So many lawyers, so little time...

Pep talk

2007-03-04T11:00:00.000-05:00

A long time ago I knew a gentleman who "bathed all decisions in prayer". I don't think he would get out of bed until he perceived the divine mandate to do so.

I always felt like less of a believer around him. I would read the Bible, maybe mutter a few incoherent requests to God, and then go my way and hope for the best. This fellow had a direct line to the Almighty. Life was going to be much easier for him. What a lucky guy.

One day he wanted to buy a new car. He fasted. He prayed. He meditated on the Divine Will, and the Divine Will made His car-buying preferences clear to him. "Go and buyeth this car, for it will go well, for you and your family. Listen to the word of the Lord".

My friend went right out, in full obedience, and bought this car. It was an AMC Gremlin.

For those of you who are too young to know about the Gremlin, or were too deeply traumatized by it, this thing routinely makes everyone's "Ten Worst Cars of All Time". It was butt-ugly, unreliable, and dangerous, like a Ford Pinto without any of its endearing qualities.

This brought about a theological crisis for me, the Crisis of the Sacred Gremlin. "Does God favor butt-ugly cars? Did He want to punish this guy for his spiritual presumption? Does He have a weird sense of humor? Was He turning to Michael and Gabriel and saying 'Get a load of this. Watch what happens when he tries to start this car up. He's only had it for two weeks.'"

After careful deliberation this is what I concluded: my friend was full of crap. He vainly interpreted every one of his whims and fancies as being Divinely Inspired. He probably didn't even take advantage of those God-given safety valves know as friends to advise him when he was in unchartered territory. He was a fool.

To this day whenever someone says he is doing the will of God, I always wonder if it is true or if he is following the will of the Sacred Gremlin.

"So," says the Very Wise Professor, "you are sentenced to live your life with detached irony, then? Never willing to step out in faith? Never willing to take the chance that what you believe actually might be God's will for you?"

The timing of this conversation was interesting. It was about 12 hours before I shared with him our plans for adoption.

It was pretty discouraging this week. We had thought we might realistically make the trip to the Ukraine by June. Now we are told, because of Federal footdragging, that September is more likely. Bummer.

I needed a pep talk, so I went to our church's internet portal and found the video blurb on adoption. It is linked above. I thought it was well done. It rings very true. And that is assurance enough for me. For now.

Reality check

2007-02-28T08:35:00.000-05:00

So folks are insane if they adopt a child, especially an older Eastern European child?

Well, maybe.

Our local adoption agency stresses the need for appraising attachment issues realistically. They've told us about the good adoptions, the bad adoptions, and the ugly adoptions.

I've been reading my way through "Attaching in Adoption" by Deborah Gray. She covers about everything that could go wrong in her book, along with coping skills to overcome them.

My wife stopped reading the book. "It's like being pregnant and reading about every possible birth defect there is. I can't take it." I'll be doing the reading for now.

The interesting thing is that even in high risk situations, eg. adoption out of a marginal background, poorly run orphanages, etc, that only about 30% of the children go on to develop Reactive Attachment Disorder. That means that 70% don't. You see where I'm going with this?

As we check around our town, that seems to be a rough approximation for the local experience. We hear about the "nightmares", and for every nightmare there are two where the families/children couldn't be happier.

Love is not enough. Let's see, we've had experiences in our family with severe learning disabilities, severe childhood trauma, marital discord, mid-life crisis issues, poverty, etc. Things have worked out in spite of all of that. I like languages (although I'm not sure about Russian), and we know lots of Ukrainians for support. I get a quick language lesson at least three times a week, and I know how to get hold of the Russian cartoon network, though I probably won't let her watch it unless she gets severely homesick.

I only speak for myself. I've gone about the last 8 years (the beginning of the first lawsuit) until now feeling sorry for my sad plight and wanting to avoid all psychic pain, maybe pain altogether (an exception made for biking). I've also felt a little less than totally alive during that time. This is something I'm called to do, and not just for the adopted. My whole family will need more of me. I think that's a good thing.

One of my favorite quotes if from Mother Theresa: "We cannot do great things, only small things with great love". I modify it for me: "I can't even do small things with great love. I can do small things with just a tiny bit of love, and the Lord, who feed the five thousand with a few fish and a couple of loaves of bread, can do the rest."

And if it ends up being a disaster, at least we will have tried.

Dear congressperson

2007-02-23T20:28:00.000-05:00

I'll be up front with you. I neither like nor respect you at all. You beat out one of hardest working, most competent congresspersonages this last election, based on you personal wealth and name recognition. Too bad for the district, I say.

Nonetheless I'm sucking up to you to give us doctors a break. I don't know how I distrust more, the Republicans with their glib talk of improving health care access while they cut the budget for Medicare and the VA hospitals, or the Democrats with their glib talk of improving health care access while they do their best to criminalize the practice of medicine.

Anyway, I appreciate all the lip service everyone is making for colorectal cancer screening. I think folks get a little carried away with it - I was recently referred a 91 year old gentleman for screening - but generally speaking the yield is high enough to make it worthwhile.

However, in order to balance the books, the reimbursement for colonoscopy has been in a free-fall over the past 15 years. I'm now getting 25-30% of what I received for this procedure in 1991, and this is not adjusting for inflation. The reimbursements for 2007 look even worse. The private carriers base our reimbursements on Medicare, so every time you folks lower the reimbursements, they do too. Except for (would I get in trouble for mentioning the company's name?), who now is reimbursing me for less than Medicare does.

A recent article in the NEJM demonstrated that when colonoscopists are in a hurry, they miss stuff. A lot. It has always been a temptation for docs to turn their practice into an assembly-line. Now I think it will be inevitable.

This is not an issue of me not being able to afford that beach house or making my Porsche payments. I'm having trouble making payroll right now, between taxes (I appreciate your pledge to raise taxes as one of your campaign promises. The voters in this district must have lost their minds on Election Day), health insurance which paradoxically has become almost prohibitively expensive, malpractice insurance, and employees who expect merit and longevity raises right on schedule in spite of the fact that it's getting tougher for me to make a living. Plus, I had to update my phones, my computer software, my computer memory, and replace my fax machine that died a violent and painful death about two weeks ago.

I'm reexamining the way I practice medicine right now. I've prided myself in taking time with my patients right up to the present. If I can make a living, or if I could do better selling Amway or something, I'll have to do what's necessary. Right now I'm working for the health insurance.

By the way, if you and/or Hillary and/or Obama want to nationalize health care, now would be a pretty good time to do it. I feel less than no sympathy or loyalty for the health insurance industry. They can all go to blazes.

Anyway, I worked in the military during the 80's and have a good idea how health care rationing works. I can get used to it again if I have to. Just let me make a living at it. I'm getting too old to be retrained.

Yours truly,

Orphan role models

2007-02-19T21:30:00.000-05:00

Here are the roles models that I think all orphans should follow:

Anne of Green Gables. Bright, beautiful and personable, Anne is a wonderful model for orphans everywhere. Orphaned as a result of the tragic deaths of her missionary parents, she is adopted by good-hearted but basically clueless spinsters, who raise her as if she were their own flesh and blood. In gratitude for their sacrifice, she leads an exemplary live and lives happily ever after.
Jane Eyre. She might be the greatest orphan ever. Orphaned because of the sad deaths of poor but noble parents, she is taken in by an aunt who despises her. She is abandoned to an evil church orphanage, where, in spite of harsh conditions, she becomes fluent in French and learns how to paint. She becomes a governess for a wealthy but troubled Master, who falls in love with her. She becomes the means of his redemption.
And of course, Little Orphan Annie. No matter how bleak today is, she always has "Tomorrow" on her lips.

We are reading a book about RAD, or reactive attachment disorder. It seems likely that orphans in reality are more like this:

George, age 5. He hugs and kisses everyone he meets, but when he is taken home by his parents, becomes sullen and distant. "We feel like he is always interviewing other families for our job", one of the parents said.
Nicole, age 8. She'll enjoy cuddling with one her parents for twenty minutes, and then, as the parent is kissing her good night, says "I wish Aunt Mary would have adopted me instead of you".
Harry, age 10. He views his adopted home as a "very well-stocked orphanage" and says that his adoptive parents are fine, but if he really loved them he would be disloyal to his biological mother, who he really never knew.

I must say that as we progress through this book, we wonder if we're spending a lot of time, effort, and money to import a psychopath. If only I could be guaranteed of Jane or Anne.

A good stoker is hard to find

2007-02-11T20:30:00.000-05:00

A few months ago my wife and I bought a tandem bicycle. As we work together (she's my office nurse) and live together, I figured we could spend every waking hour together, riding our bike off to marital bliss.

For married couples, tandems either are wonderful or evil, depending on skill of riders, temperment, control issues, and so forth. We happen to get along great together, I as the captain and my wife as the stoker, the person who sits on the back seat, peddles obediently, and, other than yelling at or cajoling the captain, has absolutely no control over where the bike is going.

It's a good arrangement if you ask me. I love doing it. And it means at least one person on the road is not going to pass me.

It's been an emotional weekend, to say the least. We went to a major fund-raiser for Ukrainian orphanages last night, of some interest to us as we are attempting to adopt out of one of the orphanages this group ministers to.

Have I mentioned yet that the Russian language is a pain in the patoosh? I'm working through Rosetta Stone. It's not their fault that Russian is so inscrutable.

Anyway we chatted with folks who have seen our adoptee and it was encouraging. "She is just the sweetest girl. We gave her extra hugs for you."

We also watched a video of what happens to these kids when they reach 17. It's on the streets for them. Girls are often involved in sex-trafficking in one form or another.

We can't save the world, but we can give one of these kids a chance. Yana (it's either that or Anya. We haven't figured out how she spells it. I hope to find out soon) will get a chance, if heartless bureaucracies don't tank the effort.

We received a digital photo album of the orphanages last night, and we poured through them looking to see if we could identify this little girl. We did. The kids get access to hot water once or twice a week, in the winter no one washes their hair, so everyone looked a bit disheveled, and most of the girls' hair was dirty looking. Yana/Anya had also hit a growth spurt and had shot up about half a head. She looked quite a bit older than pictures of her just three months ago had looked.

My wife was a bit shocked, as she was hoping to have bonding time before the onset of puberty. It also occurred to her that this undertaking was no longer some cool abstraction. It is now our responsibility to take a street urchin and raise her as our own.

Times like these, I'm glad I have a Y chromosome, along with all the rights and privileges that come along with it. While my wife is mourning a bit about losing some of this girl's growth, I'm rejoicing on how, now that she is getting bigger, I won't have to worry about converting the stoker seat on the tandem for a child.

I can't think of a better way to show off our great country, plus get a little exercise in the process. I'll worry about harsh reality, including my Russian studies, later.

On the cutting edge

2007-02-05T13:02:00.000-05:00

We passed one of the major hurdles in the international adoption process last Thursday: the home study visit. Keeping details to a minimum for now (office starts in 5 minutes), the home study people, who have gotten to know you extremely well from all the paperwork and interviews that they have done up to that point, spends a minimum of three hours in your home. Their mission is to make sure that you are a suitable family, that you have the means and resources to take care of a new child, and that you're not a pedophile or some other low life. We think it's a very good program. We also think that if we had to provide the documentation for one of your "natural" children, the human race would die off after two generations.

There are some "hot buttons" in the home study process. One of the biggest is the question of firearm ownership. The home study agency doesn't want little kids getting into the family armory and raising havoc with themselves and others. Ideally, you should not own a gun, but if you do, it should be kept under lock and key, preferably in a safe, preferably at the gun club. We were questioned about it several times, and, no, we don't own guns. I get nervous with my son's paintball gun in the garage.

We take the home studier around our house. We show her my son's house, which is astonishingly clean. She nods in approval as she leaves the room. My son is turning very pale.

He had layed out, very neatly, on his dresser, his knife collection, some ten or twelve knives, ranging anywhere from a scrimshaw pocket knife to this huge machete that his brother-in-law had brought back from Guatemala. There was enough cutlery to slice and dice everyone in the neighborhood without having to use the same knife twice.

Only guns kill people, I guess. It certainly didn't bother the home study people.

Our paperwork now goes to the CIS/INS. We hope to hear from them in six weeks.

Brushing off the cobwebs

2006-11-30T20:24:00.000-05:00

I realized a bit back that whining abut the evil tort system (and it IS evil) or writing about my modest biking exploits was not a good enough reason to generate blog entries. Maybe you'd like to join me for my latest adventure. It might be fun.

In September my wife journeyed to the Ukraine to help clean up orphanages: give them new paint jobs, take over new beds and matresses, stuff like that. She'd been to Eastern European orphanages before and was familiar with them, knew about the heartbreaking stories behind so many of the children, and our seeming inability to make even the slightest impact upon the kids' plights.

At one of the orphanges she instantly bonded with a child who's name we think is Anya, a cute little 11 year old girl who wanted to be loved in the worst way. Karin got a few pictures of her, and on her return showed them to me and explained about what she had seen.

"She's a sweet little thing. Sometimes I wish we could have brought her back." She knows that you can't get attached to those little ones else you'd bring them all back, which you can't do.

"Well, why don't we?" I said. "It works for me. We can't save the world, but we can help one child".

We thought of all the reasons we shouldn't do it:
--we're getting old.
--I could lose my job over one nuissance lawsuit (thank you, evil American tort system, almost the only one in the civilized world that has not adopted a "loser pays" approach so as to discourage stupid lawsuits).
--I might just decide to keel over from The Big One.
--There's no way I could retire until I get really, really old.
--And a lot of other reasons, like disrupting the family ecosystem, having another mouth to feed, child to educate (she doesn't speak any English), and woman to marry off.

Someone asked me why I'd even consider it, and I replied a bit flippantly: "We have three perfect children (well, we do), so we figured we needed one more chance to have an offspring break our hearts".

I think that's a good enough reason. So did my wife.

We contacted the local international adoption agency. "It'll cost you somewhere between $10 and $15 thousand, but it could all happen by June".

Cool. So, off we go.

Here's what we done so far:
--sent off for three personal non-family references.
--two family references.
--every single financial account we have, anywhere.
--last year's 1040.
--complete medical histories.
--proof of health insurance.
--proof of life insurance.
--family photo.
--birth certificates.
--autobiographies. This was kinda fun. I didn't realize I'd lived such a fascinating life.

This is just the first round of stuff. The hard part is coming up. I'll keep you posted.

All the fashionable people

2006-04-30T09:18:00.000-04:00

(I admire "fake but accurate" journalism and seek to emulate it as often as possible. However, while I've changed all the names in this post, the details of the story are true.)

We deal with death and its apparent injustice all the time, yet the death of a medical colleague in the prime of his career always presents itself as a gross anomaly, like waking up one morning and seeing the sun come up in the west. Some would say that physicians believe themselves immune to the laws of physics and biology, and perhaps they are right. Doctors aren't supposed to die until they've retired and moved away to the golf course-side condo where they play every day until they become too senile to keep score and everyone has forgotten about them and then we read an obituary about an elderly gent with an M.D. after his name who sounds vaguely familiar but that's about it.

That's what's supposed to happen, so it was a shock when one of the endoscopy nurses asked me what I knew about Dr. Tom Wandzilak, an ER physician my age who died this past week.

I knew nothing. I spend as little time in the doctor's lounge as I possibly can, and although that spares me from all the incessant whining that goes on, it also leaves me outside the loop when it comes to news and gossip.

I entered "Dr. Tom Wandzilak" into the very same search engine that markets freedom-surpressing software to the Chinese, in hopes of learning what happened to the poor man. There was nothing about his death, but there were many other citations, several of which had to do with malpractice suits.

I came across this doozy:

Med-Mal Defense Verdict in Failure to Diagnose, p. 1
Several doctors failed to diagnose 38 year old housewife's cancer of the lymph nodes; ER doctors and internist chalked it up to psychological problems. After 10 months of being told she was crazy, she found out the real diagnosis and that it had spread - she died 13 months later leaving husband and children. A variety of defendants were targeted who treated a healthy housewife with no history of mental problems as if she had mental problems. Prior to trial, plaintiff/estate (including consortium claims for husband and children) had settled with three defendants (Dr. Sam Fredericks(ER), Dr. Susan Underwood and Dr. Jack Niles (post misdiagnosis psychiatrists). Two other doctors were in for apportionment purposes (Dr. Tom Wandzilak (ER) and Dr. Raymond Smithers(ER). Which doctors were left? Dr. Abdul Nafty (internist); Dr. Jim George(internist) and Dr. Louis Goldstein (psychiatrist). Psychiatrists were faulted for failure to pursue an organic component of the problems and therefore did an incomplete exam of the patient. The settlement was unknown to the jury. Dr. Benedict Arnold, Internist, testified for the Plaintiff criticizing Nafty and George for their incomplete exams. Mr. Andy Roberts did a vocational analysis since the decedent was college educated.

Plaintiff experts: Dr. Benedict Arnold (Internist); Dr. Huey Greenburg (Internist); Dr. Charles Zadok (psychiatrist); Dr. Dwight Davis (oncologist for causation); Dr. Eugene Eubanks (cardiologist and internist); Mary Margaret and Beth Sue McAllister (psychology for children's claims); Andy Roberts (vocational expert)

Defendant experts: Dr. Hiram Hildebrand (oncologist); Dr. Jack Louis (internist); Dr. Karl Jung (oncologist); Dr. Peter Rogers (psychiatrist); Dr. Elizabeth Reardon (psychiatry).

Prior to suit - Dr. Fredericks, Underwood, and Niles had settled.

Damages? Estate - $5 million; children- $2.5 mill each; husband - $500,000.

Settlement negotiations were spurred at trial after talking to the alternate juror - she had opinions regarding apportionment, fault and damages (millions). Nafty and George settled for an undisclosed amount.

It's a good bet that none of the physicians used the term "crazy" in their description of the patient. We're trained to use no subjective word in our descriptions. For example, instead of describing a patient as "hostile and threatening" we would document that he "looked me in the eye and said 'I'm going to beat your head in, sue your ass off, and feed your entrails to the buzzards.' " Direct quotes are not subject to misinterpretation.

What really struck me about this case is that all of the fashionable people were involved. I know, or know of, all the defendants. Not only are they NOT threats to the public welfare, but they are all excellent. I never dreamed that these folks would be dragged into a massive lawsuit. That kind of thing only happens to wretches like me.

There are times when The System fails. In complex cases involving multiple specialists, especially in academic centers, there can be horrible miscommunication which cause a patient to suffer. Sometimes the patient can be caught in a struggle between two (or more) towering egos, egos which refuse to acknowledge the possibility of making a bad judgment.

But what about cases where everyone gathers all the information and comes to a conclusion which is perfectly reasonable (or else they wouldn't have all reached it together) but is just flat dead wrong? Physicians are not, in theory, expected to be perfect in all things. They are supposed to be diligent and make reasonable judgments. We're not supposed to have our asses sued off just because our judgment is wrong. Can physicians be found to be below the standard of the community when the community itself is wrong?

Let's review the case:

Prior to suit - Dr. Fredericks, Underwood, and Niles had settled.

Damages? Estate - $5 million; children- $2.5 mill each; husband - $500,000.

Settlement negotiations were spurred at trial after talking to the alternate juror - she had opinions regarding apportionment, fault and damages (millions). Nafty and George settled for an undisclosed amount.

I can't blame them there. Being faced with a $5 million judgment will give you pause.

Verdict - zero - defense verdict. Jury came back - all three (including Nafty and George) had prevailed.

And I suppose justice was done.

Dr. Tom Wandzilak, rest in peace.

The lawsuit graveyard

2006-04-25T20:31:00.000-04:00

One of my favorite movies of all time is Saving Private Ryan, partly because of the cool blood and gore war scenes, but mainly because of the tribute it paid to the American soldier and everything he did to preserve our freedom. One the most poignant scenes in turn is the one in which the elder Ryan wanders about the military graveyard in Normandy: rows upon rows of bleached white marble crosses, with an occasional Star of David, each cross or star bearing silent testimony of the life that was given during that awful campaign.

Wandering about military graveyards will make you ponder. You ponder the ultimate sacrifice of the soldier. You ponder that the sacrifice was surely made over the objection of the individual. You ponder how death represents the ultimate reality unless the eternal existence of the human soul is a greater reality. It provokes a terrible melancholy, and I deal with it the same way I deal with most of the great issues of our time.

I try not to think about them at all.

I'd rather think about biking, or my son's lacrosse games, or rooting for my daughter when she runs the minimarathon this weekend. I have such a melancholy personality that I fear if I ponder weighty issues too much, I'd withdraw from the pain of existence, living my days curled up in the proverbial fetal position under my bed.

One web site I visit from time to time is www.MalpracticeWeb.com. Looking for a good plaintiff's attorney? This site might just be for you. Not sure if you really want to sue your doctor? Want to get worked up about all the malpractice injustice of the world? Help yourself to the summaries of the lawsuits (I believe in the greater Chicago area) that have either been settled or have had a judgment for the plaintiff.

Pulling up these capsule summaries to me is the web equivalent of wandering about the graveyard, with each little summary representing what was a titanic clash between an aggrieved patient or his estate and his attorney and all of his expert witnesses versus the doctor and his family and his defense counsel and all the expert witnesses that they marshaled. Each represents a family in anguish, a patient in pain that won't go away, an anger that can only be quenched with a generous monetary judgment. Each represents a doctor who for three or four years looks at himself in the mirror each morning and wonders if the world wouldn't be better off if he just retired, the doctor who wishes he had made a better judgment in the middle of the night, or wasn't distracted by eighty thousand things demanding his attention causing him to miss the one detail which might have made a difference in the patient's course.

In this pediatric surgery malpractice lawsuit, the husband and wife plaintiff's claim that during bilateral inguinal hernia surgery (hernias where intestines bulge through a canal to where the testes descend) the above defendant doctors also removed E. B's left testicle and then didn't tell them about it. Dr. X settled for $75,000. This sounds like a bargain when you consider the fact that men consider testicles to be priceless. Dr. Y and Mt. St. Elsewhere Hospital were dismissed.

I suppose that this represents a bit of levity on the part of the authors, the equivalent of learning that a fallen soldier died because he mistook a claymore antipersonel device for a can of beer and tried to open it. Oops.

In her podiatry malpractice lawsuit filed in 1997, this plaintiff alleged, among other things, that on October 26, 1995, Dr. Evil performed unnecessary bunionectomies with osteotomies on both feet in spite of pre-operative x-rays that were clearly within normal limits. She claims that since the surgery she has not been able to play racquetball anymore, as she had played 3 to 4 times a month, cannot do step aerobics, cannot walk more than 1/2 mile without pain, and cannot walk around the house barefoot due to swelling and burning pain in the balls of her feet. On August 31, 2000, Dr. Evil was dismissed and his corporate entity, Dr. Evil, Ltd. made an undisclosed settlement.

I'd love to know what really happened in this one. Did the patient hound him and badger him into performing a surgery of dubious merits? Was he falling behind in alimony payments and churned a bit? Did he give up just enough money to make her go away? Once the case was dismissed, did the plaintiff use the settlement money to renew her membership at the local racquetball club? This information never shows up in this kind of capsule summary. Never will.

In his dental implant malpractice lawsuit filed on March 5, 1999, Mr. P., born in 1929, claimed that after having an allegedly negligently placed subperiosteal implant implanted into his lower jaw in 1991, dentist Dr. Nasty allegedly failed to provide proper care over the course of several years which allegedly resulted in an infection, nerve damage and bone loss that necessitated implant removal and hospitalization, and medical bills totaling over $94,000.
Dr. Nasty claimed that Mr. P., among other things, failed to maintain proper oral hygiene, used a metal pick to clean the implant when he was told not to, and delayed having the implant removed in March of 1997 when he was told to have it removed. This suit was settled for an undisclosed amount on January 9, 2003.

Let's see: the event in question happened in 1991, the lawsuit was filed in 1999 (that's a heck of a statute of limitations) and settled in 2003. Inmates on death row get a more merciful and swift execution than that. Any chance the plaintiff's attorney came up with delay after delay, leaving the dentist to twist in the wind until he was willing to give up some insurance money to make the whole mess go away?

