“Look at every path closely and deliberately, then ask ourselves this crucial question: Does this path have a heart? If it does, then the path is good. If it doesn't, it is of no use.” ~Carlos Castaneda

Sunday, April 29, 2007

Feeling very human ....

“Dream as if you'll live forever, live as if you'll die today.”

~James Dean

Yesterday, I actually felt a little human. I did the family thing. I felt like a normal person. It was a beautiful day.The kids actually played well together for a while.
Watching all the kids and family was very peaceful. (hard to believe I know)We have family in town, so I did what you are supposed to do, entertain. We got tickets to the Cardinal's baseball game. We had great weather and great seats. We lost, but they day wasn't spoiled.

I never thought it would be the last time I would see someone. Josh Hancock came in relief during the game. Early this morning with died in a car crash.

This reminds me how short life is. RIP Josh.

“Have the courage to live. Anyone can die.”

~Robert Cody

Saturday, April 28, 2007

Everything that is old is new again ...

“The internal dialogue is what grounds people in the daily world. The world is such and such or so and so, only because we talk to ourselves about its being such and such and so and so. The passageway into the world of shamans opens up after the warrior has learned to shut off his internal dialogue.”

~ Carlos Castaneda

There is so much that influences us in our daily lives. Our past experiences shape our opinions. Our relationships with our parents, teachers, and friends, help us to develop a sense of what we feel is right and wrong. It helps us to develop a sense of self. Our external experiences and others opinions usually will shape how you feel about self. In educating others, the educator will provide education through these eyes. As an educator, I give information that I feel is important at that given time. We have biases. We don't all teach the same or feel the same things are important . This usually makes it difficult for a learner who is just come into this education system.

Clinical medicine is cluttered with opinions supported by some science and a lot of anecdotal rationale. Everyone has a reason for doing things they way they do them. I refer to this as an "emotional issue." We do things this way because we had a "bad experience" and doing it this way "makes us feel better. " Yes, this is anecdotal and sometimes seems irrational, but how many decisions are made. I feel it is important for both the learner and the educator to understand the limitations both in the science and our clinical experience; our knowledge and skill set. It is essential to know when it is time to ask for help. This is something that many may refer to as a weakness. In my mind, the weakness is in feeling you have all of the answers.

Castaneda has some interesting thoughts and philosophies that translate very well into understanding more about yourself and you relationship to the environment around you. His philosophies come from an experience
research log describing his apprenticeship with a traditional shaman identified as Don Juan Matus. The existence of Don Juan has been disputed, but there is much wisdom in some of the statements he made. Castaneda wrote, in The Art of Dreaming, that Don Juan contended that our ordinary world-

...which we believe to be unique and absolute, is only one in a cluster of consecutive worlds, arranged like the layers of an onion. He asserted that even though we have been energetically conditioned to perceive solely our world, we still have the capability of entering into those other realms, which are as real, unique, absolute, and engulfing as our own world is.
This assertion was made with respect to the metaphysical self (spiritual self); but as a statement, really can be used when referring to ourselves as both educator and learner. It is a special person who is able to separate his/her own opinions and experiences when teaching and evaluating another. This is important for both to do, but seldom done.

Castaneda's thoughts on a number of things, although controversial, are very applicable to the journey of gathering medical knowledge. He stated -

For me there is only the traveling on the paths that have heart, on any path that may have heart. There I travel, and the only worthwhile challenge for me is to traverse its full length. And there I travel—looking, looking, breathlessly.
For me, this is one of the wonderful challenges of medicine. The gathering of knowledge is endless. The infusion of new and eager students is like injecting the whole system with nitrous. I am continuing to reevaluating myself as an educator and learner. I try to view myself from outside. I do realize that I have limitations in my own ability to learn and educate. I am continuously looking for new ways to remove my biased opinion and be open to others. It is a constant struggle to remove the human from the human being. For now I will continue in my struggle, I will do my best to provide teachings which I feel are both pertinent and needed. I welcome you do come with me for the ride.

“To be a warrior is not a simple matter of wishing to be one. It is rather an endless struggle that will go on to the very last moment of our lives. Nobody is born a warrior, in exactly the same way that nobody is born an average man. We make ourselves into one or the other.”
~ Carlos Castaneda

Wednesday, April 25, 2007

Patience young padawan ....

“All human wisdom is summed up in two words - wait and hope”
~Alexandre Dumas Père

Perspective is everything. Depending on your stage in residency, you will be concerned about different things when you perform a surgery. Depending on your practice, you may have cases that are routine to you, and then there will be cases that you may consider your "big cases." You may develop a system of how you approach these larger cases. I have my own way of approaching big (i.e. more challenging or risky) surgeries. I tend to approach them like when I was involved in sports and right before big game. I will give you a picture into my mind on the day of a routine big case, a scoliosis case.


