a transformation. A true opium for the people is a belief in nothingness after death—the huge solace of thinking that for our betrayals, greed, cowardice, murder we are not going to be judged.”

Intermezzo

I'm a faithful First Things reader. Don't understand nary a word but enjoy it nonetheless. If you're in the mood for a little good poetry, check these out:

• Distance—the poet expresses what most of us feel about our Christian walk but have such a difficult time articulating it.
• Termination for Cause—When Divine Justice seems neither Divine or Just.
• What good is it that girls need never march to war?—A Roman poet expressed his horror of abortion.

Endangered species

In a few months I'll reach a milestone in my career: twenty years as a practicing gastroenterologist, and twenty-one years as a practicing physician (I was a general internist for one year). Over that time the changes in medicine have been truly amazing. In the 80's patients recovering from "open cholecystectomy" would languish about the hospital for days, only to be restricted to light duty for six weeks after. Last year I underwent laparoscopic cholecystectomy one Friday morning, went home that afternoon, and returned to my office on Monday. I now prescribe medications which were only theoretic constructs when I was in medical school.

My own abilities have also undergone improvement, at least in my chosen field. Endoscopy has become progressively easier, which is a blessing to a middle age man. My ever-shrinking bladder capacity restricts the amount of time I can spend on any given task without looking rather nervous and twitchy.

More importantly, I'm learning a more holistic approach to patient care. I wonder if my more relaxed approach to medicine is due to my gradual accumulation of the Wisdom of the Ages, or from having so little energy that I just can't raise a ruckus anymore.

The statistics are that an average physician gets sued about once every seven years. If I've done the math correctly that would mean that the average physician in practice for twenty-one years would expect to have been sued three times. I'm afraid that makes me an average physician. I've had three lawsuits: one went to trial and two were settled out of court for non-trivial sums of money. One of the suits involved the (reputed) cat-killer and should have been dismissed.

The other two are a lot more difficult to write about, not only because they were more complex but also because there was obviously enough of a case against me that I settled rather than risk an adverse judgment. Being sued for $8 million makes one a bit reluctant to take their chances with a jury trial.

"All physicians over the age of fifty want to retire within two or three years". I don't know who first asserted this, but I have no doubt it's true. Sadly, we may not have much of a choice in the matter. Three lawsuits brand you as a "high-risk" insuree. In an earlier era I'd be at the apex of my career, old enough to have the grey hair that accompanies Wisdom and Good Judgment but not so old that I forget where I am or lose control of bowels or bladder during a procedure. Now, I'm facing the oblivion of the uninsurable.

Inverse vandalism

It's been a long day, and rather than try to write about anything worth reading, I'd thought I'd commit a little

Inverse vandalism

creating something on the Web for no other reason than the person can do it.

This is what I've learned about HyperText Markup Language, from the book I've been reading.

• You can make nifty columns and lists.
• You can change the size of the font at will.
• You can change the type of font.
• You can change font color
• You can also create an anchor to another part of your own web site.

Or you can just type what's on your mind, which today is absolutely nothing.