Maybe I'll email the webmaster and suggest that they chronicle the methods the attorneys use to ply their trade. It's just a thought.

Questions

2006-04-16T22:45:00.000-04:00

I have quite a few, actually.

Since I enjoy quality time with my daughters so much, why don't I schedule more of it?

Why is reading the Tao Te Ching relaxing and reading the Koran not? Why do I see the image of an angry Pharisee flash by whenever I read the Koran?

Since I don't see myself thriving in private practice, and as one malpractice suit would render me unemployed and unemployable, why don't I cut and run now?

Why has gastroenterology seemed more like a hobby to me for the past few years, in spite of the fact that I'm keeping up with things and that I'm pretty decent at it?

How can anyone in their right mind believe in the eternal existence of the human soul?

I know lots of Jewish folk that are better people than I. Is it fair for me to go to Heaven (assuming that it exists) and not them just because I'm a mediocre Christian?

Why do I keep trying to get mountain biking down in spite of the fact that I'm probably going to get really hurt doing it? After all, a broken finger is no biggie, but a trashed rotator cuff would be pretty darned inconvenient.

Why do I, when faced with these weighty issues, find myself wanting to blog about some mindless aspect of biking instead?

And why ask why?

Hammerheads and Nails

2006-04-04T15:19:00.000-04:00

(The following is my latest attempt to gain acceptance with the local mountain biking community).

To hammer—(vi) to pedal as hard as you can for as long as you can.

Hammerhead—(n) one who hammers. Likes to vomit during or after riding.

“There are two types of people in this world: those who like to divide everyone in the world into two types, and those that don’t”. --ancient Jebusite saying.

The biking community likes to divide the world into two types of bikers; either you’re a serious biker who some day hopes to qualify for the national championships, or you ride a junker with coaster brakes and a little basket attached to your handlebars in which to carry your groceries on your jaunts to the local Save-a-Step.

This is too bad. There are a lot of bikers who would never be caught dead on a Huffy but just don’t think that riding until you puke is any fun.

I work everyday with lots of these riders. They decline my invitations to go biking with this universal response: “I was once invited on a ride and all the riders said they were going to ‘take it easy’, and then they sped off and left me all alone. It was humiliating, and I’ll never do it again.”

These folks have obviously never ridden with me, but I digress.

We need a group of riders who occupy the middle ground, who like to ride adventurously but don’t care if they finish in front of anyone else in the world. I’ve taken it upon myself to form such a group: the NAILS, a group of riders who are almost the exact opposite of the hammerheads. We are Non-Athletic Intelligent Lazy Slugs, and proud of it.

Not anyone can become a NAILS. The selection criteria are very strict. Below is a partial list of qualifications:

You might be a NAILS if:

--all your bike stuff, including the bike, costs less than $500.
--nothing you own is made of titanium.
--people talk to you about splines and gear ratios, and you stare blankly at them.
--someone asks you what kind of bike you own, and you reply “a red one”.
--the only race you’ve ever been in was to see who could get to the park bathroom first.
--you like to ride last so you can copy everyone else’s line.
--you approach a large hill and you look to see if there is a bike friendly bus-stop nearby.
--bike shoes strike you as being a huge waste of money.
--you have no idea what ‘periodization’ means.
--you’ve never used the terms ‘gnarly’, ‘shred’ or ‘rail’ in proper biking context.
--you use ‘Hammergel’ to lube your chain.
--you’ve owned clipless pedals for over six months and stopping your bike still fills your heart with terror.
--you wake up one Saturday morning, it is 68 degrees and sunny outside, the ground is dry and firm, the Wild calls to you by name, and… you brew some coffee, settle into your favorite chair, and read a book all morning.

It had to happen

2006-03-30T20:40:00.000-05:00

I broke my first bone this week, mountain biking.

It was worth it. I'd do it again.

I ventured out on a trail that is a bit demanding. As I got on it, a freezing rain hit. This didn't make things too slick, but it made me slow down, thus causing my front tire to wash out when I hit a root. Flying over the bars, I almost made a graceful tucked-in landing, except I didn''t get my little finger pulled in.

I began to suspect that I hadn't merely jammed it when I noted that the finger was bent in a peculiar angle. I rode about four miles back to my car and was going to blow the whole thing off as I casually mentioned to my wife that the finger hurt a bit.

Next thing I knew, I was seeing my friend the hand surgeon. "Looks like you might need to get the finger pinned". Yikes.

One xray later, it was decided that I had "broke it good" but that I would be OK with the finger splinted for the next 6 weeks. I pondered this as I strolled about today in 75 degree weather, bright and clear throughout the Ohio Valley.

I was just getting good at it, too.

It doesn't interfere with my scoping ability, but when called to do household chores the pain becomes unbearable. It might stay that way for months, maybe even years. Time will tell.

Ideology

2006-03-19T10:49:00.000-05:00

These days I've had so many ideas for blogging topics that I've not been able to focus on any one thought, a sort of analysis paralysis. That, and I've been lazy, preoccupied, and content to follow the easier path of "drive-by" commentary on other folks' blogs.

The toxic atmosphere of American politics probably has something to do with it. On my local mountain biking forum one thread was hijacked by posters spewing the most hateful, crassest forms of Bush-bashing left-wing hyperventalation. I typed out carefully nuanced commentary of the revolutionary pre-emptive doctrine of Bush and cronies, along with thoughts about Wahabism and Sufi Islam, appealing to all sides to put aside petty partisanship and calling for everyone to assume a greater historical perspective on the War on Terror.

My efforts were rewarded with what has sadly become a standard response from the New Left: "You SUCK, you dumbass psychofascist!" If you think my judgment of the New Left is a little harsh, then prove me wrong. I haven't seen any evidence to the contrary.

Well, I don't suck. I aspirate. I'm a doctor.

The irony of it is that I'm a lousy ideologue. I think my favorite political joke is one that was popular in Eastern Europe in the early '80's: "Capitalism is man's exploitation of man. Communism is the other way around."

If there was one aphorism that summed up my political philosophy, such as it is, it would be this: "Power corrupts; absolute power corrupts absolutely". Free market capitalist, socialist, communist, fascist, it makes no difference what the label is. Put enough power in the hands of a Few and the rest of us will suffer mightily for it.

I think many physicians are more open to the concept of Universal Healthcare than ever before. I'd love to assert that we physicians are becoming more altruist in our maturity, but this would be incorrect. As the health insurance companies are consolidating into economic oligarchic, and as we have less and less ability to influence issues such as reimbursements and expenditures, it's occurring to more and more of us that perhaps the companies should just go to blazes and divert the money being used for enormous bonuses for the CEO's and use it instead to provide at least a modicum of coverage for the nation's poor.

I'm open to it. I'd also like some assurance that if I have the Big One while typing this out, that as a self-employed practitioner I'd be able to afford coverage. If I had the Big One I'd be in a world of economic hurt.

A few years ago I took a trip to Romania where the question of what the local church, as supported by kindly American do-gooders and their money, could do to improve the delivery of healthcare. The quick answer was "I dunno". We met with local healthcare officials to understand the Romanian system better.

On paper it looks good. Anyone who works has 7% of their pay withheld to finance their medical care. They don't make much in Romania, but then again healthcare isn't very expensive, so there should be enough money to take care of basics. There might not be enough in the system for the citizens to get PET scans, but they should be able to obtain ibuprofen and lisinopril without any trouble.

But they can't. No one has enough money to purchase them.

The healthcare officials are all ex-communists, and in the best communist tradition, they siphon off huge amounts of money into Lord knows where, anywhere but into the hands of the people who desperately need it.

We assured the Romanian church folk that in America this kind of thing would never happen. The money wouldn't disappear, it would simply show up as a $100 million yearly bonus for the CEO of National Red Star/Red Sword, and all would be well.

March is Colon Cancer Awareness Month

2006-02-22T22:32:00.000-05:00

(The following is an article being published in our local health and fitness magazine, with the tacit approval of my editor.)

Why should I care?
The risk of colon cancer goes steadily up once you hit fifty. Unless you've figured out how not to age at all as you get older, you better be aware of this disease's potential threat to you health. The disease does not care whether you are male or female, black or white. For it is the third most common type of cancer for both sexes, and altogether causes more deaths than either breast cancer or prostate cancer.

But hasn't everyone heard of Katie Couric, colon cancer, and colonoscopy?
Evidently not in Kentucky, We have the second lowest rate of colon cancer screening in the country. Sadly, Louisville/Jefferson County is bringing up the rear, having one of the highest rates of colon cancer deaths in Kentucky and the nation.

OK, I'm aware. Now what?
"Ask for IT!" as in Information and Testing. Our screening guidelines have changed dramatically over the last ten years, and they are not seared into our medical consciousness the way Pap smears and mammography are. Even conscientious physicians may overlook colorectal cancer screening in all their patients. As in all health-related issues, a knowledgeable patient is her own best advocate.

Give IT to me, then.
Because 90% of cases are diagnosed in patients over 50, we recommend that screening begin at that age. Studies have shown that ANY form of screening is better than no screening at all. The forms of screening include the following:
True colonoscopy.
Barium enema, preferably air-contrast.
Flexible sigmoidoscopy
Fecal occult blood testing
Less common forms include the following:
CT colography ("virtual colonoscopy")
Chromosome analysis of cells shed in the stool.
There are patients who should undergo testing at an earlier age. Patients with family histories of colon polyps or cancer should start their testing at the age of 40, or possibly even earlier. Patients with inflammatory bowel disease are often advised to begin screening earlier, too.

You make your living performing colonoscopy. Which test, by chance, do you recommend?
Colonoscopy, of course. It has major advantages over the other forms of screening. It is more accurate, in most hands, at detecting polyps and cancer than barium enema. It allows us to see the entire colon, instead just the third that is seen with sigmoidoscopy. It is more accurate than stool testing and, at least for now, virtual colonoscopy. It allows us to sedate patients, which is not routinely done for virtual colonoscopy. Most importantly, it allows us to spot and remove precancerous growths called polyps. In these cases we are actually preventing, not just detecting, colon cancer.

Sounds like a big hassle to me. And the clean-out for it doesn't seem inviting, either.
It is a hassle, but most folks only have to go through it only every ten years. It's not like getting yearly prostate checks or Pap smears, thank goodness! Every year we get cleverer with administering the clean-out. There are several different preparations you can take for colonoscopy. Discuss them with your doctor. Who knows, maybe some day we'llhave a prep that people actually enjoy.
The hassle is well worth it. Since 1985, coincident with the growth of colonoscopy, we have seen a 2% drop in colon cancer deaths each year, and nationally deaths from cancer are actually falling! Not all colon cancer deaths are preventable, but we think the vast majority of them are in patients who undergo proper testing.

Colonoscopy is expensive, isn't it?
The up-front costs can be a little daunting, but it is a whole lot cheaper than the costs of treating advanced colon cancer. It is so much cheaper that the Federal government is underwriting colonoscopy screening in Medicare beneficiaries.
In the long run it also saves the health insurance companies money. Recently I received a card from my health insurer reminding me that I was over 50 (thanks for the reminder!) and that I should be thinking about undergoing colonoscopy. This is proactive behavior on the part of the health insurer at its best.
By comparison, it is actually less expensive to save a life from colon cancer than it is to save a life from breast cancer.

You promise you'll sedate me for this?
We got more sedation than you have anxiety. I didn't feel a thing when I had mine, and I was glad I could check off colon cancer from my list of worries!

About that death wish

2006-02-19T22:44:00.000-05:00

Yesterday was a fine day, of a sort: 20 degrees F, 3 inches of snow on the ground, and gray, overcast skies. After struggling to get my morning rounds performed, I took my son's bike out to the local trail for my first ever snow ride. My wife had lobbied vigorously against this endeavor: "You'll kill yourself out there", she said matter of factly, and reminded me that the Fate of Western Civilization rested on whether I was able to emerge from the trails unscathed.

Taking my son's bike was a good idea. His has disc brakes, and besides looking cooler than V brakes, they work well regardless of how much ice and grunge builds up on the wheel rims. Yesterday there was a lot of ice and grunge, and salt, and even mud, I'm embarrassed to say. More about that soon.

Riding at noontime in overcast skies, I was surprised at the abrupt changes of trail conditions I would encounter. I loved the "frozen tundra", where the snow was hard-packed and made crunchy Rice Krispy sounds as you rode over it. The grip was firm and reliable, except for one spot were there was some mud just below the surface. Down I went, but it wasn't painful; it just left a huge mess on my clothes.

The trail would then change into the "snow-mosquito infested swamplands" which are the bane of all responsible mountain bikers. Riding in mud is irresponsible because it tears up the trails and accelerates erosion, and everytime someone does it, God kills a kitten out of frustration. I'd find my way to the nearest road as quickly as possible. I was not going to have some innocent kitten's death on my conscience.

Riding on a snowy trail is a rush. Riding on an icy road is not. Losing control on a mountain trail and plummeting hundreds of feet to my demise would be cool in it's own way. Falling on icy pavement and breaking a hip would only be very painful and very stupid. I'm riding the icy road trying to save the life of a kitten and I'm fearful of my own life the entire time. My fear is accentuated as I hear a sickening metallic crunch behind me. A van has skidded out of control on the icy road and taken out a road sign. Was it the sign that said "Road freezes because of global warming, and its Bush's fault"? I was too frightened to go back and check it out. That metallic crunch could have been my bike.

I got back on the trail and spent more time alternating between frozen tundra and swampland. I was able to work my way back to my starting place without rutting up the trail in too many places, although my bike (or rather, my son's) is now covered with multiple layers of snow, mud, and salt. It looks nasty. Did a kitten die at the hands of an Angry God on my account? I don't know. I do know that I felt great for the rest of the day, and fell into an Ambien-less sleep in a matter of minutes. I felt more alive this day than I had in a long time.

I will feel even more alive when my son sees what a mess I've left his bike in. At that moment I will face death, especially if I by chance messed up the rotors to his disc brakes. Pray for me, now and at the hour of my death.

Death's not my first choice but...

2006-02-17T19:21:00.000-05:00

This is one of my favorite doctor jokes:

Q: Why do doctors go into psychiatry?

A: To get free advise.

Psychiatrists didn't find that joke very amusing 25 years ago, but now they're having the last laugh. Stress disorders, depression, ADD, ADHD, and general gloominess are so rampant in our culture that knowledge of psychopharmacology comes in handy. I know how to treat Crohns disease. I don't really know how to treat Hashimoto's thyroiditis anymore, and that doesn't bother me much. But I really wish I were a bit sharper on the treatment of lawyer-induced chronic depression (a recognized medical entity, by the way).

When I was younger I wanted to go into psychiatry, until I was seduced by the dark side of the Force, that aspect of medicine dominated by Pathways and Mechanisms, by Techniques and Procedures.

I enjoyed "fixing things" or at least sharing the illusion of it. Surgery and cardiology were a bit too intense so I opted for the more laid-back field of gastroenterology. It's been a good fit, and I'm glad I chose it. These days I've been ready for a change, and for a specialty that I never would have dreamed of being drawn to.

When I turned 40 I was chunky and sluggish and determined that I wouldn't be that way for much longer. Fueled with the energy that comes with Mid-Life Hypomania, I lost forty pounds, built up muscle, took up skiing and horseback riding, and subtracted 15 years from my physiology. I felt great.

When I turned 50 I was chunky and sluggish and determined that I wouldn't be that way for much longer. At 50 I had no more mid-life energy; I had "matured", which meant that I was just tired. What excited me the most was the prospect of catching a cat-nap. I'm 53 now, but I won't be for long, and the leaves that are green turn to brown, and I'm still chunky and sluggish and have reason to believe that I'll stay that way until I get chunkier and sluggishier and so on and so on until I die some day.

I'm not being morbid. That's just the way it is.

So I could use some free advise facing these end-of-life issues. For the first time in my life I wish I had gone into Oncology, because in facing death we face life. When we face total loss we realize which things we are carrying that are worth the weight, and which ones are not. If I knew as a fact that I had pancreatic cancer with metastasis to the liver, I would not be wondering if it were worth upgrading my TV to high-def and getting TiVo installed in my cable box. I would want to tell my wife and my daughters and my son how much I love them and how I wish I'd bother to tell them that a lot more that I ever had when I thought that I would live forever. I'd tell my friends that I consider them friends. I just assume they know that. I never come out and tell them.

Last week I was discussing with a family the outlook for a man with pancreatic cancer that had spread to the liver, and almost surely by sound of things to a few other places as well. On a physiological basis there is not a lot of good news to share; there is no good news to share, other than to discuss the advances that we've made lately in palliative care.

"But Doctor, is it right to take all hope away from him?"

Baring divine intervention, do we take away all hope by sharing with families that the 5 year survival rate for advanced pancreatic cancer is essentially 0?

What survival rate do any of us have? 40%? 80%? Last I checked the same fate awaits every single one of us. Our collective survival rate is 0. Have we no hope? Shall we delude ourselves and tell ourselves something different? Would we really want it to be different?

What hope does my patient have? He knows he's going to die, like all of us, but he knows that his time will come very soon. Does he have relationships that need to be mended? Does he have people that need to hear about his love for them? Does he need to reconcile himself to whatever his belief is concerning Eternity? Does he find comfort in the fact that his thirty year mortgage and his 1040 and his zero coupon bonds are no longer of any importance to him? Is there no hope in this?

"There's something to be said about having 'the big one' and getting it over with in a hurry", I hear people say all the time. I don't think so. I think I'd have too many regrets dying suddenly, if I were capable of having any regrets at all.

My career is being prolonged because I have the priviledge of telling the vast majority of the patients that I see that they do not have colon cancer, and that has become a great source of joy to me. I hope to be able to continue to deliver this good news to people for years to come. But it is with the unfortunate ones, the ones that I must share the unthinkable, the unhearable and the unimaginable, that I am learning the most about myself and my life.

Free advise and worth every penny

2006-02-10T12:29:00.000-05:00

It was a mistake to drink that third cup of Starbucks.

I knew it as soon as the vile brown teeth-staining fluid sullied my lips. This week I have hovered in the nether-region between illness and good health, too tired and sullen to exercise but too healthy to have anyone or anything to blame for it. When I'm in that mood, a third cup of coffee is not in my best interest. Now I feel like I have two hundred rabid parakeets clawing and fluttering in my brain, threatening to explode out my sinuses at any moment.

The parakeet simile is overwrought, of course, but it is not soothing at all to walk into my office after a pleasant and tranquil morning at the endoscopy center and be faced with lots and lots of the usual: "Mr. Jones is furious that you said he drank too much", "Mr. Smith wants you to say its OK for him to skip his colonoscopy because he hasn't seen anymore bleeding for a while", "the Blessed Fields of Dreams insurance wants you to rewrite all your prescriptions to some other drug that they get for less this month", "a patient is suing somebody who hit her with a car and wants you to say that her irritable bowel syndrome is all the plaintiff's fault" and so on and so on.

As I said, that third cup was not wise. I drank it anyway because I have an addictive personality and I just couldn't help it, but I knew it was a mistake.

"Hey Doc, I know of a blogger you would really enjoy. She's brilliant, writes well, and has read every book in the English literature. She's a little to the left of center but I'm sure you'll enjoy her anyway", says a nurse at the endoscopy department. Fine then, I'll check it out. I need something to relax me a little.

The website is nothing more than tired recycled unimaginative Bush-bashing liberal tripe. There are two things that this world just doesn't need anymore of, yes, even three things: No more pseudo-elitist producing liberal tripe, no more pseudo-rednecks producing more conservative tripe, and no more foul cranky doctors kvetching to the world because he's tired, a little peevish, and overdosing on caffeine.

Now that I've cleared the air, let me offer some suggestions on what I think an enjoyable blog would include:

1) Straight party lines are BORING!!! Try to mix it up a little. That was what was so endearing about Hunter Thompson: he was a liberal who enjoyed a huge armory of weapons and loved to shoot animals and blow things up. Imagine, a liberal who is a gun nut, or a conservative who is terrified of them (such as myself). Good stuff.

2) Open yourself to the possibility that people who think or feel differently on things than you might actually have good reasons for doing so. Well-reasoned political writers of any stripe are in short supply, but they are out there. If you're a liberal, for example, make yourself read one David Brooks column a week. It won't hurt that much. Honest.

3) If you rant about how much you hate the hatemongers, it makes you look like a total idiot. Rethink your strategy.

4) Try poking some fun at yourself for a change. Never rag on someone with criticism that you couldn't possibly think would ever apply to you. Admit that you can be hypocritical, self-serving, mean-spirited, or just plain wrong. You'll feel better about yourself, and everyone else knows it anyway.

5) Never post when you are caffeine-toxic.

The principle of paradoxical risk

2006-02-05T12:47:00.000-05:00

One of our "throw-away" journals recently ran an article with this startling conclusion: 'defensive medicine' is a huge problem in America, resulting in an enormous economic drain on our healthcare system.

Practicing physicians have known this for years. Out of narrow self-interest, the trial lawyers have been misrepresenting the magnitude of this problem. If they gave two hoots and a holler about the welfare of patients, they would at least acknowledge that this problem exists and perhaps come up with some constructive suggestions on how to fix it. But they don't, and they won't.

There are many thoughtful reviews about this problem, and I won't burden the Thinking Public with yet another one. I will suggest that among the forces behind the Defensive Medicine Crisis is the Principle of Paradoxical Risk. I have no idea whether anyone else has described this. I've never read it, so I'm happy to take full credit for the concept.

If I see an 80 year old who is complaining about passing blood in the stool, there is a reasonable chance that the patient has colon cancer based on their age alone. If I blow the diagnosis, then Ill be liable for economic damages which are going to be limited to the extend that the patient's "earning potential" is likely limited. If I live in a state with some sort of limitation on "pain and suffering" damages, then my liability will be further limited unless the court can prove that I was willful and malicious in my malpractice, and I get nailed with punitive damages.

Will the threat of malpractice influence my behavior in this case? Of course not. I get paid to make the diagnosis of colon cancer, and, knowing the odds, I'm not about to pat a patient on the back and tell him to take some Preparation H. I'll schedule the colonoscopy.

How about a 60 year old with the some complaint? The patient is less likely to have colon cancer, but the economic damages will be higher, assuming that the patient is still working. The "cost" of blowing the diagnosis of colon cancer will be higher, although the risk of the patient having colon cancer is lower. Again, this isn't going to influence my decision-making. The right thing to do is to proceed with colonoscopy, and I get paid for doing the right thing.

But what about the 20 year old who presents with the same complaint? If I blow the diagnosis of colon cancer I'll have the Devil to pay. The plaintiff will claim 45 years of high economic productivity that I'll be denying him. Unless I live in a tort-reform state, the plaintiff will also parade a steady stream of friends and family who point out how a beautiful young life was snuffed out because of my negligence. I'd be thrilled to settle within the limits of my malpractice insurance. No one would be happy about this.

What are the odds of a 20 year old having colon cancer (I'm assuming the patient has no risk factors such as chronic colitis or a family history syndrome)? What are the odds of complications from colonoscopy vis-a-vis the risk of colon cancer? What is the cost-effectiveness of putting 20 year olds with rectal bleeding through the mill over what is almost always hemorrhoidal bleeding?

The Principle of Paradoxical Risk states that "the less likely a serious medical condition is, the more likely you are to get your butt sued off if you don't diagnosis it".

The Principle of Paradoxical Risk states that these questions have no relevance to the discussion. If you miss the diagnosis of colon cancer in a 20 year old, you will be savaged in every conceivable way. You'll have to look at yourself in the mirror every day realizing that you could have saved the life of a person younger than your own children. You'll be financially ruined. The ordeal of a malpractice suit would drag on for at least 4 to 5 years (plaintiff attorneys do this because it is in their financial best interest).

Fifteen years ago, a gastroenterologist who performed colonoscopy routinely on 20 year olds with rectal bleeding would have been accused of churning. Do you think they would be accused of it now? What would you do? Saying you would just retire from medicine because operating in such an evil atmosphere would take too high an emotional toll is an acceptable answer.

Taking stock

2006-01-29T12:12:00.000-05:00

Truth be told, I've always taken pride in having an addictive personality.