5am: Damn alarm. I don't want to get up. No you have to, time to run. Where are my fff --, oh there are my shoes. Ok, oatmeal, coffee and then time to run.

7am: (ring ring) Clerk say, "Hello." I say like I am just happy to be here, "Hey it's Dr. P, I am here in the hospital."

715am: Discussion with family about surgery and answering any additional questions. The same questions I answered in our preop conference.

730am: Scrubs are on. It is now game time. Head phone in my left ear. Tool is playing.

"10,000 Days (Wings Pt. 2)" TOOL

We listen to the tales and romanticize,
how we follow the path of the hero.

Boast about the day when the rivers overrun,
How we'll rise to the height of our halo.

Listen to the tales as we all rationalize,
our way into the arms of the savior.
Fading all the trials and the tribulations.

None of us have actually been there,
Not like you...

The ignorant fibbers in the congregation.
Gather around spewing sympathy,
Spare me...

None of them can even hold a candle up to you.
Blinded by choices,
hypocrites won't see.

But enough about the collective Judas.
Who could deny you were the one who illuminated?
Your little piece of the divine.

This little light of mine it gives your past unto me,
I'm gonna let it shine to guide you safely on your way.

Your way home...

I walk in to the room, silent. The x-rays are on the board. Ok, double major curve, 80 over 80. Screws at ... I begin writing on the white board, acknowledging only my scrub person. No one speaks to me. I don't like the small talk. I am focusing on the task at hand. Screws at T3-9 ... Resident comes over, he says nothing. I finish my notations on the board and my scrub starts making note of the number of screws and sizes. Disturbed is playing. This is my favorite part. (You know the part they won't play on the radio)
"Down with the sickness" Disturbed

No mommy, don't do it again
Don't do it again
I'll be a good boy
I'll be a good boy, I promise
No mommy don't hit me
Why did you have to hit me like that, mommy?
Don't do it, you're hurting me
Why did you have to be such a b!t@h
Why don't you,
Why don't you just f#%k off and die
Why can't you just f#%k off and die
Why can't you just leave here and die
Never stick your hand in my face again bitch
I don't need this shit
You stupid sadistic abusive f#%king whore
How would you like to see how it feels mommy
Here it comes, get ready to die ....

(Guitar riff is playing) I look over at the patient. F#%kin' ansethesia. Why does it have to be like groundhogs day? Why do I always have the CA-1? Why does it take them 1 hour to get lines in a normal child? FFFF#####%%%%%%KKKK. Be patient, breathe.

Spine instrumentation rep, Joe, says, “So, you been busy?" Why does he feel the need to speak to me at this moment? He knows I don't like small talk now. "Well, you know its summer. Busy season for us," I say and smile.

My resident today is Paul, ortho year 2. He has never done spine before let alone a deformity case. UUURRRGHHH, this is going to be painful. My only hope is he knows how to use a cobb. "So, Paul, while anesthesia is getting the lines in, give me the Lenke Classification of this curve." I wish the Guano Apes didn't break up. That lead singer, man, she totally rocks out.

"DICK" Guano Apes

Don’t say a word
life is like a sin-phony
brave as you dare
there’s nothing but your gain
so take off your shoes
and coming down from ecstasy
hide and turn loose
that’s why i force you to

walk like a stag
talk like a stag
come watch yourself
walk like a stag
who could wear my pants

no dick
you got no
yeah yeah how come ...

To Paul, "Ok, let's start getting the table ready. In the prone position, you need to pad here ... here ... and here." Good they are finally putting in the foley. I close my eyes. Ok, posterior approach. Knife, retractors, bovie. Watch for the bleeders, they are always there. X-ray. Burr, gear shift pedicle probe, tip out, probe pedicle, tip in, enter the body, probe pedicle, measure tap, screw. This is standard. Remove facets. Release concave side well. Rods cut. Place. Done. Simple. You have done this many times before.

"Are we ready to flip," I say. "Ok anesthesia count." She says, "1 .. 2.. 3." The patient is flipped. Everyone starts to scurry around the room. Breathe, patience, slow your hands.

"Bill, do you have good wave forms?" I say to my neuromonitoing guy.
"Sure do, Dr. P."

"Ok, you all ready? Go head and prep." Last song, focus.