Don't expect to read the diagnostic criteria on this website. Like the mainstream media journalists I emulate, I'm too lazy to look stuff like that up, and when it comes to blogging I'm no stickler for details. Trust me, addictive personality is like love itself: difficult to define, but we all think we know what it is.

Inconveniently for my self-assessment, I've not suffered from a major addiction: booze gives me a headache and flares my GERD; I'm too law-abiding to get illicit stuff; even legal addictive drugs would take too many fake complaints and doctors visits to obtain, and I'm too pig-headed to acknowledge that I could get some malady that I couldn't diagnosis and treat on my own. I have struggled with workaholism, but after suffering from massive burn-out I've been cured of that for the most part.

My addictive personality has been a peculiar comfort to me. It's reassuring in some weird way to know that there are dark forces that compel me to do stuff I may not want to admit to. It would definitely come in handy if I were accused of extra-marital relationships, for example. We're indebted to Bill Clinton for educating us all on that one.

One addiction that I've always been fearful of is gambling. I've never had any doubt that once I took my first bet that I would succumb to some primal blood-lust and take wild chances with my children's education and my pension.

So I decided to do some research on a cruise this past week (you've never heard me whine about poverty, and I'm grateful to have the means to spoil myself and my wife every now and then). One of my traveling friends invited me to join him at the blackjack table, and, against my better judgment, I joined him.

Within an hour I had tripled my initial amount. The other players at the table viewed me with admiration. The floor manager eyed me with suspicion. I started to mutter "Wopner, Wopner", under my breath, seeing if I could convince anyone I was an idiot-savant like the Rainman as portrayed by Dustin Hoffman.

If you're going to experiment with "drugs", why not just mainline them and go for the maximum effect? After awhile I started planning on how I'd be able to pay for shore excursions. Who knows, maybe if my luck held I could pay for the whole trip.

I went back to the tables several times, playing wisely and following the odds as best I knew how. My traveling companion is a "card-counter", so I would watch his bets carefully and would up my own if the "counts are favorable", an act that would have gotten us tossed out if they had caught us.

After diligent hours at the gaming table I decided I'd had enough, and that I'd retire on my winnings: $12.50. On a per hour basis I was making considerably less than minimum wage.

I quit not out of discouragement but out of boredom. I got tired of the smokers blowing their poison in my face. I got tired of counting the little numbers on the cards to see if they exceeded 21. I got tired of sitting in one spot for hours on end when I could have been off reading a book (even so I was able to read The Curious Incident of the Dog in the Nighttime and almost finished The Life of Pi, good books both).

I had to face the cold brutal truth: I felt no addictive calling to gambling.

I then had to face a colder, more brutal truth: I don't really have an addictive personality.

All these years I'd been doing more or less whatever I'd wanted to, and if challenged I would invoke dark forces over which I had no control. Work 80 hours a week for ten years? I'm a workaholic. Read every biking book and magazine in the English language? Sorry, just can't help it. Watch reruns of "Whose Line is it anyway?" every night at ten, come hell or highwater? No sane person would do that.

None of it was true. I'm just an undisciplined twit.

There are no local chapters of "Twits Anonymous" around that I know of. I'll never enjoy the camaraderie of announcing to the world, "Hello. I'm Jus and I'm a twit." I'm on my own on this one.

And that, I'm afraid, is the truth.

Time

2005-12-31T10:33:00.000-05:00

For the hardcore introvert there are three words that strike terror into the heart: "You are invited". I hate parties. They are like Death itself, except Death seems to be finite and some parties drag on for Eternity. I'd rather have a root canal.

My mission at any party is to make as clean a get-away as possible without destroying what little social standing I have. Properly done, I can condense a wedding reception into one long graceful movement: walk in the door, extend my congratulations to the bride and groom, grab a bite to eat, and thank the parents, all done without ever touching a chair or talking to anyone I don't know or would like to avoid.

I'm not anti-social, it's just that I got better things to do with my God-given time.

Maybe I have a poor attitude. Maybe I should change.

Yesterday my younger daughter was married. When it comes to wedding planning I try to be a non-combatant, either mediating between warring parties, or just ducking out of the whole thing until the fallout settles. When the big event comes, visitors graciously give me credit for all the planning and I explain that I only sign the checks, even though I didn't even do that much (my wife did).

This was my second and last daughter to be married. Our first daughter's wedding had an ad hoc quality about it. It was our first wedding and lots of things went wrong. Everyone laughed it off, relaxed, and had a great time. There was dancing into the night. Levity was the order of the evening.

This time around our (my wife and younger daughter's) planning was seamless. Everything was perfect. Instead of a DJ we had a live swing band. Instead of a buffet we had a formal sit-down dinner. Even the bride's dances were choreographed. We came prepared to dance the night away.

Contrary to my nature, I wandered about greeting folks that I knew and saying hello to folks I didn't. It occurred to me that we were not likely to ever have this crowd under the same roof again until my fourteen year-old son gets married, or until I die and they gather for my funeral.

As I was getting ready to walk my daughter down the aisle, she said "Daddy, walk slowly. I want to enjoy this moment for as long as I can". We walked very slowly, my daughter appearing as beautiful as she ever has, with me trying to look invisible as to not detract from her moment.

I wanted the reception to go on all night. This was my baby getting married. We had planned for this over the last year. Everything was perfect. This day is one to be enjoyed, savored, lingered over.

But this is America, a nation of very busy people with Lots of Things To Do.

Just as I was settling in for the evening, guests started to pay their respects on the way out the door. I'm glad you could join us, I tell them. The reception is lovely but the moms did all the work. Thank you for coming.

But that's not what I'm thinking. What's the rush? Look at my daughter, how happy and beautiful she is! Listen to the band. They're just getting warmed up. Don't go quite yet.

"Dad, it's almost time for us to go", my daughter says. That is my cue to line folks up outside and give them the matches and sparklers. The reception hall does not allow for flower petals or rice to be thrown, but doesn't mind if guests wave sparklers for the bride and groom as they make their getaway. It's an idea I've been opposed to. I have visions of some guest's hair or jacket catching fire and having our friends and Defenders of the Public Trust, the lawyers, sue my butt off. We have 750 sparklers and, to my dismay, it's not raining, so we have to use them.

To my relief no one catches fire. The only injury I know of was my older daughter who had a slight burn on one of her fingers. She told me later that she thought about calling a personal injury lawyer but didn't want to sue herself out of her inheritance.

My new son-in-law, romantic to a fault, has a horse-drawn carriage awaiting the newlyweds as they work their way through the gauntlet of fire. They give us a quick wave and then they are gone.

"How lovely!" say our guests. They thank us once again, and then they are gone, too.

And it is over so quickly.

Milestones

2005-12-19T19:06:00.000-05:00

In this quiet year of my life I've passed several milestones. This year marks my twentieth anniversary as a gastroenterologist. I'm thankful that the field still provides me with challenges and is a source of fascination, no less now than in the first year of training.

This month I picked up my younger daughter for the last time at college. She went through on an accelerated program, cramming four full years of school into three and a half. I'll miss her school's beautiful campus. I won't miss her school's tuition payments.

Part of my daughter's final studies involved taking a personal finance course, or "Getting ready for Harsh Reality 101". Part of her assignment was to review our car insurance, including deductibles, limits of coverage, etc. I either wish I'd done the review three years earlier, or not at all. I had no idea I have a $100 deductible on an old junker I own. I had forgotten about a fender-bender my wife had been in 5 years ago. And they said it was all her fault. Bummer.

Just then I realized I had passed yet another milestone: it has been five years since anyone has sued me for anything.

The lawsuits are ever with me, so it came as a shock that it has been that long since I received that frightening letter:

We are reviewing these circumstances to see if there is any merit to the suit that the plaintiff is now pursuing. We are definitely suing some other doctors involved in this case. Could you be next?

I suspected that the function of this letter was to see if it could prompt me to call the attorney and offer to turn "state's evidence" and give inside information/dirt on the other doctors in order to save my own hide. My own attorney agreed.

"These guys do that all the time, and some doctors fall for it. I'm glad you didn't. It would have voided your own coverage, you know".

I knew.

It's been five years since then. I wish I could say that I'm such a better risk because I'm better as a physician, but I'm not. I'm certainly more cautious. I avoid high risk patients like the plague; I dismiss any patient I catch lying about anything. I'm just better at avoiding lawsuits, I suppose.

If I've learned anything, it's that no one is going to give me a good citizenship award for working 16 hours a day as a matter of habit. The wisest thing I've done is to see myself as a retired physician, one who is no longer able to work because of unavailability of liability coverage. So what do I do with myself now? Who knows, but life will surely go on.

Until then I will enjoy my practice but will keep taking Wednesdays off to go mountain biking. I won't come in on Saturdays for out-patient procedures so that the patients don't have to burn a sick day. I'm going biking with my son then.

And I will, as always, keep up with the literature. The field is just too interesting to go along as a bystander.

Happy festive occasion!

2005-12-09T13:44:00.000-05:00

This isn't original - I'm not even sure where it came from - but it is very funny.

FROM: Patty Lewis, Human Resources Director

TO: All Employees
DATE: 1 October 2005
RE: Christmas Party

I'm happy to inform you that the company Christmas Party will take place on December 23, starting at noon, in the private function room at the Grill House.

There will be a cash bar and plenty of drinks! We'll have a small band playing traditional carols. Feel free to sing along!

And don't be surprised if our CEO shows up dressed as Santa Claus!

A Christmas tree will be lit at 1.00pm.

Exchange of gifts among employees can be done at that time; however, no gift should be over $10 to make the giving of gifts easy for everyone's pockets.

This gathering is only for employees! Our CEO will make a special announcement at that time! Merry Christmas to you and your family!
Patty

*****************************************

FROM: Patty Lewis, Human Resources Director
TO: All Employees
DATE: 2 October 2005

RE: Holiday Party

In no way was yesterday's memo intended to exclude our Jewish employees.

We recognize that Chanukah is an important holiday, which often coincides with Christmas,, though unfortunately not this year. However, from now on we are calling it our "Holiday Party". The same policy applies to any other employees who are not Christians or those still celebrating Reconciliation Day.

There will be no Christmas gift exchange, it is now called just a gift exchange. No Christmas carols will be sung. We will have other types of music for your enjoyment.

Happy now?

Happy Holidays to you and your family.
Patty

***************************************

FROM: Patty Lewis, Human Resources Director
TO: All Employees
DATE: 3 October 2005

RE:Holiday Party

Regarding the note I received from a member of Alcoholics Anonymous requesting a non-drinking table....................... you didn't sign your name.

I'm happy to accommodate this request but if I put a sign on a table that reads, "AA Only", you wouldn't be anonymous anymore. How am I supposed to handle this?

Forget about the gifts exchange, no gifts exchange are allowed since the union members feel that $10 is too much money and executives believe $10 is a little chintzy.

NO GIFTS EXCHANGE WILL BE ALLOWED.
Patty

***************************************

FROM: Patty Lewis, Human Resources Director
TO: All employees
DATE: 4 October 2005

RE: Holiday Party

What a diverse group we are! I had no idea that December 20 begins the Muslim holy month of Ramadan, which forbids eating and drinking during daylight hours. There goes the party!

Seriously, we can appreciate how a luncheon at this time of the year does not accommodate our Muslim employees' beliefs. Perhaps the Grill House can hold off on serving your meal until the end of the party - or else package everything for you to take it home in little foil doggy bags.
Will that work?

Meanwhile, I've arranged for member of Weight Watchers to sit farthest from the dessert buffet and pregnant women will get the table closest to the restrooms.

Gays are allowed to sit with each other. Lesbians do not have to sit with gay men, each will have their own table. Yes, there will be a flower arrangement for the gay men's table.

To the person asking permission to cross dress, no cross-dressing is allowed.

We will have booster seats for short people. Low-fat food will be available for those on a diet. We cannot control the salt use in the food, we suggest those people with high blood pressure to taste the stuff first.

There will be fresh fruits for diabetics, but the restaurant cannot supply "no sugar" desserts. Sorry!

Did I miss anything?!?!?
Patty

******************************************

FROM: Patty Lewis, Human Resources Director
TO: All effing employees
DATE:5 October 2005

RE: The effing Holiday Party

Vegetarian effers, I've had it with you people!!! We're going to keep this at the Grill House whether you like it or not, so you can sit quietly at the table furthest from the "grill of death", as you so quaintly put it, and you'll get your effing salad bar, including organic tomatoes. But you know, tomatoes have feelings too. They scream when you slice them.
I've heard them scream. I'm hearing them scream RIGHT NOW!

I hope you all have a rotten holiday! Drive drunk and die.

***********************************************

FROM: Joan Bishop, Acting Human Resource Director
TO: All employees
DATE: 6 October 2005

RE: Patty Lewis and Holiday Party

I'm sure I speak for all of us in wishing Patty Lewis a speedy recovery and I'll continue to forward your cards to her.

In the meantime, Management has decided to cancel our Holiday Party and give everyone the afternoon of the 23rd off with full pay.

Happy Holidays

Nothing but the finest

2005-12-08T18:52:00.000-05:00

I must receive twenty head hunter mailings a week, each promising obscenely large sums of money if you relocate to an out-of-the-way town and work 80 hours a week until you retire from burnout or repetitive stress injury on your hands from pushing scopes all day long.

Every now and then I receive a mailing that looks interesting, and this past week I got one that was so appealing that I promptly send the recruiter my CV:

Take care of military personnel and their families! No weekends, no night call! (No malpractice because you can't sue government workers!) Nice city! Teaching available!

What more could I want? Right after I sent the recruiters my CV, I composed a letter to my patients:

Dear patient,
I have lived in this area for almost twenty years and regard many of you as friends, even members of my family, so I am sorry to announce that I am closing my practice in six months in order to take a cushy government job where none of you can sue me for my house, kids' college educations, or pension. When a physician was elected governor of this state we all hoped that meaningful malpractice reform was right around the corner. Instead, the opposition party, which relies on the State Bar Association for sizable campaign contributions, not only has blocked his every move but is forcing him to waste his time defending himself from persecution from the State Attorney's Office (who is a member of the opposition party) from charges that would have made the Salem puritan magistrates blush.
Well screw it, people. When you wake up and find that no one with more than three years experience is available to take care of you, you'll have all the rich ambulance chasers to thank.

A tad harsh, to be sure, but I figured by the time the letter actually went out, calmer heads would prevail and the letter would lose some of the edge. I can always dream.

The sad thing is that when the recruiters call me back, I always feel like I'm applying for the position of cashier at the local convenience store because I'd be a little overqualified. "I must say that your CV looks great! Any chance you can start work next week?"

"Um, next week? I'd love to, but I'm a solo doc in a very busy practice and it would take me about six months to close the practice down (a very optimistic estimate, by the way)."

"Oh, darn. This is a contract position that would last one year. It might be renewed at the end of the year, maybe not."

"Let me be sure I understand. You're looking for a competent gastroenterologist who is prepared to pull up stakes in a moment's notice and relocate to a new city with no more than one year's guarantee that he'll be employed?"

"Well, no one said that our job was easy."

Good luck. I'm just an average Joe who can whip a scope around, but I cannot imagine them finding a decent doc who is in such a position. Maybe they exist. I hope so. I'd hate to think that the government was only looking for warm bodies to take care of Our Finest.

How to tell if you've joined the vast right-wing conspiracy

2005-12-06T21:20:00.000-05:00

1) You hear someone talking about "morality" and you no longer instantly assume he must be a sexually repressed religious nut.

2) You're actually relieved that your daughter plays with dolls and your son plays with guns.

3) You sit all the way through Dead Man Walking and at the end still want the guy to be executed.

4) Christmas season rolls around and it hits you there may be a religious connection.

5) At your kids' back-to-school night, you are shocked to discover the only dead white male on your tenth-grader's reading list is Oscar Wilde.

6) And by the end of the night you realize the only teacher who shares your values teaches phys ed.

7) Much as you'd like to, you can't get yourself to believe that screwing around on one's wife is an addiction.

Taken from "How I accidentally joined the vast right-wing conspiracy and found inner peace" by Harry Stein

Freak snowstorm closes Paris subway system

2005-12-01T19:22:00.000-05:00

One of the most obnoxious bumper stickers I've seen lately said something to this effect: "If you want to be patriotic, you'll have to do more than slap a yellow sticker on your car. You'll have to get informed." I was tempted to leave a note on the windshield that said, "Thank you for encouraging open and honest political discussion in this country by announcing that anyone who disagrees with you is an ignorant fool. BTW, you're a stinking traitor."

That might have been a little harsh. I really came away wondering, "OK, I've had it with the unwashed red state masses. Just where do I go to get educated properly? CNN? CBS? The New York Times? The Daily Kos?"

I'm afraid I'd have to overcome some major distrust issues, like being asked back to a marriage with a habitual philanderer. Which brings me back to what I thought was a weird headline from my local paper in 1982 or so: Freak snowstorm closes Paris subway system

In 1980 our country suffered a horrible epidemic the likes of which had never been seen in any civilized culture. This epidemic vanished in the 1990's, only to make a resurgence over the last five years. This was the epidemic of the homeless: millions of perfectly normal people who, because of the viciousness of the Ronald Reagan Tax Cuts Only For The Rich, were tossed out of their comfortable middle-class homes and were forced to sleep over grates and live by looking for half-empty dog food containers in the trash of those few people (mostly Republicans) who were able to hang on to their own homes.

I was a registered Democrat and a loyal ABC Nightly News viewer back then. It bothered me a little that the few homeless people I ever personally saw were schizophrenic drunkards, but ABC and all the other Major News Outlets surely knew what they were talking about. And they made sure that I understood that mass homelessness had never occurred in any other culture or country. It was strictly a modern American phenomenon directly related to Ronald Reagan's Tax Cuts Only For The Rich.

So the headline I saw one day, on A8 of the local paper was very perplexing. A subway is underground, so how on earth would a snowstorm close it down? I read on. When the snowstorm hit Paris, everyone was caught by surprise. All the homeless of Paris, some 50,000 strong, fled the streets to the relative comfort of the Parisian subway system.

It was not the snowstorm that closed the subway system after all, but all the French homeless that jammed up the underground so that paying customers could not get access to the trains.

50,000 homeless in the most urbane capitol of the most enlightened nation on earth, one not only untouched by Ronald Reagan's Tax Cuts Only For The Rich but in a system that prides itself on its compassionate socialism? I felt as if I had wandered into my bedroom to find my spouse in the arms of a significant other.

Many women, when victimized by a philandering husband, obtain a divorce and remarry yet another philanderer. In 1982 (or thereabouts) I swore that I would never watch ABC Nightly News again. Instead I relied on PBS/NPR to provide me all the information about the world I would ever want to know. This changed in 1991, when NPR campaigned actively on behalf of Bill Clinton. I still like NPR, but when I listen my mind's eye shows someone continually giving me the "wink wink, nudge nudge". I don't trust them, or ABC, or CBS, or the New York Times. They have to earn back my trust if they want me to take them as anything other than a mouthpiece for the Democratic Party.

They haven't been trying to win my trust back very hard. Consider these two fairly recent headlines, seen in the A4 or A6 pages of the local newspaper:

Polar icecaps on Mars receding.

The "Great Red Spot" on Jupiter slowly vanishing

Both of these changes are occurring because of global warming issues on these planets, yet they have no SUV's, defoliated Amazon rainforests, ignored Kyoto treaties, or drilling in the Alaskan wilderness.

What I know about America's greatness I learned from immigrants

2005-11-14T06:27:00.000-05:00

Like many places, my city plays host to many different groups of immigrants: primarily Ukrainian, Bosnian, and Hispanic. I appreciate the last group because I'm trying to learn Spanish, and nothing helps to build the vocabulary better than walking through the local Home Depot.There's a smattering of other nationalities here from Eastern Europe, primarily Romanians. Romanians don't get no respect; our local drug stores provide free translation services for Poles, Vietnamese, and Filipinos, but not for Romanians. I think that's unfair. Any nation that has lost virtually every war they've ever fought in, yet thrives as an independent state (another country that comes to mind is Finland) deserves some respect, for resilience if nothing else.

An immigrant once told me, "No one knows exactly what the American Dream is, but what all Americans share is that we all believe that there is such a thing." Just as few defend the faith with the vigor and clarity of enthused converts, new Americans often see our country with the respect that we jaded old-timers lose after just a few generations.

I was proud of the unity that our country initially displayed after 9-11. In many ways I hope never to see the most touching scenes ever again: walking by a visitor's lounge at the hospital and seeing a dyed-in-the-wool "redneck", with his long hair braided into a pony-tail, openly weeping as the camera panned over the rubble of the twin towers. I didn't ask him if he were a registered Republican or a registered Democrat. That kind of thing didn't seem very important at the time.

One of the most passionate and outraged Americans I encountered was a Ukrainian who had recently just received her American citizenship and works as our hospital's librarian.

"How can zey do zees to my country!?!" she exclaimed in her heavily accented English. She'd been in this country for ten years, and she was every bit as American as my family that can trace it's descendants to the 1700's. Maybe even more so, given that members of my family couldn't tell you what the three branches of American government are to save their souls.

Back then one of my patients was an 95 year old woman from Poland. She showed up for appointment wearing a beautiful embroidered tiny American flag on the label of her jacket (like most folks her age, she would never have gone to the doctors wearing jeans and a sweater). She had had classic irritable bowel syndrome for sixty years, and nothing I prescribed ever affected her symptoms one way or another. She could remember the exact day her symptoms began.

"My father owned an apartment building in Poland. I remember one night the Nazis came and dragged off all the Jews. I remember the sound of their heavy boots coming up the stairs like it was yesterday. I've been nervous ever since. Then after the war one night the Communists came to my father's apartment building. This time they were looking for my father because he was a land owner. We left very quickly. I've had bad diarrhea ever since."

I've traveled to Romania three times and came away with two things. I'm told I have an excellent Romanian accent, probably because I naturally speak in a monotone and I can roll my "R's". I also have an enduring hatred of totalitarianism, regardless of ideological stripe. Nicolae Ceausescu was a "liberal" of sorts who routinely thumbed his nose at the "conservative" Kremlin hard-liners. He was also a vicious lunatic who damaged the Romanian psyche so deeply that it will take a generation or two for his ugly scar to heal.

Because I at least try to speak a little Romanian, I get to see what few Romanians live in my area. One of my patients is an older woman who was educated as, of all things, a lawyer.

"My education was a total waste of time under the Communists," she said. "The judges didn't care about the law. Most of them didn't even know it. You couldn't bribe them because they were rich compared to the rest of us, who had nothing. All the opposing lawyers could do is to convince the judge which one of them was the biggest Communist. I didn't care for the Communists, so I never won any cases."

I never knew what she thought about our Supreme Court and the conduct of the Senate Judicial Committee. I don't know what she thinks about our political climate in which our first question to any statement of "fact" is not "Is it true?" but "What is the party affiliation of the claimant?" Next time I see her I'll have to ask.

From what I can tell (perhaps there is some irony in this statement), the only just war we have fought since WWII was the Serbian campaign, in which we dislodged a murderous tyrant who, although he was a constant menace to his neighbors, posed no security threat whatsoever to our country. During the campaign our home shower door broke and needed replacement.

Two Bosnians came over to replace our shower door. One was a Muslim, the other an Orthodox. This struck me as a bit curious, given the enmity between the two groups that we were all seeing on CNN.

"Of course we would probably be trying to kill each other if we were back in Bosnia," the Muslim said, "but this is America, and here we all can voice our own views without any threats".

I think that moment was the proudest I've ever been of my American citizenship.

Crisis of the uninsured

2005-11-13T10:10:00.000-05:00

The enormous number of Americans without health insurance constitutes a moral and economic crisis. Perhaps we could extend coverage to these folks if only doctors, hospitals, health insurance companies, pharmaceutical companies, medical supply companies, and malpractice lawyers all decide that for the Public Good we'll do with less money.

As I ponder that last sentence, I think of which groups willingly and cheerfully work for less money than what they could be earning in the "free market". Those in the ministry (including the occasional secular do-gooder) and those teachers who shun the public school system and work for peanuts in private schools are about the only people who are willing to make that sacrifice.

For everyone else, to expect us to surrender income obligingly is to indulge in Utopianism/Totalitarianism. I say this not from any ideological perspective, but from simple observation. If you are thinking, "Well, I'd take a big pay hit for the good of mankind!", I would conclude that you are in the ministry, or teach in a private school, or are unemployed, or are less than honest with yourself.

The rest of us take pay cuts either when we're forced to, or when we make trade-offs for lifestyle considerations. We're just not wired to surrender our earning potential "for the Public Good".

The boiler-plate media portrayal of the uninsured is that of a 50 year old middle class male who gets laid off by his profit-seeking company, loses his health benefits, has a heart attack over the stress of it all, and incurs hundreds of thousands of dollars of medical bills which he cannot hope to ever pay. I'm sure this really does happen from time to time.

I'm on ER call this week so I kept track of all the uninsured folks I was asked to see. I've never met a "boiler-plate uninsured" and I thought this would be a good opportunity to look for one.

Here is my list of the uninsured:

middle aged male with alcoholic pancreatitis. He actually was laid off and lost his benefits for his erratic behavior which I suspect was due to his alcoholism. He was a very nice fellow who thought that his three sisters were unfairly ragging on him for his drinking.
middle aged male with alcoholic pancreatitis, in and out of the chemical dependency center. Not really interested in stopping because it was his ex-wife who drove him to drink.
young gangsta with alcoholic pancreatitis. He is a good-looking charismatic gentleman who could amount to being a lot more than a gangsta under the right circumstances.
middle aged male with GI bleeding. He owns his own business but chooses to save money by not covering himself. He's not worried about his bills because he was rear-ended by someone two years ago and he's going to sue the driver and all the physicians who saw him six months afterwards. "You don't have a thing to worry about, Doc". Thank goodness.
young male with belly pain due to anxiety, and probably from karmic retribution for being such a sociopath. He also owns his own business.
middle aged male with bad esophagitis. I'm not sure why he doesn't carry any insurance, but his responsible next of kin was his mom. That always raises a red flag for me when the patient is a middle aged male. Could it be that no one other than his mother wants to put up with the guy?

This is a random unscientific survey, of course, but I would conclude from this list that if we were to eradicate alcoholism and figure out a way to integrate sociopaths into our society better, that just maybe the problem of the uninsured would get a whole lot better very quickly.

A first

2005-11-03T08:44:00.000-05:00

Yesterday was planned out well. I'd go in early in the morning (never my first choice on a Wednesday, my "day off"), do a quick colonoscopy for a friend, go to the office and do "admin work", go home at noon and be available for the heating people to give my furnace an overhaul, then spend the rest of the afternoon on a local bike trail.

I would never complain about anybody being late for anything, so I simply note that the furnace person didn't show up until around 3, and took for ever doing whatever it is that those folks do. By the time he was done, it was clear that there would not be time enough to hit the trail.

I begged my son to give me some remedial wheelie instruction in our backyard. No sooner did we start to ride around than we were joined by six kids ranging from 8 to 12 years old, all on their cute little BMX bikes. I sensed a Lord of The Flies moment.

"Little dudes and future malchicks", I announced, "Let us form a bicycle gang and ride around the neighborhood. We shall threaten to beat people up unless they give us money or Gummi Bears or whatever floats your little boats."

"Cool!" they said.

"And I shall be your leader."

Next thing I was on my back, looking up at six hostile little kids. "How much is worth to you, Pops, for us not to leave tread marks on your face?"

After settling my account I had the further indignity of watching these kids fly off the backyard ramp we had constructed, even as I was unable to lift my front tire more than one inch off the ground.

Of course these kids have been riding for years and I've only been riding for four months, I reasoned. Maybe I should just do real basic stuff like they might do and see what happens. I started bouncing up and down on my bike in as exaggerated a motion as I could muster.

And then it happened. My entire bike left the ground and both wheels were at least a foot off the ground. Well, at least six inches. I had definitely completely left the ground. I had performed my very first bunny hop.

One of the little kids saw it. "Cool!" he said. "How did you do that?"

"Give me my Gummi Bears back and I might just show you," I said. The rest of the evening was spend in a state of pure bliss.

I just wish my knees didn't hurt so badly today.

Sometime nice guys finish first

2005-10-27T16:40:00.000-04:00

Welcome to you stray readers from the Fat Cyclist's blog.

If you've read a few posts from this site, you may have come across a story in which I deal with a patient dying from a bleeding ulcer. Things go well, I'm able to stop the bleeding, and the patient survives, only to die of something else ten or twenty years from now. And I swear it won't be my fault.

In retrospect it would have been a better post had I not whined about not getting paid for my services; after all, the poor man was uninsured and had had tough financial circumstances. I really did not expect any reimbursement.

My patient accounts coordinator, AKA billings and insurance lady, was surprised to receive a call from said patient. "You know," he said, "I've gotten a bill from everyone involved in my care but good old kindly Dr. Juspasenthru. I'm going to get mad if he doesn't tell me how much I owe him."

My insurance lady told me this and, after she had revived me with smelling salts, submitted my bill which the patient has paid. In full.

To be honest, after that phone call I would have been perfectly content if he had sent me some chickens and some homemade marmalade, like they used to do in the old days.

Cash works well, too.

Survey

2005-10-25T18:42:00.000-04:00

Dear Beautiful Fields of Happiness Healthcare Insurance Company,

Thank you for thoughtfully sending me a "participating provider survey" two days after you refused to authorize nutritional counseling for a patient with recently diagnosed celiac disease. Please excuse the writing on the back of the survey, but as all your questions were designed to get a favorable response from your "providers" and you left no space for comments, the back was the only place I was free to write.

I really appreciated your thoughtful response to my letter of appeals (a copy of which is included in my last post). Don't you think you are being a bit too generous for giving me a whole five days to provide you with PROOF that my patient really has celiac disease? After all, I'm only a board-certified gastroenterologist who has signed thousands of documents reminding me that if I misrepresent a patient's illness in order to facilitate obtaining benefits, I've committed fraud and could go to jail. I see hundreds of patients who BEG me to put them on a highly-restrictive diet that they have to follow for the rest of their lives. I'll be damned if I give in to any of them. Let them eat cake, I say.

Once you give in and authorize nutritional counseling for celiac disease, just where would it stop? Counseling for patients with dumping syndrome from prior stomach surgery? Counseling for patients with weight gain before they become diabetics? Crap, can you imagine a more outrageous deal than to try to PREVENT diet-related health problems? What a waste of the CEO's year-end bonus, er I meant to say our precious financial resources.

By the way, your reimbursements suck and certainly don't cover the aggravation your company gives me. Don't come whining to me when you guys tank.

Have a good day.

Translation

2005-10-20T09:01:00.000-04:00

Yesterday I had a great bike ride, except for a nasty spill leaving me just a little banged up. In a perverse way I've come to covet crashes; maybe it's because the injury kicks up endorphins that so generously flow afterwards.

The endorphins were flowing at full tilt until I returned to my office to do "admin work", known by some as "stoopid B.S. flung about by bean-counters to prevent patients from getting care and doctors from getting paid". I view it as performing penance to the Lord of the Free Market: it's necessary, but whether it's Evil or not is in the mind of the supplicant.

Recently I had made the diagnosis of celiac disease on a patient. Making the diagnosis gives us a warm and fuzzy feeling; with proper treatment, which consists of a very strict wheat-free diet, patients live full and healthy lives. The flip-side is also true: without proper treatment, the patient develops all sorts of bad things and can die a miserable death. Making the diagnosis and getting it treated is definitely a "win-win" situation.

Unless you're a bean-counter for the Beautiful Fields of Happiness health plan. A short while after scheduling the patient for a meeting with a dietician, we received this letter, which I am embellishing, but not a lot:

Dear Profit-loss center, AKA Healthcare Provider:
We will not cover your request for our client to receive Dietary counseling for his celiac disease. If you would have looked on page 127, paragraph 4 of the patient handbook and explanation of lack of benefits, you would have noted that dietary counseling is approved only for type II diabetes mellitus. Whatever celiac disease is, (we don't have time to look that crap up, we got a business to run here, you know) it does not appear to be type II diabetes mellitus. If you or your client don't like it, you can protest to our appeals board, or send a letter to the state insurance commissioner, or write your congressman, or camp out in front of the president's ranch. We know that if you're like most doctors, you'll lose patience (get it? har har) with it and just let the whole matter drop. We don't give a damn. Now go away.

Early in my career I would take this stuff personally, but know I realize that it's not personal. It's just business. Dutifully I write my appeals letter. I'm providing you a copy, with the translation provided in bold:

Dear BFH appeals person AKA contemptible bean-counter,
I have received you letter refusing to authorize nutritional counseling for my patient and your client. Celiac disease is a type of allergy to wheat to requires the patient to adhere to a strict and complex diet which you would have known if you would have picked up your stupid Merck manual . The standard of care known as things that cost a lot of money to you folks is for patients to receive proper dietary counseling. If they don't receive it and follow the proper diet, they will develop all sorts of gruesome complications and die a miserable death as listed on page 348 of the Merck manual, if you ever get three minutes to look at it.
It would be a shame for my patient and your customer to go through all of this just because of your refusal to authorize the nutritional counseling, not to mention that I don't give a rip if your CEO gets less than a $52 million bonus this year. Would you reconsider this ill-advised decision? You and I know that I'm bluffing here. If all those things bad things happen, you get blanket immunity from lawsuits from ERISA. On the other hand, I can get sued out of my pension.
cc: my patient and his lawyer. We can always hope.

A quick note to the commentary-spammers

2005-10-10T17:10:00.000-04:00

Comments (and site-meter hits) are the coin of the realm to us zeta-bloggers. Long ago I gave up on Glenn Reynolds A-listing or B-listing or listing me at all, so hits above 20/day, or even one thoughtful comment on my posts makes my day, engenders warm and fuzzy feelings, puts a smile on my face and a song in my heart, and results in long wandering sentences full of cliches which is what anyone might naturally expect from a doctor.

Hey, if you want good prose, go check out the Fat Cyclist or somebody.

If comments are the coin of the realm, then the comment-spammers are evil conterfeiters. I scan my posts and see several comments, experience a moment of satisfaction for having stimulated considered responses, and then I see that the comments are nothing more than form-letters advertising male-enhancement products and other worthless garbage.

Well, just stop it.

Let be be clear: I do not endorse any male-enhancement product. They've never worked for me. Save your money (OK, I'm thinking of a very funny scene from the Full Monty).

I would also die a thousand deaths, and the tortured soul of each would endure a thousand hells before I would endorse ANY lawyer, trial or otherwise (thanks be to the author of the Kite Runner for inspiring the last remark).

Finally, if I have to tell you once I've told you a thousand times a thousand: quit wasting time on this and get back to your Latin class.

The imitation of self is the sincerest form of vanity

2005-10-10T14:28:00.000-04:00

I waste a huge amount of time on the local mountain-biking website. It enjoys a wider circulation than this blog, I'm sure. I would hate to have what I consider to be some pretty good lines go to waste, so they are reproduced below.

********

When I see an obstacle in the distance I try to quote to myself what Gen.. Patton would say, at least in the movie: "L'audace, toujours l'audace". But then when I get right up to the obstacle I remember that I can't speak a lick of French, and down I go.

********

It was a good ride, folks.

My thanks to Moe, Larry, Curly, and Wolf-Man for breaking me in with my first ever group ride.

It was a bit humbling. I hammered down, faced the fork, ate the cookie, tossed the cookie, and used up some long-saved good karma to enter the Mystical flow and achieve Speed that I heretofore had never Even Dreamed Of. Then I looked up and there wasn't a soul there; not even Curly, who had been anti-trash talking about how much slower he was than I. Everyone waited for me, though, which was very kind.

Yep, I'm that slow. I've gone through Shock, Denial, Anger, Bargaining, and Acceptance of my 'velocity-challenged state'. I can live with it.

The only thing that hurt was someone saying "Yeah, some of your posts are weirdly amusing. You're the one who's always hitting up on (a female MBA member).

No, no, no. I am an adherent to conventional Judeo-Christian morality, and I have Great Fear for the combined wrath of my wife, two daughters, son (the infamous T. wrecks), and numerous other friends who only want the best for me. Any appearance of hitting on anyone is coincidental.

Come to think of it, I'm glad I wasn't accused of hitting up on some MALE MBA member. That REALLY would have hurt. Bad.

And now, a shower, nap, and back to the salt mines.

********

A note to all the good trail gnomes:

I for one could grovel in the dirt and kiss your feet, or perhaps buy you a large container of mead or whatever you view as acceptable libation. There has always been an evil little Trail Troll who lives near the Seminary. That little offspring of an unwed mother always grabs at my back wheel when I take the switchback in question with the erosion, etc. More than once I've had to struggle for my life while that b%st%rd tries to drag my bike into it's lair in the creek.

That little bridge was fantastic. Thank you for building it. The next time you gnomes work let me know so I can at least leave milk and cookies out there.

BTW, for the bikers who don't think the sport is any fun unless their life is in danger: hop the fence at the lachrymose Loop and take off down the interstate during rush hour. It will keep you on your toes.

********

I've done some careful research into the fancy-dan beers you folks like drinking. Here are my findings:

Berghoff Bock Beer--tastes like beer.

Petrus Triple Ale, in a tiny little bottle that cost $3.59 --tastes like beer.

Arrogant Bastard--I'm saving this for the weekend when I am not on call, as it comes in a very big bottle. I bet this'll taste like, well, beer too.

********

I performed additional research this weekend while visiting my daughter in Greenville, S.C., with a side trip up to Asheville, N.C. Here are two additional data points:

Duck-Rabbit Ale--this was a featured ale served at the restaurants of the Biltmore Estates. A product of a Western Carolina microbrewery, it is touted as an autumnal brew because of having bold chocolately/caramel overtones. Just regular beer in which someone working in an abandoned warehouse in Asheville mixed with melted Rollo's? I don't know.

The most striking detail about this beer was the name, no doubt related in some way to the label, which had a drawing of something that looked a little like both a duck and a rabbit. Was the label a result of some private family joke, like the two favorite animals of the brewer's daughter being a duck and a rabbit? Or did someone doodle out a duck-rabbit on a napkin or tablecloth and say "Cool! What a great idea for a name of a beer!" I don't know.

I poured the bottle into a glass and noted the dark rich color. My nostrils flared with both anticipation and apprehension as I wafted in the chocolate aroma. I lifted the glass to my lips, and just then decided that I didn't really like beer. I ordered a diet Coke.

Arrogant Bastard Ale--I've never tasted rat pee, but if you took rat pee and mixed it with PGA, I wonder if it would taste a little like Arrogant Bastard Ale.

A rant consummated

2005-10-07T09:38:00.000-04:00

In my nocturnal passion I neglected to mention that I'm planning on writing a book along the lines of Robin Cook or John Grissom. It will feature the gruesome deaths of members of a large corrupt personal injury law firm.

It will be a comedy.

A word from our sponsors

2005-10-06T22:48:00.000-04:00

One of the appeals of mountain biking is that it requires total focus. If your mind wanders during a ride, you will find yourself wrapped around a tree or bounced off a large rock in short order. It's a wonderful diversion; on the trails I couldn't ponder our friends, the lawyers, even if I choose to.

In our fair city the buses have been painted to resemble giant milk cartons, advertizing local car dealerships and storm window salesmen. About a year ago one of our personal injury lawyers began to peddle his wares on the sides of the buses, his gentle smiling face beaming from the Breckenridge Special . He is the brother of an excellent local physician so I was willing to overlook this otherwise classless mercantile legal display.

It was soon followed by ads for a much larger personal injury law firm. There is no gentle smiling face on the bus for these gents; instead, they feature a highly paid actor glaring indignantly (probably at some doctor) demanding that justice be done.

Not to be outdone by his competitors, a snivelling little twerp by the name of A.K. plastered his face on the bus's backside, snarling: "Injured? Call A.K., he'll make 'em pay". I have to look at this face every day I drive into the hospital.

There are positions that may be right in some way but are so repugnant that I'm glad I never have to offer justification for them. Who knows, maybe late-term abortion/infantcide is a good thing, or euthanasia, or pedophilia, but I'll never have to worry about prostituting myself in order to present an argument on their behalf. I occasionally receive comments or emails regarding our sacred right to sue to the crap off our fellow man, and maybe this is a good thing, but I'm still glad I don't have to defend the tasteless, classless display of trolling and playing on the worst impulses of people in order to make a living. Lawyers advertising on the side of city buses? No thanks. I'll deal with the nice clean colons of the community instead.

Catching up

2005-10-03T08:28:00.000-04:00

I'm back due to popular demand, as defined by one of my daughters (I'm not sure which) and all the person who thinks that, based on careful demographic study, my reader(s) would be interested in male enhancement products.

Mostly I've been too tired to post. On weekends I undertake epic mountain biking journeys which leave me so exhausted that it takes several days to recover to where I can get back out on the bike again. I've been pleasantly surprised; although the only way I can get as good as I'd like is to quit my day job (the defenders of the Public Trust will do everything they can to help out, I'm sure), I have gotten quite a bit better over the last several months.

This weekend my son and I returned to one the first trails we had ridden, a trail riddled with huge roots, rocks, and abrupt Plutonian descents. It is a trail my son had not wanted to travel because it has a reputation of being a hang-out for Folks Who Are Just Like Us, Except That Dark Genetics Forces Over Which They Have No Control Compel Them To perform Oral Sex On Each Other In Broad Daylight In A Public Park (otherwise known as FWAJLUETDGFOWTHNCCTTPOSOEOIBDIAPP).

I'm so ashamed. I've done my best to teach my son about the wonders of Tolerance and Diversity and that the revulsion he experiences over watching men perform oral sex on each other in public places is nothing more than cultural bias. I've obviously failed. I have half a mind to send him to public school where they can properly condition him.

It took a lot of assurances that I personally had never seen any couple so much as read poetry to each other there before I could coax him on to the trail. As beautiful a day as it was, we encountered very little traffic: one trail runner, two mountain bikers, and a bevy of beautiful young women, all of whom had cool-looking tattoos on the back of their right shoulders and were walking angry-looking dogs.

As for the trail, we discovered that with several months of conditioning and gear upgrades, it was no problem to ride up to an imposing obstacle, hop off the bike, deftly lift it up with one arm, and drag it down the trail to safer climes.

Becoming one with the dirt

2005-09-16T16:47:00.000-04:00

My weigh-in this week was a disaster: 200.2 pounds. Adding to the injury, I've been celebrating my birthday this week. Most of my birthdays go unnoticed, the way I like them. This year I've received three birthday cakes, which I have had to sample out of politeness. They were also very good.

I enjoyed a moment of Zen-like bliss this week, as I try to achieve at least some minimal competency at my latest addiction, mountain biking. As I was pedalling along in a secluded park, three Basic Truths of the Universe came to me, and for no charge I'll share them with you.

Life is better in the middle ring. Modern mountain bikes have three rings attached to the peddles. The smallest is the "granny gear", named because while you're using it, little old ladies can easily outwalk you. I've spent my time ejoying the safety and slowness of the granny gear. This week I forced myself to use the middle ring, and, guess what? Biking is easier with that gear: you have more speed, more momentum, more stability, and less time to contemplate disaster. It's a paradox, and there's a metaphor in there somewhere I bet.
Become one with the dirt. For the first time ever I relaxed, eased up on my death-grip of the handlebars, stopped thinking of my orthopedic surgeon, and just felt the flow of the bike, the trail, our friends the birds, the wonders of Gaia, the pure joy of physical activity in a beautiful relaxing setting.
Don't forget that the dirt really doesn't like you. Just as I was going with the flow, I lost focus, caught my handlebars on a rogue tree while attempting a switchback down a hill, and fell on my keister. Thanks to low dose aspirin, I have a wonderful set of bruises up and down my leg, a love-tap from Gaia. I wish she'd keep her hands to herself.

True confessions

2005-09-07T19:08:00.000-04:00

Thumbing through the New England Journal of Medicine, I come across this paragraph out of a case presentation of Jacob-Creutzfeldt disease, the dreaded neurologic condition related to "Mad Cow Disease":

The patient had been in his usual state of health until approximately four weeks before admission, when he noticed severe fatigue, frequent yawning, and difficulty concentrating; insomnia, intermittent confusion, and unsteadiness of gait developed. During daily activities, he required multiple breaks that he had not needed previously.

Rats. I knew something was wrong with me. There's good reason not to read the New England Journal of Medicine anymore than absolutely necessary.

Since there is only a short time before I start drooling on myself, I better get this off my chest: I have chronic Twinkie poisoning. I know I've made an occasional snide remark about this ailment, but that was only a facade to keep my vast readership from guessing the truth.

During the time that I was prevented by my imagined neurological condition from blogging, I came across several extremely humorous and well-written blogs, my favorite being The Fat Cyclist (google it and you'll find the site; my medical problems prevent me from providing the link). The Fat Cyclist chronicles his weight-loss efforts, reports his weekly weigh-ins, and actually offers prizes to folks if he fails to meet his goals.

This is a great idea, and in my typical fashion I lifted it. There will be some alterations: as my income has plummeted as a result of ever-increasing malpractice premiums, there is no way in Hades that I'm going to offer a nickel if I fail to meet my goals. Before and after photos are also out or the question.

Other than that, I'll provide you with my story about the journey towards Buffness, mixed in with biting commentary regarding the tort-lawyers of this country. I might add that at one of the hospitals there is on office pool for when I break something while mountain biking. The over/under stands at three weeks.

Here goes: height 5' 10". Weight 200.6 lbs. Goals for next Monday: height 6' 0" (just kidding), weight 199.5.

It just happens

2005-08-21T18:56:00.000-04:00

I'm in my office on a scorching Sunday afternoon, catching up on roughly three, OK, four weeks of administrative stuff and listening to Leo Kottke on Napster. I'm not complaining; if I weren't here I'd be at home paying bills. It's pretty much a wash.

At the end of the week I was about as blue as a Kentucky Wildcat sweatshirt, pondering the meaningless of it all, etc. etc., when I had the most delightful office-full of elderly patients on Friday. If you don't get a chuckle out of an 88 year old lady telling you that: "just because I'm old doesn't mean I'm dead. If Mr. X ain't interested in the (92 year old lady he was hitting up on in my office), you send him my way," then, well, you will chuckle. It can't be helped.

Old folks are supposed to be the bane of a highly-efficient medical practice: they are slow, have a million problems of which usually none can be resolved, and the Medicare payments they generate barely cover office overhead. However, I do not have a highly efficient practice, and Friday is always a "slo-mo" day for me. It gives me a chance to tarry with the folks and chat about what's been going on over the past 85 years.

I regret the attitude I had in my younger years when I viewed the elderly as burdensome. They'll teach you a lot, or at least entertain you, if you just take a few (poorly reimbursed) moments and listen to them. Funny how aging does that to you. I suppose old age is like the Republican Party: you go through your life thinking very little of them, and then one day you wake up and you ARE one of them.

Peace be with you.

I wish I could feel guilty about this...

2005-08-18T17:57:00.000-04:00

Early in my career I volunteered to be a Reviewer of my Peers, one of those citizens who reviews medical records to determine if appropriate medical care was delivered to Medicare beneficiaries. As an upper echelon reviewer I would get cases that had attracted the attention of a screener, then a nurse practitioner, then perhaps a physician generalist. After careful review, I would venture an opinion as to the quality of the care delivered. This feedback would reach the physician or hospital, and could have led to a variety of sanctions and punishments.

My motivation for participation was simple. I wanted to improve the delivery of healthcare in my region. I wanted to do my part. I wanted world peace.

The review organization changed hands and I received no more cases to review, which was fine. They took a lot of time to do well, and the pay was shabby. Then in the past year the medical charts began to reappear on my desk.

Before I left on vacation I had a little pile of charts for review on my desk. These charts sat untouched by human hands until earlier in the week when I received an urgent letter: "Doctor, we really need those charts back. Will you get off your duff and review them?"

In my fatigue I sat down and opened the first. A physician had hospitalized a patient who had been puking his guts out. The patient was a diabetic and a bit frail. The doctor kept him in the hospital for three days, giving him IV fluids and anti-nausea medication. He left the hospital in a greatly improved condition.

The review organization asked me to review the case to see if he merited a "good citizenship award". The doctor's writing was legible, his orders appropriate, and his intervention prevented, say, the patient from going into renal shutdown which would require very expensive dialysis.

In a parallel universe. What the screener was bringing to my attention was this:

Did this intervention justify admission?
The patient was in the hospital for three days. Could he have been discharged in two?
The patient in his history reported fever and chills leading up to his hospitalization. Why were there no fever and chills documented while he was in the hospital?
The patient's history listed "frequent urinary tract infections". Why was this used as one of the discharge diagnoses?
Are there any other violations that we did not spot?

I've always been a person who does his best to honor his commitments, but this was the wrong case at the wrong time. I'm not going to be party to institutionalized harassment of physicians who are out there trying to do a good job.

So I sent the charts back. "I'm sorry but the time demands of my practice prevent me from giving the attention that these charts deserve. Please take me off your list of reviewers".

And I brace for the onslaught.

The benefits of low dose aspirin

2005-08-14T21:06:00.000-04:00

All bleeding stops, sooner or later.

I was reminded of this aphorism earlier in the week as I stood in the operating room watching a citizen do his best to bleed to death. The gent turned up in the ER with a low blood pressure and had barfed up a very scary-looking amount of blood, so we made the decision to take him into the OR and have the anesthesiologist intubate him. I would then run an endoscope down and see if I could identify the bleeding site, and, if we were all lucky, get the bleeding lesion to stop. I didn’t think this was likely to succeed, and the surgeon stood at my shoulder, ready to take matters into his hands when I failed.

As I was waiting for the anesthesiologist to do his thing, I was struck by the marvelous efficiency of the American healthcare system. The whole OR was filled with folks doing exactly what needed to be done: the anesthesiologist figuring out how to put the fellow to sleep while keeping him from bleeding to death, one of his aids holding the hand of the frightened citizen assuring him that he had nothing to worry about, the endoscopy team setting up my equipment, the OR nurses setting up the surgical trays, and the surgeon and I trading aphorisms.

“All bleeding stops, you know, sooner or later.”

As I pondered this, I realized that with just a little modification this would be the perfect epitaph for my gravesite:

“All problems go away, sooner or later.”

And it’s true, if you’re willing to wait ‘em out. It may take Eternity to dispose of some problems, and that can be a little impractical, such as the time I developed biliary colic and collapsed in my office. Eternity would have taken care of that one, to be sure, but Eternity can be a long time, especially towards the end of it (per Woody Allen), and having a surgeon fix me up seemed like a better approach.

It isn’t necessarily a good thing to elevate one’s avoidant tendencies to an art form, but that’s what I’ve done. Biking has been my means of escape lately, and although I’m grateful that I’ve avoided the lesser diversions such as alcohol, women, etc, I’m not sure my current obsession is any safer.

Yesterday my son and I went back to our Boonieville bike trail, but we didn’t get out early. This time we waited until late morning, with the temperature gauge pushing 90 and the humidity running around 80%. Any child of Ma Gaia with a nanogram of sense to it stayed out of the heat. No deer or chickens, not even the giant goat-eating spiders were to be seen. It was just too flaming hot.

That didn’t deter us initially, but it caught up with us very quickly. My athletic performance is shabby to begin with, but when I get overheated my body goes into frighteningly random motion, which can be very inconvenient on a mountain bike. Before long I had ridden off the trail and into a tree, the bark of which felt like a cheese grater as it tore into the tender flesh of my left forearm. I dragged back to the trail, looking like I had been savagely raped by Mr. Mestofeles (Trey Parker and Matt Stone).

“Lucky!” my son exclaimed. “You always get the cool injuries!”

I looked down and noticed that a cut on my arm was bleeding profusely, thanks to the low dose aspirin I had put myself on. It looked like I might bleed to death, although the blood loss probably didn’t exceed one ounce. It provided a great excuse to call it a day. And the bleeding stopped, as it always does.

My patient’s bleeding also stopped, courtesy of some metal clips I was able to attach to a blood vessel in the base of a stomach ulcer. I was glad I could help him, especially as I had to send an office-full of patients home without being seen in order to free me up for the procedure. Did I mention free? The patient had no insurance (he was in town on a job interview) so I don’t plan on getting paid. No money could replace the satisfaction of saving a person’s life, especially when the Federal penalty for refusing to see patients in the ER is up to $2 million per infraction.

Putting off procrastination

2005-08-11T18:51:00.000-04:00

Hard work may pay off later, but laziness always pays off now.
www.despair.com

Sometimes blogging is like flossing teeth: you know you should really do it, but you just got other things to do. Vacation in North Carolina was great, and, frankly, it's getting easier and easier to put the Internet off limits and do weird things like read books and talk to heretofore unidentified family members. Coming back home I encountered the usual Total Chaos that I expect from a week's absence, along with discovering that I'm on ER call and that I'm covering for another GI guy.

When faced with this brutality, I did the only thing a reasonable person could: go mountain biking.

Not the entire week, mind you. We went Wednesday morning, waking up at 6AM and getting an early start, before the suffocating heat and humidity of the Ohio Valley came on.

My son and I went out to a place so remote that we were seized by the urge to hum the theme song from "Deliverance" on our way out. Being amidst Nature's Wonder, communing with Gaia Herself was a special treat: we were surrounded by six very angry-looking deer who looked like they were holding us personally responsible for the death of Bambi's mother. We saw a giant spider drag off someone's goat. My son was almost killed by a chicken who darted in front of him while he was screaming downhill on a Ride of Death.

The whole thing was pretty cool.

So rather than discuss the malpractice crisis or explain why emotivism is killing our culture, I'll leave you with these infinitely more helpful thoughts:

A cheater wheelie is just as good for the most part as a real wheelie and is a heck of a lot easier to do.
The farther you stick your hindquarters back, the less likely you are to go endo.
You don't have to be faster than the attacking spiders. Just be faster than your son.

Smoke 'em out

2005-07-24T22:17:00.000-04:00

For the sake of argument, accept the statistic that the number of deaths in America from medical malpractice outnumber the combined deaths from breast, colon and prostate cancer (I don't accept this as a fact, but visit virtually any tort lawyer's website and the figure is taken as God's own Truth). Considering that our medicolegal system sucks off billions of dollars from the delivery of healthcare, and that lawyers currently offer precious little to protect the health of patients prospectively, and that for all the attention the malpractice crisis has gotten we've seen little demonstrable improvement in the overall quality of healthcare over the past thirty years, one might reasonably conclude that, as an organization dedicated to the reduction of medical errors, the American Trial Lawyers Association is a dismal failure.

At my "risk management" seminar I saw one of the most astounding video clips on malpractice I've ever seen. In 2000, a family lost their two year old daughter due to medical negligence at Johns Hopkins University. The mother, in her anguish and while fighting back tears, recited how the university had, through gross miscommunication, more or less executed her little girl.

What made this so astounding was that the mother was delivering this lecture at Johns Hopkins University, to the medical staff.

As the camera panned the very attentive audience, there were few dry eyes to be seen. There were more than a few of us at the seminar who were also fighting back tears.

In every family statement regarding a malpractice lawsuit I've ever heard, the family spokesperson invariably says "It's not about the money (although we expect huge amounts from the trial)" and "We just don't want anyone to suffer like we have (although we aren't about to lift a finger to try to fix whatever situation lead to the tragedy)". Astonishingly, the family of the little girl took a sizable portion of their malpractice award and set up a program at Johns Hopkins to improve medical communication so that no one else might have to suffer the needless loss of a loved one.

Imagine. Taking money awarded because of malpractice and reinvesting it in improving the delivery of healthcare. I had never heard of this before.

Then the vision came: our local, state, and national medical societies appealing to the Trial Lawyers to join us in seeking constructive improvements to the system. "Our lawyer brothers and sisters, join us in improving healthcare in our country. Donate your time AND money for systems review and development. Work with us to make medical errors a thing of the past."

Expecting lawyers to tell us stuff beyond "If you didn't document it, it didn't happen" and "Be nice to your patients, you arrogant bastards" and "Work smarter, not harder" is of course delusional. But it would smoke 'em out and dispel the notion once and for all that what they do is supposed to be in the Public Interest.

Nasty lawyer tricks

2005-07-16T12:21:00.000-04:00

This week I attended my biannual Risk Management Seminar, "risk management" euphemistically referring to malpractice lawsuits and how to avoid them, if possible. Most of these things tend to be dreary affairs, with an insurance representative standing before us and telling us such helpful things as "If you didn't document it, it didn't happen", and "Work smarter, not harder", followed by some sanctimonious defense lawyer assuring us that if it wasn't for HIS hard work we'd all end up in jail.

This seminar was actually quite interesting, for a change; I should be able to milk it for two or three posts without any trouble.

In a civil trial, the opening statements by both the plaintiff's and defense attorneys are made, followed by witnesses called by the plaintiff's attorney. After each witness, the opposing attorney will cross-examine the witness and try to rebut any ugly assertions the witness has made. In the past, more often than not the plaintiff's lawyer will call the accused doctor as his very first witness. It makes sense: pull the doctor up on the stand before he's had a chance to acclimate to a court setting; try to make him look like an idiot, and, failing that, make him lose his cool by badgering him mercilessly, setting him up to appear to be such a jerk that the jury will rule against him even if he were completely innocent.

It turns out that this approach is a thing of the past. Doctor depositions are now videotaped. In the pre-trial preparation, the attorney will put together a Power Point presentation, splicing together any unfortunate statement the doctor may have made and then running very selected portions of the videotape in the plaintiff's attorney's opening statement. That makes sense, too: the lawyer can still badger and harass the doctor during the deposition AND then choose only the worst clips to play for the jury AND it cannot be immediately rebutted in cross-examination because it's just part of the opening statement.

"Docs, we might not be able to get you up on the witness stand to defend yourself for at least three or four days. By then its an uphill battle, no matter how innocent you are."

Those doctors in the audience with Blackberries were pulling up the latest stock-market quotes to see if their portfolios were adequate to allow them to retire. I, however, was glad to see that the Public Interest was in such good hands and was being so well protected.

Thermostat wars - a theological perspective

2005-07-13T12:05:00.000-04:00

The author of The Da Vinci Code is sympathetic to the concept of the "Divine Feminine", that primordial nurturing force of the universe represented by Venus and Aphrodite and Isis and maybe Mary Magdalene. Towards the end the book, the author makes the plea that our world must once again celebrate the Divine Feminine, that we must become whole and fertile and get in touch with our feminine self and repudiate the evil militarism of our patriarchal society.

If he is speaking metaphorically I can live with that. There's not a one of us who wouldn't benefit from getting away from the TV or office and commune with Mother Nature, enjoying Her splendor by strolling through forests and meadows, watching our furry little friends go hippity-hop down the Bunny Trail, stepping on venomous snakes, being attacked by blood-sucking sand flies, contracting Lyme Disease...whoa, I guess snakes and sand flies must be from the realm of the Masculine. Mother Earth would never treat us like that.

If Dan Brown really believes that there is a Divine Feminine, then all I got to say is this: I sure hope not.

Here I sit in the Ohio Valley, with its heat and humidity, and as I type this I'm wearing a scrub top, and under it, some Patagonia long underwear. I've been in one too many endoscopy rooms where the thermostat has been set down to 62 degrees by some perimenopausal nurse. After a few procedures my fingers grow numb, my core temperature drops to 92 degrees, and I listen to patient after patient compare our room to a walk-in meat locker.

It gets worse. Combine a woman going through menopause with a woman suffering from low thyroid hormone levels and a female Generation X'er who is just plain tired of listening to the old folks complain, and you have Total Primordial Chaos. One turns the thermostat down to 58. The other counters by putting their space heater on their desk and turning it on full blast. One sneaks around the flank and turns the thermostat up to 80, the other gets a minifan and plugs it in, cranking it up while papers and office documents go hurtling through the air.

No, I'm too much of an empiricist to believe in a Mother Goddess. If she really existed, our global warming would end abruptly, our temperatures would go down 5-10 degrees planet wide, we'd have glaciers in Florida and mass extinction everywhere, with only the most cold-resistant life forms surviving. I wouldn't trust Venus with a thermostat. Not until Isis sneaks around to the flank.

Jewish Zen

2005-07-11T17:31:00.000-04:00

This is from a post in Free Republic. I've added it to my research on zen.

If there is no self, whose arthritis is this?

Be here now. Be someplace else later. Is that so complicated?

Drink tea and nourish life. With the first sip... joy. With the second... satisfaction. With the third, peace. With the fourth, a danish.

Wherever you go, there you are. Your luggage is another story.

Accept misfortune as a blessing. Do not wish for perfect health or a life without problems. What would you talk about? The journey of a thousand miles begins with a single oy.

There is no escaping karma In a previous life, you never called, you never wrote, you never visited. And whose fault was that?

Zen is not easy. It takes effort to attain nothingness. And then what do you have? Bupkes.

The Tao does not speak. The Tao does not blame. The Tao does not take sides. The Tao has no expectations. The Tao demands nothing of others. The Tao is not Jewish.

Breathe in. Breathe out. Breathe in. Breathe out. Forget this and attaining Enlightenment will be the least of your problems.

Let your mind be as a floating cloud. Let your stillness be as the wooded glen. And sit up straight. You'll never meet the Buddha with such rounded shoulders.

Be patient and achieve all things Be impatient and achieve all things faster.

To Find the Buddha, look within. Deep inside you are ten thousand flowers. Each flower blossoms ten thousand times. Each blossom has ten thousand petals. You might want to see a specialist.

To practice Zen and the art of Jewish motorcycle maintenance, do the following: get rid of the motorcycle. What were you thinking?

Be aware of your body. Be aware of your perceptions. Keep in mind that not every physical sensation is a symptom of a terminal illness.

The Torah says,"Love thy neighbor as thyself." The Buddha says there is no "self." So, maybe you are off the hook.

The Buddha taught that one should practice loving kindness to all sentient beings. Still, would it kill you to find a nice sentient being who happens to be Jewish?

Though only your skin, sinews, and bones remain, though your blood and flesh dry up and wither away, yet shall you meditate and not stir until you have attained full Enlightenment. But, first, a little nosh.

Why I love one of my daughters more than the other

2005-07-10T17:37:00.000-04:00

A long time ago, in the antediluvian era of iron men and wooden ships, when giants walked the halls, I returned to our squalid little home, weak, exhausted (me, not the home), discouraged beyond belief, feeling like two things would never end, one being my medical training, the other being this sentence, wandering about the wilderness like the children of Abraham. I came to rest in my prized Salvation Army easy chair which offered me so much comfort that I came to regard it as a friend and perhaps even a trusted mentor, more of a mentor than those narcistic fascists who ran the training program and kept me in an endless state of torment. There I sat, finally at peace after a brutal 36 hour on-call marathon when you approached. Although you were only 7 months old at the time, you possessed a deviousness far beyond your age, given away by the impish gleam in your eyes as you crawled up to the chair, carelessly knocking over my sun tea and revealing a maliciousness that was both startling and alarming.

As I traveled to Branson, Missouri and back in order to pick up my as of that time unborn son from summer camp, I listened with your mother to the audio version of The DaVinci Code and thought to myself, "Surely I can write pretentious prose about largely fictitious pseudohistorical events, too."; after what seemed like an eternity of internal struggle but in reality represented the time it took your mother to hop out of the car, run into the McDonald's, go to the bathroom (I resolutely refused any liquid refreshment to obviate the need for such activity), and bring back two luscious hot-fudge sundies in which the peanuts had been held (purely for dietetic reasons), I reached this startling conclusion: Just Kidding!

Now get back to your studies and/or go find a job, depending on which one of you reads this.

The Virgin

2005-07-09T14:04:00.000-04:00

My dictum:

Never hang around the doctors lounge if you're already depressed.

My deviant:

Never hang around the doctors lounge even if you're not depressed if 1. they have pizza there and you're on a diet, and 2. there's anyone else there.

"Doctors in this state are freakin' idiots!" proclaims the Virgin, an excellent, personable physician who had the misfortune of wandering, for the very first time, into the gunsights of the malpractice lawyers. "We could have gotten malpractice caps in this state if our lobbying efforts hadn't been so clearly pro-Republican. Now every Democrat in the state torpedoes any effort to clean things up around here, simply because it's the Republicans who introduce the reforms. We'll never get any meaningful tort reform around here."

We will when you and I resign, retire, or move out of this state, I thought.

"For the first time ever I was named in a lawsuit two weeks ago. The noneconomic damages are not terribly high, and I'm willing to take my chances in court with them on that. But they're asking for $5 million in non-economic and punitive damages. If I lose that, I'll be financially destroyed. I'll have to settle with those buttholes because our state medical association didn't have the sense to make tort reform a bipartisan issue."

I felt like a deer seeing it's mother getting blown away by the evil hunters. I certainly could empathize, so I endeavored to say the most encouraging things I could think of: "You arrogant fool! You're getting what you deserve. Just what do you intend to do about all the uninsured people in this country? How are you going to improve quality control? Economic ruin sounds about right for anyone crass enough to try to make money off the sick and dying. Feel free to call me any time. I'll always be here for you."

When you come to a fork in the road, take it

2005-07-05T22:21:00.000-04:00

This is the beginning of what I think will be a very nice article should I ever actually finish it. If the perfect analgesic/anti-depression drug were available, would you take it? Come to think about it, I believe one could obtain the desired effect by washing down a pack of Peanut M&M's with a can of Miller Lite. But I digress.

Futurists are divided in their visions of what is to become of our culture. One camp sees a dark dystopian landscape, at best resembling the urban overcrowding of Bladerunner, at worst resembling the anarchy of The Road Warrior. The other sees a lighter vision of a world where genetic engineering and pharmaceutics allow the human race to live a peaceful, comfortable but meaningless existence as what was described in Brave New World.

Free of the guiding force of Providence, which fork in the road we travel down will be determined largely by accident. If the Wahabists gain access to the Russian nuclear arsenal or if the dire predictions of global warming prove to be true, we will likely undergo near-extinction, with the unlucky survivors left to fend for themselves amidst the rubble and chaos. If we get lucky and avoid such a cataclysm, I think it is inevitable that our race will do what it can to eliminate all forms of disease, infirmity, pain, and even suffering. Big Pharma and Genetic Industries will lead us to the bliss of the Promised Land.

In this Utopia we'll surely have a drug (Soma?) that will free us from pain and induce a mild euphoria without the troublesome side-effects we see with the opioids we now have. Perhaps the same compound will also keep our seratonin and norepinephrine levels pleasantly and permantently high, rendering depression and neuroasthenia rare if not unheard of.

Wherever you are, you weren't there before you got there.

2005-06-27T20:00:00.000-04:00

Over the past decade the years have taken on a monotonous and tiresome pattern. In the frozen fog of January, I fire off a harshly written letter to our "so-called" public servants demanding that they repeal the entire month of February. Time and again my very reasonable request is ignored, forcing me to weather out the forty some-odd days of that foul month. This is followed by the false promises of March and April, with their faux-warming days fueling the discouragement of otherwise ceaseless frigid rain. The glorious festivals of May and June arrive; alas, their fleeting fairness fades after only three or four days max.

In July I finally run out of F's, sending me to remedial alliteration classes at our local community college. My family spends a week of bliss at the Carolina shores, and as I contemplate what I should be getting everyone for Christmas, the fearsome fatigue of Seasonal Affective Disorder descends on me as I reach deep into my dictionary for one or two more F's. In no time flat I find myself at Walmart late Christmas Eve, frantically ferreting out whatever presents I think will keep me out of trouble with my family.

Then the whole thing occurs again, year after year. Lather, rinse, repeat.

Not this year. Until just recently the weather in the Ohio Valley has been lovely: high of 80, 40% humidity, totally uncharacteristic of this area. So no computer last week, no TV, no drunken drivers. Just me and a variety of endophinogenic activities which involve non-virtual reality.

If this seems like some sort of excuse for laying off the blog, let me assure you that it is. I might have been linked by Glenn Reynolds in the past week for all I know. If I have been, please feel free to email me. I could use the encouragement.

Roid buffin' in the summertime

2005-06-16T20:18:00.000-04:00

There are times in a young man's life when he has energy for blogging or strenuous physical exertion but not both. Then there are times when he has the energy for neither. That has been my status as of late.

My initial forays into the world of mountain biking consisted of taking a track going off into nowhere called the "Lachrymose Loop" or something to that effect. I feared for my life the entire time, so the next time I visited the bike shop I inquired about just how one goes about learning to mountain bike without, you know, getting killed.

"No probleemo", the LBG (local bike guru) says. "Just spend time on an easy course like the Lachrymose Loop and you'll be shredding with the best of them in no time."

Well, I'm 52, I've lived a good life and have plenty of insurance. Off to the Loop I go.

My last two trips to the Loop have been pretty exciting. For the first time I was able to hop a (very small) log, a thrill for someone who only a week before almost met his Maker by trying to hop a little curb. The last trip I went around the Loop twice, undeterred by trying to hop the (very small) log, mistiming it, slamming into it and bouncing back, landing unceremoniously upon my amply padded backside.

I figure if I'm not able to shred the singletrack like a pro, I can at least learn the lingo and sound like I know what I'm doing. These are some of my favorite terms:

horizontal bike rack:
that would be me when I come to a stop but am not able to remove my feet from the toeclips in time to prevent my bike and I from assuming the horizontal position.

pruning the half-tracks:
this refers to going through a trail that is heavily overgrown with vegetation, so that one emerges from it covered with foliage he has gathered from along the trail.

going endo:
one of my favorites as an endoscopist. One goes endo when he misjudges a jump and goes flying over the handlebars. See "giving blood" for further details.

Roid buffing:
my favorite, of course. When one goes down a steep incline, in order to keep from going endo one gets up off the bike seat and sticks his (or her, depending on ownership) butt way back over the rear wheel, acting as a counterbalance. Do that long enough and you've done some roid buffing.

Part II is coming, I promise. Or not.

Part I

2005-06-12T12:33:00.000-04:00

Capitalism/the free market is a lousy way of getting things done in the healthcare arena.

Now before folks demand that I turn in my membership card to the VRWC, I should add this: having spent a brief time in Eastern Europe, I believe that socialism/the centralized economy is a catastrophic way of getting things done in the healthcare arena, or in anything else for that matter.

We're stuck with the free market for now. We might as well do the best we can within the system.

What are physicians' options in coping with the malpractice crisis? Our medicolegal system has been so corrupted that it is impossible to dream up a complaint that has not actually led to a lawsuit in our country. Even more telling, it is becoming increasing more difficult to dream up a lawsuit in which some jury somewhere in our fair land hasn't actually awarded damages to the plaintiff. Pay a visit to Overlawyered.com or sickoflawsuits if you need to be convinced of this point.

The free market understands supply and demand very well. Reduce the supply of a service and combine it with increased demand for said service and you will exert irresistible pressure on the way in which the service is delivered. Physicians (in contradistinction to lawyers?) are constrained by ethical and professional considerations in the way we supply healthcare. As attractive as some sort of collective bargaining action might seem, going on strike (for example) is illegal, unethical and ultimately counterproductive. We can strive to put more and more limits and boundaries on what services we provide; consider the number of OB-GYN's who no longer will deliver babies, or the number of specialists who refuse to have their names put on ER call rosters. We can try what I'm attempting, which is to limit severely the amount of services and numbers of patients I will accommodate and rejoice in being able to meet my overhead and pay for my health insurance coverage if nothing else.

None of the above protects us from the $23 million judgment and the financial ruin it would bring. The only way we can do this is to quit.

Yes, I'm aware of all sorts of methods to shield our assets from lawyers. This is like trying to construct a squirrel-proof birdfeeder: it can't be done. They're too clever. There will be a way in our system for the lawyers to get to the money. Charging "elder abuse" instead of malpractice in claims of negligence on the elderly is just one way that lawyers are now circumventing measures like malpractice award caps. Other maneuvers will come.

This is a problem for anyone who has put twenty or thirty years of training and practice into their field. It seems like a tremendous waste of human capital to toss it all. What I do ain't rocket science or brain surgery, but it takes a high-school graduate thirteen years of training to prepare for my field. Maybe they could condense it down to two or three years of training at a technical school. I wouldn't want to get a colonoscopy from one of them, but who knows? That might be the only option we have in the future.

To be continued.

Fake but accurate?

2005-06-10T16:57:00.000-04:00

Some writers, by virtue of extensive training and/or native ability, have beautifully expressive styles that are a pleasure to read. Others of us erstwhile "new journalists" just fake it. The last formal training I had in creative writing was in 12th grade, when I had to write a "How did you spend your summer?" essay (mine was "Nothing but work on the dirt farm and I resent being reminded of it"). To get by I do what countless people have done before me: rip off as many styles from good writers as I can and throw them together in a melange that is so garbled that most folk don't recognize anyone in particular, and give me credit for at least some originality if nothing else.

There are some wonderful role models for us writers out there. I personally enjoy the style of the "legacy media", represented by such fine institutions as the New York Times, CBS, and Newsweek: report only those facts that further your agenda, distort the ones that don't, and just flat out make things up if it enhances the story line. This "fake but accurate" style is perfect for writers like me who are too lazy to check up on facts and links and who are too partisan to care much one way or the other.

As I reflected on my post entitled Free legal advise, I thought that readers might suspect that I got a little carried away. I mean, two lawyers who extort physicians out of their fees by threatening malpractice suits? No one's going to believe that. Even I began to doubt it until I ran into the doctor in question yesterday, quite by accident.

"Whatever came about that case?", I asked Keith.

"Yep, the lawyers' strategy worked like a charm. All of the doctors wrote off their fees over the threat of a lawsuit, even the ones who were only marginally involved. What's even better is that the hospital wrote off their charges, too. Here you have a guy who was admitted on an emergency basis, owned a small business but didn't bother to carry health insurance, required triple bypass surgery and a heart valve repair, and because he had a commonly described and accepted complication that resulted in at worst one extra week in the hospital, got the ENTIRE bill written off. Not even the hospital wanted to mess with it."

It turned out out that I got the facts right after all. I wish I hadn't, in a way; knowing it is that easy for lawyers to game the system these days isn't comforting.

By the way, complaints about lawyers in my state are kept secret until they are resolved. This allowed one sexual predator to molest several clients (all of whom complained to the Bar) with impunity until someone finally took out a criminal charge against the guy.

A colonoscopist's lament

2005-06-07T20:32:00.000-04:00

A sonnet composed today at the MCE Butt Hut upon learning that there exists a group of my patients that call themselves "Bubba's Butt Club".

Basking in heaven's light we should reside
When we are in the blest Platonic realm.
But in the darkest cave we're forced to hide
When scope in hand we're stranded at the helm.
Medicine calls us as its holy Light
To rid disease from every human soul.
A shame that we're so limited in sight
That we see only up your exit hole!
The profit motive gathers us as one
As we gaze up into the colon's void.
And yet we know that when the hour is done
We'll see naught but a ripened hemorrhoid.
Know that our efforts shall not ever cease
Until the day that we run out of grease.

Free legal advise

2005-06-06T22:10:00.000-04:00

One of the first lectures I heard in medical school was on gout. The professors enjoyed lecturing about it, in part because it was one of the first conditions for which a drug was specifically designed (allopurinol), and in part because it was a very fashionable disease. Not everyone would announce to the world that they had a bad case of tinea cruris, but anyone would take pride in having a good case of gout. You needed two things: the inherited trait, which was traditionally associated with only the very finest of families, and a diet that only the wealthy could afford, rich in red wine and red meat.

Some disorders are more fashionable than others. Here is my personal ranking of some of the more "popular" disorders, based on nothing scientific. Your list might look entirely different:

Disorders to be proud of:
gout (of course).
athletic injuries, especially skiing accidents.
"walking pneumonia" (a sure sign of toughness).
pilonidal cyst (I have absolutely no idea why).

Disorders with no stigma attached to them:
cancer.
peptic ulcer disease (especially since we realize you don't have to be a "type A personality" to get it).
coronary artery disease.
diabetes.
hypertension.

Disorders a civilized society wouldn't talk about:
PMS.
hemorrhoids.
erectile dysfunction.

Very serious disorders that nonetheless have a certain je ne sais quoi about them (I think because so many creative, talented people have had these):
bipolar disorder.
attention deficit disorder.
HIV.

Disorders struggling to escape an undeserved reputation:
depression (half the population has it, the other half belittles it).
Crohns disease and ulcerative colitis (sufferers were once thought to all be neurotic, but if some are it's because the illnesses take a tremendous emotional toll on them).
hepatitis.
panic disorders.

Disorders you still had best keep to yourself (so to speak):
sexually transmitted diseases.
sociopathic personality disorder.

As a societal disorder, medical malpractice has generally been in the "best kept to yourself" category, but that is slowly changing. You don't have to saw off a wrong limb or try to perform a hysterectomy on a guy to get sued these days. Something as seemingly innocuous as ordering a CT scan on a psychic can trigger a lawsuit if the plaintiff claims that the CT scan somehow damaged her psychic power (such a lawsuit occurred, and the jury ruled for the plaintiff and awarded her well over $2 million in damages). The stigma of a malpractice case is not so significant anymore, so doctors are a little more willing to disclose their experience with their colleagues.

As I'm a little more open about my suits than most doctors, I'm viewed by some as a bit of a legal expert, so I'm occasionally approached for free legal advise. My advise is worthless, and they all know it, but it's an oddly therapeutic exercise for us, and I'm always happy to share my opinion.

"Doc", one of my colleagues said, "could I get your opinion on something? A short while ago an older patient without health insurance came into the ER here with a serious heart condition. He required emergency surgery, and he had an extremely rocky post-operative course. To be honest, he was a real trainwreck. About five consultants were called in, and I was one of them. After a month and several touch and go moments he was able to go home. It was a bit of a miracle.

"It turns out that this gentlemen had two sons who are lawyers. They approached the cardiac surgeon and told him that they were very unhappy with his care and were strongly considering a lawsuit. If the cardiac surgeon wrote off ALL of his charges, and if he convinced all the other consultants to write off all of their charges, too, they might get change their minds and, who knows, maybe forgive the doctors for their slipshod care.

"The cardiac surgeon approached me and begged me to write off my charges. He was so fearful of a lawsuit that he personally went around to all the consultants and pleaded with them all to do the same.

"What do you think I should do? I mean, this is little more than extortion, but I also know that any lawsuit becomes part of your record and can affect your insurability for the rest of your career."

"It's a pity that the surgeon is not a little braver, although I hardly blame him. As for your charges, I'd write them off. Even if the case were dismissed, it would probably hang over your head for at least two years. Who needs it?"

And that's what he did.

Medical Grand Rounds XXXVI

2005-06-01T21:30:00.000-04:00

Medical Grand Rounds returns! Check out Dr. Sanity's site. This is the second week in a row I've had a link. Glenn Reynolds still hasn't called...

Cap'n Andy's advise for the lovelorn lawyer

2005-05-29T13:36:00.000-04:00

Not long ago I encountered one of the most miserable-looking patients I had seen in my office in a long time. Overweight, out of shape, hypertensive, his face frozen in a scowl, this poor gentleman recited a litany of complaints ranging from stomach pain to lack of energy to sexual dysfunction. As he was getting ready for his physical examination I stole a glance at a large stack of papers he had brought with him, just in case I was running way behind schedule: "Party X alleges that Party Y knew or should have known that their actions, being negligent and wantonly irresponsible, caused damage and irreparable harm and yada yada yada..."

I might have known. A lawyer. Too bad.

One of the Big Lies in our culture is that we value freedom of expression and the right to express our opinions often and loudly. What we really value is the license to spout off whatever vulgar, ill-conceived and offensive nonsense we want. The Real Truth is that anyone who speaks the Real Truth takes a risk of getting sued, screwed, or crucified.

I speak the Truth in my office at most once every two or three years. I'm not proud of this, but it's true.

I recall one such time: "Bill, you claim to be a born-again Christian but you sleep around with every available woman in your congregation, catch hepatitis B, come to me to get patched up just so you can go and do it again. I'm writing on the prescription for you to take a vow of abstinence until you get married. No intercourse, no diddling around, no nothing. Put it in your wallet where you used to store your condoms."

Lest anyone think I was being brave, self- righteous, or (gasp!) judgmental ("Honey, pull the blinds and hide the children! I'm scared! A judgmentalist!"), I should add this:

He was smaller than me. I knew I could whoop him if I had to.
He wasn't a gun owner.
He wasn't a lawyer.
I was struggling with my own Mid-Life Crisis issues, so I was speaking as one pilgrim to another.

There are a lot of other times I would have liked to have told the Real Truth. "I'm sorry to hear that you're getting divorced, but over the last ten years you've been self-centered, self-indulgent, and image-consumed. You've put all of this over your family and it's taken a huge toll on your health."

"Just because you're gay doesn't mean you have to put any eager appendage into any willing orifice. Mother Nature isn't kind to the promiscuous, gender preference and condom usage be damned. If you don't stop, you're going to pick up something worse than hepatitis (I actually said something to this effect once, and the guy's two buddies almost fell off their chairs laughing. I'm glad I was a source of joy to them)".

"Ma'am, it's impossible to gain 30 pounds in six months if you're only eating 1200 calories a day, and no, you don't have a thyroid problem because I've already checked it. Truth be told, you have one bad case of Chronic Twinkie Poisoning."

Just this once I decided to tell the Real Truth to my lawyer patient: "You know, you make your living by siphoning money from your clients in return for no other benefit than to protect them from your own kind trying to do the same. What are you going to say when you're on your deathbed and recalling what you've accomplished with your life? 'Gee, I wonder if this is considered a billable hour?' You fool! Life doesn't owe you a Lexus and a summer house on the beach. Give them up. Tell you partners to buzz off. Open a bagel shop. You'll feel like a new man."

The Real Truth is that I said this: "Take these pills and you'll feel better. Oh, by the way, it looks like you're pushing it pretty hard. Try to take more time off and get some exercise."

No kidding!

2005-05-26T10:19:00.000-04:00

I'm heading out of town for a day or two. Check out this very funny site to meet my soulmates.

Medical Grand Rounds XXXV

2005-05-24T07:14:00.000-04:00

Grand Rounds have returned at Iatremia: The Chaplin.News. Should I be offended that they didn't publish any of my haikus?

Positive feedback

2005-05-23T11:50:00.000-04:00

"What? You've never done serious biking before and now you're trying mountain biking? Are you nuts? You're going to kill yourself!"

Now they tell me.

More medical research

2005-05-22T14:12:00.000-04:00

This time last year I was training for the Marine Corps Marathon. Disturbed by the rise of my resting pulse from the mid-50's to the low 70's, and inspired by the writing of John Bingham, I took up the sport and had managed to run a couple of half-marathons, enjoying it immensely.

My research demonstrated an important kinesiological principle: every two miles run beyond ten miles requires a doubling of the effort (and misery) of running it. If running ten miles requires, say, 100 exertion units, then running twelve miles requires 200 units, fourteen miles requires 400 units, and so on.

By the time I reached sixteen miles I developed such a bad case of plantar faschiitis that I'm still not able to run any significant distance without paying for it in blood later in the day. The uncreative doctor that I am, I simply stopped exercising. Let's be honest; when you've had the joy of experiencing a road race of about 6,000 people (I was stationed strategically in the back so I could take in the entire spectacle), sweating it out on an elliptical machine becomes unbearable tedium.

Losing that endorphin surge only plunged me into deeper fits of melancholy. If I didn't resume exercise, I knew that no amount of Zoloft would pry me out of bed in the morning. My resting pulse, which had gotten down to 48 on very mellow days, crept up to the high 60's.

That's when I bought a mountain bike. The decision was not a carefully reasoned one in which I balanced the risk of mountain biking vs. that of road biking, or any some such. I didn't want to wear those sissy black spandex biking shorts. In my neighborhood, the rubes hunt those folks down for sport. It wasn't for me.

For those of you that contemplate taking up a dangerous sport in their 50's, I'd be happy to give you some pointers. I bought an entry level mountain bike at a real bike shop manned by buff salesmen with calves the size of my thighs. It wasn't terribly expensive, and had all the basic stuff: front end hydraulic suspension, cool knobby tires, 24 gears, genuine Shimano everything.

I failed to calculate (because I had no idea) the cost of the accessories, which have exceeded the cost of the stupid bike. Here is my running total so far:

Cost of a black helmet with red flames down the sides: $49.

Cost of fingerless riding gloves: $15.

Bicycle rack: $105.

Sissy black spandex biking shorts with an outer nylon shell so they look like ordinary shorts: $69.

Drab looking riding jersey (so I don't look too foolish): $45.

Under-the-seat storage bag: $15.

Self-sealing bike tube in case I have a flat: $5.

Tube of Pedro's lubricant: $5.

Nifty swift army-type tool with 18 different gizmos, none of which I know how to use:$39.

Tire irons: $5.

Bottle carrier: $3.

Bottle: $2.

Portable light-weight bike pump:$19.

Really cool-looking Smith sunglasses with interchangeable wrap-around lenses (to my daughters and their friends: do not dare tell Mom how much they cost or I'm a dead man): um, $109.

Camelback hydration system: $29 (on sale!).

LED's for night riding: $25.

Chain-degreasing tool: $29.

Cost of careening wildly down a narrow path so steep that no one in their right mind would even walk down it, then running into a mud flat so deep that for a moment I thought that I wouldn't be seen again until archaeologists in some future epoch encountered my fossilized remains, all while my son was busting a gut laughing: priceless.

Things they taught me in medical school

2005-05-16T21:53:00.000-04:00

It's been fun to visit the blogs of medical students and residents. Its good to see that all the old battles are still being fought, such as the student's desire to learn vs. his need for sleep and family interaction, or the student's humanitarian instincts vs. the cynicism that medical training seems to breed. It also give me cause to reflect on my own academic heritage. Like it or not, our instructors exert a profound impact that remains with us during our careers.

I don't always remember complex interactions and metabolic pathways, but I usually remember pithy aphorisms. Here are a few that I remember:

Only half of what we teach you is true. It is up to you to figure out which half it is.
I don't think this was true, actually. Most of what they taught us concerning the science of medicine was true, although big chunks of it are now obsolete. I missed most of my pharmacology lectures because I was not about to sit in class for eight hours straight. The time was much better spent down at the glider park (I no longer had my motorcycle and needed some reason to needlessly risk my life). I'm glad I didn't expend a tremendous amount of energy learning about nitrogen mustard or reserpine. We never use that stuff anymore.

Of course, the love of knowledge and the discipline of study is what we needed, but it definitely wasn't being taught in our pharmacology classes. I hope the medical schools are doing a better job with it these days.

If the patient has pain anywhere below the 'belly button' and if s/he has an an appendix, then always at least think about appendicitis.
This has been a nifty little rule as of late. Gastroenterologists are basically internists with endoscopic skills, so we don't usually see much appendicitis; they usually go straight to the surgeons. If the patient has a weird presentation, such as pain on the wrong side of the abdomen, or a protracted course, they often get misdiagnosed and sent to me, the lowly GI guy. "They still have an appendix; why, I bet they have appendicitis!" I've been right about that several times this year already. Its a great 'grandstanding' diagnosis to make, and the outcome is always good. It makes me want to learn how to go in and whack those suckers out myself sometimes.

Medicine is a jealous mistress.
This of course isn't true in this day and age, with the growing numbers of women in medicine. Maybe medicine is a dysfunctional viragoe who treats its practitioners like sex slaves chained down in the basement. Maybe not. But it certainly isn't a jealous mistress anymore. The allure just isn't there.

The problem with being on call every other night is that you miss half the action.
The medical school I attended truly believed this, and changed it only when applications for residency began to fall because people were just not willing to be abused when they could go to a perfectly good program that had every third or even (gasp!) every fourth night call. It was also wrong. It reduced the practice of medicine to the learning of techniques and the acquisition of facts so that we, the doctors, can fix them, the patients. It ignored our own human limitations, our need for family interactions, our need to participate in communities of faith. In short, it called us to sacrifice a big chunk of our humanity upon the altar of medicine.

Don't wear the clothes in which you dissect your cadaver to the student union if you want to hit on the babes.
I bet this one is still true.

A little research

2005-05-16T21:37:00.000-04:00

I've taken a week or so off to conduct research on the tensile strength of senescent fibrous and fibroelastic tissue. In my effort to bond with my son and get his lazy backside out from in front of the TV, I bought a mountain bike. I have no mountain biking experience at all, so it seemed like a logical thing to do. Pedalling around the neighborhood, my son hopped up an 8 inch curb and made it look easy. My new bike has front end suspension and cool-looking knobby tires, so I assumed it would hop over the curb pretty much on its own. This was a mistake. I went slamming into the curb full-speed, doing a humiliating face-plant on the concrete.

My fibrous and fibroelastic tissue was not in the slightest bit amused. It was a few days before I could walk straight, and I still haven't figured out how to do a bunnyhop on the bike.

So I did the only thing that made sense in this situation. I sued my son. That'll teach the little turkey.

The Great American Novel

2005-05-04T13:01:00.000-04:00

The demand for my authorship of a book has been overwhelming.

It takes very little to overwhelm my fragile psyche these days, so I should add: I've received one suggestion to author a book, by a very kind reader whom I suspect wants me to quit wasting broadband.

It would be a stretch, to be sure. My method, such as it is, is to craft a finely worded opening paragraph, beat it into the ground for a few more paragraphs, and when I lose interest in the topic, bring the post to an abrupt halt, hoping that readers will misinterpret my short attention span for irony. This is probably not an effective method for writing a full length novel.

I'm also hampered by having nothing much to say once I've finished whining about those nasty lawyers, and even that gets old after awhile.

My favorite paragraph was the one about the zen of Yogi Berra. What a great idea for a book, I said to myself; I bet no one else has ever thought of that one.

I assembled my reading list for this project:

Zen and the Art of Motorcycle Maintenance.
The Compleat Idiot's Guide to Zen and Other Weird Mystical Stuff.
The Tao of Pooh. I almost dropped this from the list after I read about the author's sequel, The Te of Piglet which was universally condemned as a "mean-spirited neoLuddite polemic against everything Western".
Any three books written by Thomas Merton during the last ten years of his life.
The Tao Te Ching, of course.
And finally, When You Come To a Fork in The Road, Take It by the Great One himself, Yogi Berra.

Impulsively, as I was ordering all this stuff on amazon.com, I entered "Yogi Berra Zen" in the search function and was bitterly disappointed to see that the book has already been written. I ordered it anyway. If the book is shabby I'll write my own version of it, and put in some medical lingo to give it a distinctive style.

Otherwise I'll write Zen and the Art of Colonoscopy. That I know almost nothing about zen won't be a problem. In our culture, if you say something kindly and compassionately that doesn't make a bit of sense, that's close enough. The subject of colonoscopy contains enough scatological allusions to keep me going for weeks.

I'm losing interest fast. May the cecum of your soul seek it's sole grounding in the grinding of the succus entericus.

Just one more!

2005-05-03T22:23:00.000-04:00

The heart only beats
To pump blood to the colon
Been working too hard

Bad for your health

2005-05-02T14:11:00.000-04:00

Turnover at the "Butt Hut" was a little slow today. That's not a problem for me, but it did give me a few moments to compose some of the worst haikus I have ever read. If you have a strong aversion to pitiful poetry, I suggest you click on the "Next Blog" button in the upper right hand corner of your screen.

You've been warned.

Let the light shine forth
Oops, the prep is bad today
Have to reschedule

The colon lining
Looks like its scrubbed with steel wool
Steroids on the way

The angry patient
Seeks disease. When none is found
Wants her money back

His gas is so bad
Pet dog gets up and leaves room
Sorry, just can't help

The fecal stream flows
Scopes go against the current
As the lawyers wait

Rocking the bridge

2005-04-29T22:33:00.000-04:00

In the mid '80s San Francisco threw a party to mark the 50th anniversary of the opening of the Golden Gate Bridge, and I was there.

When the bridge opened in the '30s it was initially closed to cars so that the citizens could stroll leisurely about, enjoying the magnificent view of the Bay, the city and the Marin Headlands. What better way, the city planners thought, to mark the 50th anniversary of the bridge than to close it to traffic and allow the citizens once again to stroll about the bridge?

It was a great idea; so great in fact that on the morning of the Great Stroll, about 500,000 people gathered at the south end of the bridge (one of which was me) and an additional 300,000 souls assembled at the north end. When the signal to let us on the bridge was given the two huge masses of humanity rushed upon it, met in the middle, and came to a complete halt. 800,000 people were on the bridge, all standing shoulder to shoulder, unable to move.

Had this happened in less civilized climes like Malaysia or New York City, it could have resulted in tragedy. Just a small group of people in a state of panic could have started a stampede that might well have resulted in thousands of deaths, people getting trampled and crushed by a human tsunami. Fortunately, the reaction of the Californian crowd to this hopeless gridlock was "Cool. Let's watch the airshow." And there we all stood for about three hours.

Two things happened on that bridge that were henceforth and evermore seared, and I mean seared into my memory. I had the misfortune to be standing near a group of Irish women who passed the time away by singing "The Hokey Pokey". It was cute to begin with, but after about an hour and a half of it my mind was filled with dark fantasies of dragging them over to the guardrails and tossing them into San Francisco bay. I have since contacted the CIA telling them that if they need a nonviolent way to extract information from a Wahabist, just lock him in a room with a group of Irish women singing "The Hokey Pokey" for hours on end. He'd sing like a canary in short order.

As we all stood in the middle of bridge without the prospect of going anywhere anytime soon, someone got the idea to see if we could get the bridge to rock from side to side. It is, after all, a suspension bridge. First a few people began to shift their weight from side to side. They were joined by hundreds more until about two or three thousand people were moving in perfect harmony, shifting the weight to the east side, then the west side, then back to the east side of the bridge.

The bridge began to move an inch or two, then several inches, and then what felt like a yard or two, swinging back and forth like a giant Foucault's pendulum. Initially the crowd was exhilarated by their power to move such a massive structure. As the bridge swayed back and forth more and more, the collective consciousness of the crowd visualized the bridge snapping in two because of the motion and the weight of the crowd, with untold thousands plunging to their death in the frigid waters of the Pacific Ocean.

"Maybe we shouldn't really be doing this", somebody called out. Proving that consensus is possible in our pluralistic society, we all instantly stopped and the bridge settled down.

This blog is a therapeutic exercise, a Primal Scream into Cyberspace if you will. But our medicolegal system is profoundly dysfunctional and needs to be rocked and shaken to its very foundations. The actions of one lonely blogger railing against the system will not change anything, though it'll help me feel better. I have very little weight to throw around these days. If someone reads this blog and is moved to express his or her own experience, and then more and more doctors take up the challenge of blogging or writing for the nonmedical community, our collective weight can rock the system and promote legal reform.

The death of one man is a tragedy; the death of a million is a statistic. If an entire hospital gets closed down for lack of liability insurance, its a statistic unless you happen to go to that hospital. If your own doctor faces a year to year difficulty with liability insurance, then it becomes a problem. If your own doctor is like a trusted friend to you, then its a crisis.

Stay with me; see the human "face" of the malpractice crisis. Don't feel sorry for me, but get angry, join me and push for reform.

Worthy of comment

2005-04-27T08:42:00.000-04:00

I've had some feedback from my "narrative" post, ranging from "That was a good post, Dad", to "Do you know the number of the local Suicide Prevention hotline?". One very thoughtful comment read as follows:

Many patients, as your experience has taught you, confuse the circumstances of their lives, with who they are, e.g. "PWA", Person with Aids, as just one of seemingly limitless number of examples.

But physicians, too, fall into this same trap. Their monetary success, academic rank, or involvement in malpractice litigation (whether or not they were at fault) is often the fuel that fires their narcissistic awe or narcissistic rage, as the latter case may be.

This all too often leads to the problems that befalls so many physicians; substance abuse and dependency, burn-out, divorce, depression, suicide, and early death.

Reducing their view of themselves and their world to the "if only..." you can see how this happens.

Serving G-d and the community, no matter how one defines success, is usually difficult and often painful.

The advice I give to my patients, and to many physicians, is first, through self-love, find compassion for yourself, and forgive yourself. Once having done that, you can then forgive others. No longer will your rage linger and fester, as this is symptomatic of your resistance to what is.

Love and compassion.
Forgiveness and humility.
Prayer and faith.

These are the tools that made you a great doctor. They are also the tools that will enable you to find comfort.

There is of course much wisdom packed in those few short paragraphs.

One concept that has helped me to have a better understanding of virtue is Aristotle's "principle of the mean", which states that a virtue is not a polar opposite of a vice; rather, a virtue lies between the extremes of two vices. For example, courage is not just the opposite of cowardice, but occupies the middle ground between cowardice and recklessness.

Our response to adversity likewise can lie at two extremes. One is a narcissistic self-absorption, or as Frank Pittman would put it, a belief that somehow our particular brand of suffering is unique in the universe. The other is denial of pain, that ANY pain is evil and we best do all we can to avoid it. The ultimate expression of this vice is substance abuse or it's surrogates such as workaholism.

I suspect that most of us go pinging wildly back and forth between these extremes. I certainly do, although my own tendency is "extinguish the pain at all costs" which has led to my battle with workaholism.

The biggest single weakness of the blog is that it is not a very good vehicle for an extended narrative. I may spend three months and numerous posts to create a tension that finds a catharsis in the expression of pain, which then allows me to push forward and find the joy that surrounds us all if we're only attentive to it. If your first reading of my "working-through" was "A narrative", it would be easy to imagine poor me railing against the universe for having had such a bad time of it as of late.

The reality is that my suffering in the grand scheme of things is trivial. That is why I enjoy forays into "third world" countries. The folks there know what real adversity is, and they often don't even see it as anything other than life-as-usual.

On the other hand, I'd be less than honest if I said that my experiences weren't painful. Yes, we all can deny our pain, or we can savor it, but the precious middle course is to confront it, receive healing, and move on.

And that cannot happen without the input from our friends, our family, our colleagues, and from God.

A dilemma

2005-04-24T11:29:00.000-04:00

"Do I do a quick blog, or do I run upstairs and get dressed before my wife gets back and we go to Sunday brunch?"

"Why don't you do a quick blog about the dilemma of whether you should blog or get dressed?" my son-in-law suggests.

Good point. I've got to be quick.

Lest folks wonder about what my Zoloft levels have been these days, let me share with you one of my favorite passages, written by Frank Pittman, entitled TURNING TRAGEDY INTO COMEDY:

A young man named Jeff, who was dying from cancer that had metastasized to his lungs, was a patient of mine 30 years ago. His family cried and prayed over him and pretended he would recover, though they knew he knew better. I was initially called in to relieve Jeff's pain through hypnosis. That worked fine, but he was still lying in bed out of breath, bored, angry and resentful of the fact that his life was being cut short. He demanded to know why God was punishing him in this way. His family had offered him the Book of Job, but it proved to be no help. Jeff was left wondering why God went out of his way to torment innocent people.

As Jeff and I talked about how he could use his last few weeks, the idea came up of reading a great novel about life. Jeff had been an athlete with little patience for school and he had never read a book. He chose War and Peace, the longest novel we could find, and dedicated himself to reading it, determined that he would live until he had finished it. He was a slow reader, and he lived weeks longer than anyone thought possible. He refused all pain medicine that might cloud his brain, and each day we discussed what he had read and learned about life.

Jeff's favorite scene was the one of Nicholas unhorsed and knocked out on the battlefield, coming to and noticing the cloud formations and then the cloud of dust on the horizon. As he realizes that the dust was being kicked up by French soldiers on horseback coming to kill him, Nicholas wondered, "Why would anyone want to kill me, me whom everyone has always so loved?" The wonderful absurdity of Nicholas's sunny self-satisfaction in the face of death connected Jeff to all the rest of us who will one day meet our fate. Whether we deserve it or not, whether we embrace the world or shrink from it, whether we burst with self-esteem or shrivel with self-loathing, we're all going to die.

When Jeff died peacefully the night he finished the book, he no longer felt singled out by a cruel or capricious god. Instead, he knew he was sharing the human condition, a different part of the human condition than he expected to experience at his age, but nonetheless part of what is universal for humankind.

I hope that balances my last post a bit.

A narrative

2005-04-23T12:27:00.000-04:00

In the late 80's I found myself mired down as a semi-permanent employee of a small group practice in a small town. It was bad match from the start, and after considerable soul-searching I decided to pack up the family and move to the big city, where I would start over as a solo practitioner.

This was in the pre-Katie Couric era, when few had heard of colonoscopy and those that had heard of it believed it to be some sort of Medieval torture. Referrals were not abundant, so all gastroenterologists faced the prospect of sitting in their office, staring at the walls and wondering when the next new patient appointment would come in.

As I had neither trained nor been raised in this big city, I had no reason to believe that patients would be pounding on my door. I assumed I would starve to death and have to give my children up for adoption and put my wife to work in the local Waffle House (noble work, to be sure, but it doesn't pay all that well). Under such circumstances it is easy, instinctive really, for us to turn to God, to pray that He would "give us this day our daily bread".

I remember listening to a Chuck Swindoll sermon about faith in the marketplace. It's been a while, and I'm quoting only as best as I recall:

One business owner in our community had always put the "bottom line" ahead of ethical considerations. Although he was successful, he experienced an emptiness which no amount of money could fill. He turned his life over to God and dedicated his business to Him, vowing that from that point on he would conduct his business with the highest of ethical standards.
Not long after his conversion, he got a call.
"You've got to come quick! Your business is burning down!" he was told.
Upon arriving at his business place, he saw that indeed an uncontrollable fire had broken out and that the business he had worked so hard on in his life had just burned to the ground. His associates thought he appeared oddly unconcerned about the course of events. They asked him why.
"Well," he replied, "I dedicated this business to the Lord, and He can take it as a burnt sacrifice if He wants to."

One can debate God's role in this. Perhaps He did want the business for Himself; perhaps His only involvement was a permissive one, choosing not to strike some street thug arsonist dead for trying to impress his gang. But it made sense to the business owner. Seen through the eyes of faith and believing that God is in control and that our lives are a narrative of His action, this event would be just one more chapter of a story that will make sense in the fullness of time.

I dedicated my practice, such as it was, to God. Soon I had more work that I could handle, and financially we were secure.

During the next decade I succumbed to my workaholism. I wasn't interested in fame or fortune; I just wanted to prove to the world that this dumb old Army doc and son of a dirt-farmer could make it as a first-rate physician.

Then the lawsuits came. The first, which went to trial and in which I prevailed, left me bitter. The second, which I settled for a non-trivial amount of money in spite of some urging not to, left me defeated. The third, again settled for a non-trivial amount of money, left me crushed. I expressed to my defense attorney that maybe I should just get out of medicine. He told me, "If it makes you fell better, you're an excellent doctor whose been at the wrong place at the wrong time and has been royally "f--'d. I've never seen anything like it."

Well, it didn't make me feel better. I feel a little like the business owner looking on the burning of his business, knowing that his life will never be the same. It's not that my practice has been reduced to smoke and ashes, but it has been soaked in kerosene, waiting for the next malcontent to toss a cigarette butt on it in the form of a nuisance lawsuit.

Maybe I'd feel a little better about the whole thing if I understood what it meant. Am I being punished for the sin of workaholism (or something else? There's plenty to choose)? Am I being toughened up for some bigger challenge about to enter my life? Is it that it's simply time to move on and I'm so dense to God's guidance that He has to lead me by the nose?

My consolation is that these questions have been asked by men far better than I. Listen to the complaint of the psalmist:

Tell me, what's going on, GOD?...What am I doing in the meantime, Lord? Hoping, that's what I'm doing--hoping you'll save me from a rebel life, save me from the contempt of dunces.
I'll say no more. I'll shut my mouth, since you, Lord, are behind all this.
But I can't take it much longer...GOD, listen to to my prayer, my cry--open you ears. Don't be callous; just look at these tears of mine. I'm a stranger here. I don't know my way--a migrant like my whole family.
Give me a break, cut me some slack before it's too late and I'm out of here.
Psalm 39:4-13, taken from "The Message".

The art of being uncertain

2005-04-21T22:30:00.000-04:00

In his latest post, Dr. John Ford, aka the California Medicine Man discusses many of the factors that go into our profligate test ordering. It boils down to the fact that we want NO uncertainly in our life, and we're willing to spend a lot of (other people's) money to rule even the most obscure possibilities.

The post is a good read and I recommend it. I've been reading a very thoughtful essay that just happened to dovetail into this discussion: Medicine, Love, and the Art of Being Uncertain by Dr. Daniel Sulmasy of Georgetown University, taken from his book The Healer's Calling, published by Paulist Press. I've enjoyed the essay and will share an extended excerpt from it:

The quest for certainty undermines trust. The quest for certainty fills the vacuum that remains as trust evaporates from the doctor-patient relationship. Intolerance for uncertainty results from the absence of a certain basic trust, informed by a strong belief that the future could not possibly turn out OK for me unless I manipulate things and people in order to make it come out OK.
Tolerance for uncertainty, by contrast, demands a level of basic trust. In the present era, however, this trust is hard to come by. It now seems as if doctors no longer trust their patients and patients no longer trust their doctors.
It is not easy to say what accounts for this situation, but I think health care professionals themselves, taken as a whole, are largely to blame. One source of this distrust and intolerance for uncertainty is that medicine has been so successful in convincing the public of its invincible powers and the certainty of a cure for everything, that death and other human limitations on medicine are now interpreted as someone's fault. This in one for the causes of the malpractice explosion and the growth of defensive medicine.
Another source of mistrust is the cynical attitude toward doctors that doctors themselves have cultivated among the public...Patients fail to see how organized medicine can claim to put patients first when organized medicine has, by and large, fought against every type of true health care reform.

Exactly.

A plug

2005-04-20T18:58:00.000-04:00

For those of you whose interest was piqued by Dr. John Patrick's essay on the Hippocratic Oath, may I invite you to check out the Christian Medical and Dental Associations' website where there a wealth of lectures, tapes, etc. delivered by John. His talks are much more accessable than his writing, and he's a very clever and entertaining speaker to boot. He was the featured speaker on this month's "The Christian Doctor's Digest", and one who always challenges me in a most profound way.

The CMDA is one of the few organizations that are fighting for a return to the Hippocratric ideals, and are worthy of our support even if you do not consider yourself evangelical or Christian. The monthly Doctors Digest alone is worth the price of membership.

Of Cabbages and Coots

2005-04-15T23:22:00.000-04:00

A doctor joke:

What is an alcoholic?
Someone who drinks more than his doctor.

My corollary:

When is a doctor an old coot?
When he's about ten years older than I am.

A gratuitous bonus:

In Kentucky, what is a pervert?
Someone who likes sex better than basketball.

A recent study in the Annals of Internal Medicine demonstrated an "inverse relationship between a doctor's age and his performance", which is a very graceful way of saying that the older we get, the less we stay up to date with the current trends in medicine. I don't think this is a very surprising study, and one does not have to assume that it's because we older docs have early Alzheimers and have short term memory loss.

I don't think it's because we have short term memory loss, either.

And I don't think it's because we have a short term memory loss.

OK, it wasn't that funny, but...what in the heck was I talking about?

Oh yeah. Losing one's grip as he gets older. Let's see, when I was just a mere slip of a doctor, we would treat peptic ulcer disease with heavy cream, and were thrilled when the wonder drug Tagamet was introduced. When Star Wars first hit the theaters CT scans were just entering the medical mainstream, and were greeted with the same wonderment as we had for the laser-saber. Now some radiological entrepreneurs want the CT scan to be part of the routine physical examination, like getting your blood pressure taken or your cholesterol checked.

The times, they are a-changin'.

I don't hold myself up as a model for up-to-datedness, but I'll share with you my attempts at trying to keep up with the Doogie Howsers of the world:

Harness the power of your inner geek.
Use some of your love of electronic toys for your practice. For example, I subscribe to JournalBytes that downloads medical abstracts of current interest into my handheld. I read them at my leisure and take a test on the handheld which then uploads it to their server. If I pass the test I get 3 CME credits. Epocrates and UpToDate are other fine services I subscribe to.

Let others feel your regulatory pain.
It is impossible to keep up with the literature AND take care of OSHA, CLIA, HIPAA, the CorrectCoding Initiative, Stark I & II, the Kennedy-Kassebaum Act, Medicaid utilization review, FMLA forms, Prior Authorizations for Proton Pump Inhibitors (half the population is on them), predatory insurance practices by such folks as National RedStar/RedSword, COBRA/EMTALA, endless credentialling and recredentialling, etc. etc. I'm approaching the point where the only time I'll fill out a form is when they threaten to jail me if I don't. If you don't like it, complain to the powers that be. I don't have enough resources to fight over every single PA for medications that you could get (almost) over the counter. Don't dump it on me.

Remind yourself every morning that you don't know squat.
This is particularly difficult for a gastroenterologist to admit. The longer I'm in medicine the less I feel I truly comprehend; combine that with trying to adopt a holistic approach to your practice by considering the emotional and spiritual aspects of humanity as it relates to their health, and I'm convinced that I won't ever master this noble art.

While we were passing gas...

2005-04-14T13:16:00.000-04:00

Most colonoscopies are performed with conscious sedation, a pleasant concoction of a pain-killer and a sedative that induces a "twilight-zone" state in the patient. Once they're in that state, we can then do our examinations without causing much if any pain.

Not all patients do well with conscious sedation. Occasionally we call the anesthesiologist in to give industrial strength sedation, inducing a level of sleep that most gastroenterologists feel uncomfortable giving on their own.

During a recent case, the "gas-passer", as anesthesiologists are sometimes called, was in a fairly chatty mood.

"Doc", she said, "have you heard about that lawsuit in Arizona? Some doctor is getting sued because he didn't order a mammogram on a demented nursing home patient. But they're not suing him for malpractice. They're suing him for elder abuse!"

I hadn't heard about the case and still don't know any of the details.

"There is precedent for this kind of stuff," says I. "In California some family members wanted to destroy a physician and make a buck on it because they thought he undermedicated their dying father for pain control. California restricts non-economic losses to a mere $250,000, and of course there would be no way to generate economic losses on such a case, so they sued the doctor claiming elder abuse. The doctor was found guilty and the family was awarded $2,000,000. I doubt the jury realized that such a judgment would not be covered by malpractice insurance because it is a criminal case. The doctor was financially destroyed."

"When will this stop? When will they figure out that they've pushed too far?"

"When we all quit, which we're not likely to do because basically we enjoy the practice of medicine. Besides, we have no other marketable skills, and they know it."

So we don't worry about the simple malpractice case anymore. Instead we worry about being given a felony conviction so lawyers and families can make a buck and destroy us.

One way for us to escape this threat is simply not to see anymore Medicare patients. Because their Medicare reimbursements are slated to go down another 30% over the next few years, more and more doctors are thinking about dropping Medicare. The government has constructed huge barriers to doing this, and traditionally doctors haven't wanted to put themselves in the position where they "won't take care of Grandma".

Still, we live in a free-market society and sometimes the only thing the market understands is that a huge demand for a service or product that is in short supply will ultimately drive costs up and availability down. It seems to me that the only way things will change is when a patient calls 911 because of a medical crisis and is told that the only person they could find to man the emergency room is some third year law student.

In the meantime, I try to take solace in the words of Mother Teresa:

People are often unreasonable, illogical, and self-centered. Forgive them anyway.
If you are kind, people may accuse you of selfish ulterior motives. Be kind anyway.
If you are successful, you will win some false friends and some true enemies. Succeed anyway.
If you are honest and frank, people may cheat you. Be honest and frank anyway.
What you spend years building, someone could destroy overnight. Build anyway.
If you find serenity and happiness, they may be jealous. Be happy anyway.
The good you do today, people will often forget tomorrow. Do good anyway.
Give the world the best you have, and it may never be enough. Give the world the best you've got anyway.
You see, in the final analysis, it is between you and God. It was never between you and them anyway.

Good for another year

2005-04-13T09:21:00.000-04:00

At home, digging through tax information that I should have staightened out a month ago, I receive a call from the office: yes, you have liablility coverage for another year, and yes, you can afford it. Cool. Year to year existence can make long term planning very difficult, but then again, none of us has guarantees about tomorrow. It's good to know that I'll have another year to generate anecdotes and vignettes for my blog.

If you don't go to other people's funerals, they won't come to yours.

2005-04-12T20:46:00.000-04:00

Hundreds of years from now, after our race has extinguished itself in some cataclysmic paroxysm of violence and/or pure foolishness, a future race will unearth our remains and artifacts and attempt to make sense out of a hopelessly muddled and deranged civilization. (Don't you just hate tax time? It always brings out the worst in us.) When they do, I have no doubt that if they discover the sayings of Yogi Berra they will worship him and hold all that he said as sacred. His comments will have a koan-like quality, containing the paradoxes and mysteries of the universe in pithy sentences which, at least on initial inspection, seem to defy the rational process.

As Yogi said, if you want other people to come to your funeral, then you had best start going to theirs. I'd like to see a lot of people at mine, so I've been going to a lot of funerals and visitations as of late. This has included the visitation of several of my patients, a doctorly form of going down with the ship, if you will (obscure reference to the Cantatrice Chauve)

I'm no great shakes as a physician, but you'd never know it from the reception I get when I pay a visit to the grieving family. It provides me a sense of closure if I was closely involved with the patient, and the family is always touched that I would take the time to visit the funeral home.

I see aspects of the patient that I had never seen, pictures of their childhood, their confirmation, their wedding, and what they held as dear. I see them long before they started drinking too heavily, before the pancreatic cancer blossomed forth, before they experimented with drugs and contracted hepatitis C.

I become ashamed of my nominalism, my tendency to put patients and family into fore-ordained roles: "The Codependant and Somewhat Clueless Wife", "The Deeply Conflicted Son", "The Sister with Her Act Together", and "The Out-of-town Relative Whose Good Friend is A Doctor and Suggests That You're Doing It All Wrong". The roles disappear at the funeral home. They're just glad you dropped by.

If I had to do it again I would have gone to a lot more funerals in my career. I wouldn't have shied away because I didn't want to have to think about anything other than organ systems and responses to medications and coding the patient's illness correctly to insure maximum reimbursement for my efforts. Perhaps I would have seen to it that plenty of people would be on hand for my own, to see "The Doctor Who Squandered His Talents On Nonsense Instead of Involving Himself With Others". Perhaps.

A modest proposal

2005-04-05T22:53:00.000-04:00

If given free rein, I could have the malpractice crisis pretty much straightened out in this country in about a years time. Limiting noneconomic damages is the right thing, but it is only a start.

There are better ways to deal with just compensation for injured patients than we have, and I may expound on them later. Quality control is a major issue, or as my attorney put it, "I think that knowing that you could get sued at any time makes you guys better doctors." It certainly drives up our blood pressure, increases the risk of addictive behaviors among physicians, and forces us to order lots and lots of expensive tests. It also forces physicians coming into their prime to plan an immanent retirement, either from the stress of practice or the inablility to find malpractice coverage. Whether it makes us better doctors isn't at all clear.

Nonetheless, human nature being what it is, we need a strong disincentives to laziness, sloppiness, and permanent bad judgment.

I don't think we really need to spend a lot of money on this. Most of us have lots of ego (have you ever noticed?) and we hate to be wrong, especially in front of others. Nothing would terrify me more than opening up my city's paper and seeing a lengthy article on the case that I mangled beyond recognition. That's actually one of the ways in which I was intimidated into settling. No one wants to see their shortcomings discussed on page one of the Metro section.

For the egregious blunders, I recommend the Abu Graib approach: doctors who really foul up should be made to wear underwear on their heads. Photographs would be printed on page one of the newspaper. Only the most hardcore sociopathic doctor would fail to be kept in line with this punishment lurking about them.

Then the malpractice attorneys, having nothing to do and no visible means of support, can learn useful skills such as massage therapy, dental hygiene, and life-style coaching.

Consumerism and autonomy

2005-04-02T13:59:00.001-05:00

Dr. John Patrick is one of the finest and brightest individuals I've ever had the pleasure of meeting. These are excerpts from his paper Hippocrates and Medicine in the Third Millennium, which can be accessed by visiting his web site (I won't ever again lead you to a site where you can't get full access to the article!). He wrote this paper in the 90's although it seems as if he might have written it in the aftermath of the Terri Schiavo case.

In this narcissistic era where individual autonomy is always first it comes as a surprise to realize that patient rights have no place in Hippocrates' thinking. That, say the modern generation of bio-ethicists, is good reason to dismiss Hippocrates. But is it? Hippocrates lived in a pagan ethos where life was cheap and promises easy. His time did not have two thousand years of Christian thought anchoring it down. In such times patient autonomy was meaningless because the relationship was intrinsically unbalanced. All the power lay in the hands of the physician. The patient's safety therefore lay in the ethics of the physician. If the physician took the Oath of Hippocrates he swore to do no harm, to recognize the limits of his competence and refer appropriately, he swore to honour his profession by not abusing his opportunities for sexual gratification and he swore to treat all men equally. The patient's safety lay in doing everything to preserve the physician's integrity, to avoid even subtle coercion to kill or to abort. Remarkably there is little evidence that European culture did other than encourage physician integrity to the Oath of Hippocrates until the last century where once again rationalistic hubris began to erode this cultural gift...When one is ill, one needs someone whom one can trust to do what is best for us. No amount of verbal papering over the cracks by substituting client for patient will change the reality that sick people want someone else to handle the difficult problems. You may be a client when you choose who will fix your hernia but you are not a client when you have septicaemia and renal failure. This is where Hippocrates changed the direction of medicine. Ancient and modern pre- and post-Hippocratic physicians were and are willing to kill for a price, whether financial or ideological. There is, as Gerald Manley Hopkins put it,"a death dance in our veins"; Kevorkian illustrates this for anyone with eyes to see. Thus when you go to such physicians you must always worry whether someone else has paid more for your death than you have for your life. Those followers who took the Oath of Hippocrates removed this fear, generated a substantial trust and consequently became the physicians of choice. It was patient choice and the desire to have an income, which forced the medical profession to adopt the higher ethical standards of the Hippocratic community not the intrinsic nobility of the medical community.

Lessons from the heart

2005-03-31T18:46:00.000-05:00

This week has been, as one of my daughters would put it, a whole lot of no fun. My accountant is clamoring for my tax stuff, my health insurance needs to be renegotiated (can you believe how expensive it is these days?), my office staff is in turmoil because none of the ladies really like each other, I forgot to pay a couple of (household) bills because I've been so busy at the office, my feet hurt from standing around so much, an attorney called and asked if I might be an expert witness (I guess because I'm so experienced with the legal system), I have a couple of patients with Crohns that perplex me, my BP was 150/99 earlier today, and it's been drop-dead gorgeous outside and all I can do is sigh and think of the days of my youth when such a day would motivate me to ride my motorcycle or go gliding or to do something other than sit around and complain to a bunch of total strangers.

It's good of you to listen. Sometimes the only thing you can do is be there for me.

In the Christian tradition followers often withdraw to a quiet place for solitude and meditation. In the American medical tradition the best place for solitude and meditation is the bathroom. They never find me there, and if I turn off the pager for ten minutes I can be guaranteed peace and relief from whatever burdens I might be carrying, if only for a fleeting moment.

I can read a lot on the move, so to speak, because I download a ton of stuff to my handheld. During times of stress when I feel like hiding in the basement until my creditors drag me out, I'll turn to something uplifting so I'll remember why I went into medicine in the first place.

The article that helped me today is an article from JAMA entitled Twenty lessons from the heart of medicine (see the link above). Dr. Alan Guttmacher is a medical geneticist who suffered a heart attack in the late 90's and went through an arrest, cardiac electrical shock, and lengthy rehabilitation. The article is both amusing and thought-provoking, and I've extracted the lessons for your enjoyment. Enjoy.

Never sleep with anyone who doesn't know CPR (his wife, a nurse, saved his life).
Although neither may know it, patients are actually more motivated than their caregivers.
Patients feel guilty if they don't meet caregivers' expectations.
Both unconsciousness and amnesia can be good (why do they have such bad reputations?)
While not as bad as I imagined, 250 joules (of electric shock) is better to give than to receive.
The sicker you are, the more helpful a sense of humor, in you and in loved ones.
Patients do not fully share physicians' excitement in "interesting" cases.
Always wonder, "Why does this person have this disease?"
Illness may not be the patient's fault.
All physicians become patients.
Always ask about family history, particularly if the patient is a geneticist.
Even for a physician, it is easy to be passive as a patient, especially when scared.
To prepare for Olympic swimming or a heart attack, shave your entire body.
Too seldom inquired about, the patient's view of therapy often differs from the physician's, and is valid.
In medicine, one size does not fit all. Treat the patient, not the disease.
You can't overvalue family and friends.
Illness is an intense part of the human experience. While always unwanted, it is often literally invigorating.
Every day is a gift. Be well. Do well for our patients.

The little mouse in the corner

2005-03-26T14:54:00.000-05:00

Mealtime for the family of a gastroenterologist is not for the weak-of-stomach. It's not my fault that seeing flaming Cherries jubilee brought out to our table prompts an uncontrollable reflex in me to discuss the really cool case of hemorrhoidal bleeding I'd seen lately. It just happens.

For that reason the rest of my family has no hesitancy in bringing up subjects that others might find a bit unappetizing.

One evening at a nice restaurant Daughter the Younger told us of a time she had been to a zoo and got to watch feeding time for the snakes. "There was this one fat old lazy snake they were feeding. The workers dropped a little white mouse in the snake's cage. The snake woke up and took one bite of the mouse's tail, lost interest, and fell asleep. There was the poor little mouse with half his tail gone, shivering in the corner as the snake slept. I kept thinking, 'Why are we just standing here? Isn't anyone going to rescue the poor little thing?'".

I agreed. We mammals had better stick together. Under threat of punishment we quickly changed the subject.

By the end of the meal, though, I thought I might break down and cry. Countless thousands of innocent people had died in the tsunami just the week before. Mice are eaten by other animals everyday. The hamburger I just ate required the killing of some cow who never meant me any harm. Yet this story touched something deep within my soul, a feeling that life-as-it-is-ordained is unjust and cruel and mean.

Somewhere in Florida a 'little white mouse' of a person is slowly dying as the snakes sleep and as we stand about wondering, "Why are we just standing here? Isn't anyone going to rescue the poor little thing?" People die all the time, cancer patients long for the day they will no longer hurt so bad, people with Lou Gehrig's disease look upon their future with only fear and dread, and life for the rest of us goes on. Yet this story touches something deep within my soul, a feeling that life-as-it-is-ordained is unjust and cruel and mean.

My pet alligator

2005-03-23T21:33:00.000-05:00

During my recent vacation I visited an alligator farm in the Everglades. Because I had never paid close attention to Jurassic Park I hadn't realized that the gender of alligators is determined not by genetics but by the ambient temperature when an egg is fertilized. You learn something every day.

That alligators make lousy housepets didn't come as a shock. Baby alligators are cute in their weird reptilian way, and they grow up with nice toothy grins on their faces. They just don't posses a limbic system. Try as they might, they can't form emotional attachments.

You can take a freshly hatched alligator and nurture it for years, but it still wouldn't hesitate to bite off one of your body parts if it were hungry enough. Without a limbic system and a cerebral cortex, the alligator does not have the circuitry for sentimentality. Little wonder that people feed the alligators in their neighborhood hoping that the it will be grateful and behave accordingly, only to have it chomp down on an unlucky small mammal when given the opportunity.

I saw a very nice young lady in the office for evaluation of abdominal problems which get worse when she goes to court. As a trial lawyer she goes to court fairly frequently.

"I recommend you quit your job, go back to school, learn a trade, and make your living by helping people. Not only will your pain go away, but you'll also sleep much better at night."

In my dreams.

The reality is that she received the same treatment that I give all my patients. I reviewed the different diagnoses she could have, discussed diet and pharmacological therapy, and presented the diagnostic yield of the vast array of tests we have. She listened attentively and asked very good questions. It was a pleasure taking care of her.

For the life of me, I just could not get the image of those cute little alligators out of my mind the entire time she was there.

Tragically, all patients look a little like alligators these days.

Slow rabbits and fast wolves

2005-03-21T20:43:00.000-05:00

Every morning the hungry wolf wakes up knowing that if he's not faster than the slowest rabbit, he won't make it through the day. Every morning the rabbit wakes up knowing that if he's not faster than the fastest wolf, he's not going to make it through the day, either.

This little fable kept popping into my head as I sat in on the coding and reimbursement seminar today. Lest anyone get the wrong idea, learning how to increase our reimbursements is not why we go to these things, even though that's nice should it ever happen. We go to these seminars to stay out of jail.

Trying to stay off the radar of the Medicare reimbursement and fraud prevention people is like driving along a tortuous road on a dark and stormy night in a car with no speedometer and where the cops change the speed limit every few days but it doesn't matter because they don't post the speed limit anywhere you can see it, and if you don't get to your destination very quickly a tiny little kitten will die a slow and miserable death.

The analogy might seem a bit overwrought, but to the doctor who's trying to be a good citizen, stay out of jail, and pay his malpractice premiums, it's actually understated.

I won't bore you with the details, but the consultants are warning us about some pretty ugly stuff coming along. Obesity is a growing problem in this country, and the surgeons performing gastric bypasses are seeing their practices burst at the seams.

Insurance companies are not happy pouring the feed into the trough, and their solution is very simple: put a lifetime cap on payments they'll make for bariatric patients.

My first reaction was a blase "Boy, that's too bad" until the consultant mentioned that in order to make the cap stick the insurance companies intend to limit what they'll pay for all digestive disorders.

"How can they get away with that?" Beats me, but with assets greater than most countries in the world, the insurance companies will find a way.

This means that gastroenterologists may simply not allow bariatric patients into their practice. And that would be a shame.

There are times that this old rabbit thinks his knees are getting just too sore.

A bad truth or a good lie?

2005-03-20T13:31:00.000-05:00

"Doc, there may be times during your deposition that you will not like the answers you'll have to give", my lawyer intoned. "I'm telling you now, what ever you do, don't lie. I'm not telling you this for any ethical or moral considerations, it's just that a bad truth is always easier to defend than a good lie. The lies will come back to bite you in the butt every time."

I appreciated my lawyer not wanting ethical or moral considerations to get in the way of winning the lawsuit. Still, there are times when I'm trying to drift off to sleep that I hear my Bad Angel mutter to me: "You could have lied and gotten away with it. No one would have known except you and me, and you can always trust me. Let's face it, you're a fool. No one's going to give you a good citizen award for being honest."

My guardian angel whacks him with a flaming sword and off to sleep I fall. That's the advantage of trying to keep the lies you tell in your lifetime down to a bare minimum. It's a lot easier to get to sleep.

Perhaps that's one of the reasons so many people in America are sleep-deprived. We all struggle with dishonesty, but when it's required for career success it can wear a body down.

During a recent town meeting a representative of the Doctor Defender malpractice insurance company reassured the crowd that there was indeed no malpractice insurance crisis. What we're seeing is a market correction of sorts, but like all issues economic the market will soon take care of what ever inconvenience the doctors are experiencing.

What he didn't mention is that Doctor Defender had recently terminated coverage for the entire Department of Neurosurgery at the Local University, home to a very fine Level III trauma center.

I wish I would have had the pleasure of refusing to write the guy a prescription for sleeping pills.

Then again, I would have sympathized with him and called it right in, I suppose.

Two little questions

2005-03-16T22:23:00.000-05:00

At the age of three or four we start asking two questions that would make us all a lot smarter if we made a life-long habit of it: "Who sez?" and "Why?". These questions don't tend to survive our college careers, not if we don't want to tick off our women's and ethnic studies professors.

The really bright doctors ask them all the time. At the GI rounds at the Major University in the Large City in the 80's, a bright GI trainee presented his study of Ogilvies Syndrome. Ogilvies syndrome is a nasty condition in which the patient's colon slows down and the cecum, ever obedient to LaPlace's Law, swells up with gas until it pops and empties stool into the peritoneal cavity.

The Wisdom of the Ages holds that the cecum will rupture when it reaches a diameter of 9 cm., so intervene before then or risk serious consequences.

"Who sez that 9 cm. cecum is on the verge of rupture, and why did he say it?" the GI fellow wondered. So into the library he went. He started with Roberts Rules of Medicine which cited a study in the 1978 edition of the National Medical Dispatch, which in turn cited an article from the 1969 edition of Surgery: Yesterday, Today, and Forever which in turn cited a 1961 edition of Rhode Island Surgeons Club which in turn cited a 1957 edition of the New Zealand Journal of Fish and Poultry which finally lead to an article from the 1952 edition of The Xray Journal in which the author admitted that he just made up the 9 cm. cecal diameter cutoff that had been accepted as gospel truth for thirty years.

This is not arcane lore. Knowing that there is nothing magical about the 9 cm. cecal diameter, we can give conservative measures a lot more time to work before risking any sort of surgical intervention.

These days I've been asking "Who sez?" and "Why?" about a study being quoted all the time asserting that there are 98,000 deaths each year from malpractice.

I tried to hunt the study down by googling it. The first fifty web sites were from malpractice firms informing us that doctors were killing off patients like flies and that only their law firms can protect the public. None of them referenced the actual study, and my Zoloft level wouldn't sustain additional research.

I then pulled up the statistics on cancer deaths. Colon cancer takes about 57,000 lives a year in the U.S.; breast cancer takes 41,000 lives a year.

If my math skills are holding up, the lawyers claim that for every person who dies of colon or breast cancer in this country, some doctor knocks off an innocent patient.

Think about it. If this were true, instead of wearing pink ribbons commemorating Susan Koman, patients would be wearing tiny little rope nooses on their lapels reminding them of the last time they dragged a doctor out into the streets and hanged him. The figure as cited by the lawyers is clearly nonsense.

There are legions of bright bloggers out there who may be more familiar with the study who can come to my aid. In anticipation of that assistance, I will maintain that the 98,000 figure defies common sense.

Parking diagonally in a parallel universe*

2005-03-14T22:46:00.000-05:00

A long time ago in a parallel universe I lived in a small town with one of those charming weekly newspapers that had articles in it like this:

Mrs. Elma Tutweiller from Mt. Washington paid a visit this weekend to her first cousin-once removed, Doris Tutweiller of 231 E. Liberty Street. "I like the Shoneys here lots" Elma said. "The brownies in the chocolate-lovers delight are soft and chewy, not them little brown bricks they got back home."

Not all of the articles dealt with the social scene. Some very thoughtful comments hid amongst the high school sports scores and the crimes reports.

"A doctor's wife copes with the malpractice crisis", the tiny heading read, right underneath the article announcing that Joe Jimmerson's dog had given birth to a litter of beautiful lab puppies. The wife of one of the family doctors in town shared her thoughts of the shame and uncertainty that a lawsuit brought to her medical family. It was well-written and deeply moving.

I knew her husband and had heard about the circumstances of the lawsuit. My considered opinion was that the doctor should have been stripped of his license, tarred and feathered and run out of town on a rail. How the others doctors felt about him I was never sure, other than the fact that shortly after the occurence the doc was elected as president of the county medical society.

Few of us like taking care of the woman who shows up at the ER at all hours of the day and night, complaining of horrible headaches or backpain, severe pain that would get a lot better if the doc on duty would only write her a prescription for Percocet. The family doctor certainly let his feelings be known when he admitted the 35 year old "frequent flier" lady to the hospital for observation of belly pain.

"This lady is a loser, a blight on the town, happy only when we give her a Demerol fix" he wrote in the chart. Off he went deer hunting.

This was in the 80's and few had cellphones then. The doc didn't have one, or at least he wasn't answering it. He ignored the nurses' call letting him know that the patient's belly pain was worsening, even with high doses of pain-killers. He ignored the call letting him know that the patient's abdomen had become board-rigid and that the patient could barely breath because of the severity of the pain. He ignored the call letting him know that she was going into shock. When he returned from his hunting trip, he answered the call informing him that the patient had died from a perforated ulcer and peritonitis.

In my sinless perfection I had nothing but contempt for the man. I resented that he never showed any public remorse over this blunder, chosing as best I could tell to portray himself as the victim of some cruel joke the patient had pulled. I resented that the local medical community rewarded him with the presidency of the medical society. I resented listening to him at cocktail parties mutter to his colleagues about the number of young specialists that were moving into the community and what a threat to his income potential they represented.

And I resent him now. Try as I might, I'll never believe that what I write will ever strike anyone as being anything other than excuse-making for my own blunders.

*The title is courtesy of the tagline of someone at Free Republic. Where she stole it from I don't know.

Very bad karma

2005-03-12T10:22:00.000-05:00

Life was hard as the dirt-poor son of a poor dirt-farmer in Southern Maryland in the 60's. To this day I remember the humiliation of Farmers' Market on Saturdays, seeing all the displays of neatly stacked corn and tomatoes as we sat trying to sell our dirt.

"Why would anyone want to buy that stuff?" the other farmers would say, laughing derisively at our wheelbarrow. "Anyone can dig that up in their own backyard!"

That was a long time ago and I admit that the recollection may not have been seared into my memory with total accuracy. It's true, though, that when I graduated from college I didn't have a pre-Carter-inflation nickel to my name.

Rather than take out a loan and graduate from medical school $80,000 in debt, I applied for a military scholarship. Everyone hated the military in the 70's, and getting a full ride to medical school courtesy of the Armed Forces was easy.

After medical school the Service owned my as-of-that-time unchapped hide. Part of the arrangement was that I could do as much of my post-graduate training in the Service as I wanted without incurring more "payback" time. I did all of my training (internship, residency, and fellowship) while in uniform.

I'm proud of my training. Some of the very brightest and best doctors I've ever known were also the progeny of dirt-farmers, drawn to the military by the lure of scholarship money.

That made it insufferable when we were led to the back of the academic bus as second-class citizens and third-class doctors by the civilian training programs. I remember the humiliation of sitting in a conference at the nearby medical school (the same school that was drilling Savary dilators into peoples' chests), decked out in uniform, listening to the audience yukking it up as the Distinguished Speaker recalled his own Army days:

"My title was MD, USA which some thought meant 'medical doctor, US Army', but which I knew meant 'Many Died, U Shall Also'."

Pretty funny if you ask me.

Adversity makes us better people, or as a famous philosopher once said, "That which does not kill me only postpones the inevitable." I studied my hide off and scored in the 96th percentile in both my internal medicine and gastroenterology boards. One of my colleagues scored even higher. Screw 'em if they thought we were nitwits.

All doctors have ugly memories of their training, often centering around the ER. ER's in the military were particularly ugly. We could not charge anything for anyone coming to the ER for any reason, so there was no incentive whatsoever for people not to use it for even the most trivial of illnesses. The result was that you'd have 100 folks checking in, only one of whom needed to be there. Would you be able to figure out who he was?

One busy night at the ER, a harried intern and his attending were dealing as best they could with the onslaught. A little boy had cut his lip and was raising five sorts of Cain, screaming and crying and otherwise very loudly expressing his unhappiness with the situation.

"Let's go ahead and sedate him until we can take a few minutes to sew him back up" said the attending. "Give him some Phenergan and Demerol."

Someone with a higher level of training than internship would have realized that the attending meant for the medications to be given IM, which would be slowly absorbed into the bloodstream, rather than IV, which would reach full effect very quickly. The intern didn't realize it and gave the meds IV. As the doctors were scurrying around, the little lad was placed on a comfortable bed in the corner where he stopped breathing. It was probably twenty minutes later that he was found dead by one of the nurses.

The first I heard about this case was when I read about it in the papers. The case was quickly and quietly settled out of court for large sums of money from the government, as well it should. If you are a military physician you can't be sued, only the government that employs you. The intern won't ever have to list this on his applications for malpractice insurance.

I probably didn't sleep for three or four days after reading about this. At the time I had two beautiful daughters at about the same age. It was beyond comprehension trying to imagine the shock, the loss, the anger and grief and misery that such an occurrence would have caused a parent.

It was also beyond comprehension trying to imagine what life was like for that poor intern. In my training I had some less than stellar moments, although nothing that came close to this level of error or consequence. With any of my own blunders I would lapse into a depression, wondering each morning why I should even go into work, fearing for anyone unlucky enough to fall into my clutches. Unless the hapless physician received electroconvulsive therapy or is heavily medicated, I can tell you that not a day goes by when he thinks about the little child under his care dying in the corner of the ER thirty years ago, his parents out in the waiting room ready to take him home, his lip all sown up, stopping at the Baskin-Robbins on the way as a reward for being such a good little boy.

Zen and the art of colonoscopy

2005-03-10T16:14:00.000-05:00

As an erstwhile writer I fancy myself a cheap-imitation Robert Pirsig, the author of Zen and the Art of Motorcycle Maintenance. Though I didn't understand some of the book (I'll take his word on it regarding Poincare) and didn't agree with most of what I did understand, I admired his style and skill. Pirsig wandered about multiple subjects such as the nature of Quality, the care of motorcycles, and the relationship with his son, while tying it all in with the narrative of his slow descent into madness.

While I'm open the the possibility of the descent into madness, I prefer to think of the underlying theme of this blog as my march to extinction. I'm like a brontosaurus who wakes up one day and writes in his journal "Boy, it's cold today!" as the planet plummets into the nuclear winter of a massive asteroid strike.

Before too long, if I dwell on the dumb asteroids in my life, my limbic system melts down and I risk stroking out at the keyboard. Gotta change the subject for now. I'll return to my tail of woe later.

Which has precious little to do with either Zen or colonoscopy, so I'll leave you with this thought:

The fecal stream flows
Scopes go against the current
As the lawyers wait.

Fifteen minutes of fame

2005-03-09T09:54:00.000-05:00

I'm not sure what category of blog SMLSLT is. I despise my cats, and my poetry output is so meager that this site would never qualify as either a kittyblog or blogerrel.

At times I think this is a Godblog, with two huge reservations. I often view my faith as being at least a bit of a fraud. W.H. Auden put it this way:

Those of us who have the nerve to call ourselves Christians will do well to be extremely reticent on the subject. Indeed, it is almost the definition of a Christian that he is somebody who knows he isn't one, either in faith or morals.

I also don't think Jesus would have taken a bold public stance on the malpractice crisis. I know that the malpractice attorneys out there are good people. You go to church and pay your taxes, plan for your children's college educations, and coach Little League teams. I just think you hurt people and place your own personal interests over the public good, like the doctors you condemn. I want to see most of you put out of business, or at least make you get by on one-fourth of your current income. It's not personal. It's just business.

SMLSLT is if nothing else a Hugh Hewitt inspired blog. After I read his book Blog I started this site and sent him a copy of what I thought was one of my better posts. As I was tracking my hits, wondering if I'd ever break the 20 hits/day ceiling, I noticed that I'd received something like 700 hits in one hour.

Hugh was very kind to make a reference to my site, and given his readership (several million hits a day, I'm sure) if just 0.001% of his readers visit this site it's still a lot.

Too bad I went on vacation the very next day, and refused to log onto the Internet for an entire week. Here's my fifteen minutes of fame and I make all of two posts over two weeks. Talk about a momentum killer.

As this week settles down, I'll return all the kind comments I've received during this "flash-in-the-pan". It's a pleasure to visit your sites, which I always do if your comment isn't anonymous. So many great writers, so little time...

Anatomy of a blunder

2005-03-08T12:55:00.000-05:00

Some folks were offended when told, before they had the chance to see the movie, that the Titanic sank. If you're like that, skip this post. I'll continue my sorry fake-but-accurate shipwreck of a tale later in the week.

For everyone else, this is how the story ends: I didn't perform the colonoscopy demanded by the patient, and he turned out to have colon cancer, and I got my butt sued off.

How could something like this happen? For many of you this will be a once-in-a-lifetime experience to listen to a doctor admit to anything less than perfection.

These are the factors I've identified:

Over-reliance on technology. We have the finest diagnostics in the world, but we sometimes forget that all tests have their limitations. Sadly, we've let our physical examination skills and, to some extent, our clinical accumen atrophy. It's easier just to order a CT scan.

A misplaced sense of fiduciary responsibility. Healthcare costs are skyrocketing. The national debt grows every day. It would be wonderful if we docs cut back on all the tests we order. We'd save a lot of money.

Well forget it. Unless a physician participates in a capitated insurance plan (which I don't), there is little to be gained and a lot to lose by even thinking about being careful with your healthcare dollars.

Information overload. There are a lot of things vying for our attention. Sometimes the urgent crowds out the important.

Arrogance. I pride myself on my sense of humility, but there are times I make up my mind and don't want any additional facts to confuse me.

Guardian angel vacations. Evangelical lingo would sound like this: sometimes God, for whatever reason, removes His protective hand from us. Or like this: the Good Lord let Satan take a chain saw to my hedge of protection.

Relying on the work of other doctors. I never dreamed that the Best GI Guy In Town, Maybe Even The State would miss such a serious lesion.

Stupidity. Just what on earth was I thinking? Do the flipping test. Collect your fees. Don't worry about it. Hope the patient doesn't get a complication from yet another "unnecessary" test.

Now if you'll excuse me, I'm going to curl up in the fetal position and hide under my desk for awhile.

Guardian angels

2005-03-07T19:04:00.000-05:00

Guardian angels are good to have around. Mine was quite busy in my misspent youth, given my proclivity for driving vehicles off roads and into trees.

As I began to acquire a little maturity and common sense, my angel kept track of me in different ways. I've noted that when I've been able to make an obscure diagnosis or use a novel form of therapy, the angel always seems to have put just the right medical article in my hands the week before.

Skeptics scoff at this. They'd say I'm not aware of what I've missed, or I wouldn't have missed it. I'll have none of it, though. It's occured too frequently to be happenstance.

The problem is what to make of times when the angel's not around. A hard working angel might just need to get away every now and then, dancing the night away on the head of a pin somewhere.

I once treated a man my age for heartburn and such. He was a bit of a malcontent, changing family doctors every two or three years. We got along well and he stayed with me for years.

While I was on vacation one summer, the gentleman developed signs of internal bleeding. For reasons I've never understood, instead of sending him to one of my erstwhile associates, the family doctor referred him to the Best GI Guy In Town, Maybe Even The State. The BGIGITMETS scoped the patient top and bottom, finding no significant pathology.

True to form, the patient took offense over some comment his family doc's receptionist made, so off he went to another family doctor, who in turn sent him back to me to repeat the studies performed by the BGIGITMETS. It wasn't clear to me why, given the short time that had elapsed (three months), so I dutifully reviewed all the scope records. The work-up looked to be thorough.

The patient returned several months later, this time demanding to have the scopes repeated. He just knew there was something lurking in his bowels somewhere.

I could have really used my angel's help just then. I reviewed the original work-up and the tests that had been performed in the interval and concluded that repeating the scopes didn't make sense. Medical costs are skyrocketing, and it seemed like a foolish waste of resources. And I told the patient so.

To be continued.

Personal best

2005-03-07T08:05:00.000-05:00

I have just set a personal best: eight days (count 'em, 8) without any internet connection. It was available, to be sure, but I chose not to do as much as review my email during our marriage enrichment seminar. I realize that recent studies warn us of the risks of too much family time and the serious adverse consequences it can have on our internet relationships. I thought it wise to pay attention to the bride of my youth. A thriving practice with a lousy marriage is nothing of any lasting value, but a good marriage with a loving wife and three wonderful offspring is a pleasure in God's eyes.

But I've got a lot of catching up to do.

Man does not live by blogs alone

2005-02-26T20:35:00.000-05:00

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

2005-02-22T21:02:00.000-05:00

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

2005-02-18T22:42:00.000-05:00

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

2005-02-15T13:55:00.000-05:00

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

2005-02-12T11:56:00.000-05:00

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

2005-02-10T19:32:00.001-05:00

Surrounded by experts

2005-02-09T10:41:00.000-05:00

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

2005-02-08T10:36:00.000-05:00

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!

2005-02-07T13:25:00.000-05:00

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.