"Judith" A Perfect Circle

You're such an inspiration for the ways
That I'll never ever choose to be
Oh so many ways for me to show you
How the savior has abandoned you
F#%k your God
Your Lord and your Christ
He did this
Took all you had and
Left you this way
Still you pray, you never stray
Never taste of the fruit
You never thought to question why

It's not like you killed someone
It's not like you drove a hateful spear into his side
Praise the one who left you
Broken down and paralyzed
He did it all for you
He did it all for you ....

I walk into the bathroom to pee, the last one for a little bit. Time to wash my hands. I take my head phones off. While washing, I close my eyes. Lord please guide my hands today so that I may do good and cause no harm. Please watch over us so that we may do what is right for this child. AMEN.

We finally begin the case. "Knife to the young doctor. Ok Paul, go from here to here." Ok, with the next pass, you can actually go through the skin. "Good job, wheaty to me. Paul take your bovie and cut between my snap. So, where are the normal bleeders we will encounter while approaching the spine." I know he will have no idea. They never do.

OK, it is 930, we are exposed. "Let’s pick a level we know we are going to fuse. Alright, burr." Patience, same steps every time. "Tap, screw..... OK, C-arm. let's verify these levels." .... "Good we have enough exposure."

I put in all of my screws. Now it's Paul's turn. Be patient. "Ok, Paul have you looked at the pedicle screw chart."

Paul says, "yeah."

"Ok, well then let's go. Burr to the young doctor." He picks up the burr with one hand and starts to go towards the spine. "Stop! Now, Paul, everything over the spine is a two handed instrument. Brace yourself, and don't plunge, because that would make me sad." I show him how to place 5 screws, but I put the rest in because of time.

"X-ray!" Well that wasn't so bad, that stressor is over. "Bill, how are those signals." Bill shouts, "great." Good, xrays are good. Ok, what time is it? 1030am.

"Paul, can you cut rods this length?"

"Sure," he says.

"Ok, rods. Cap." FFFF#####%%%%%%KKKK, why do they always have to go on break when we are at this part, g*d d@*n, mother f#%ker, sh1t, b@$t@rd, Son of a b1^ch. "The cap is in that tray, use the blue handled ... Joe help her." I close my eyes. Breathe, breathe. Why me, what have I done? I think they must hate me.

"Xray ... That looks pretty good. Let's see how the xray looks."
"That looks FFT baby." FAN-F#%k!n-TASTIC. "Final tighten and let's close. Put on the Idol man.”

Shouting out, “Bill are you happy?"

“Yes Dr. P, I am happy.”

“Well, alright. Let’s rock out.”

God, I thank you god guiding my hands. Amen

“The two most powerful warriors are patience and time.”
~Leo Nikolaevich Tolstoy

Monday, April 23, 2007

My grampa is tall as trees ....

“I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”
~Maya Angelou

My mother is a writer/poet. She wrote a wonderful children's short story that, I think, is fantastic and describes from a child's point of view how she looks up to her grandfather. Eventually, her grandfather dies and how she has difficulty believing that can happen because "My grampa is tall as trees." I feel this story emulates some of what may be occurring today in the academic world. See academics has always been seen as an area that is kind of sacred. It was the place that all of the "bad cases" were sent to. It was the place were the undeserved and uninsured could get care when the private physicians refused to see them. It was the place where you, as a physician, were told, "yes you may get payed less, but you will not have to work as hard as the private guys; you will have protected time to do 'academic endeavors'; and you will be respected for the 'specialty care' you provide." Times have changed.

"My grampa is tall as trees. Tough as tigers. Big as bears. When he walks the house rumbles and the china in Gramma's china closet shakes. I love mama more than peanut butter. But grampa is tall as trees"
In the past, orthopaedic surgeons at academic centers were protected from the world of billing. There was not as much of a concern for the costs of medical care. The expectation was as an academician, you were perfecting your craft. Part of your job was to search for advances in medical care. The clinical side was where you would practice your theory. You were told, "publish or perish." It was important that you taught others, spoke at meetings, get your and the institution's name out there. By speaking and teaching in and outside of your institution, you will gain prestige.

"Grampa's eyebrows are as big as clouds, and his wink is quick as lightning. Only I am fast enough to catch it. he always winks when mama makes a fuss. She tries to make him wear the new sweaters she buys him. The ones wihout the holes. Or make me wear dresses and comb my hair. I love mama more than biscuits and eggs with the juice runnin' out. But grampa is tall as trees."
The greats come from very academic institutions. They published papers and operated with residents. The did invited lectureships and taught new procedures. They were seen at the forefront of medicine. Academics is were the new ideas were born, practiced, and then released to the mainstream. Academicians became set in their ways. Doing things they way they have always done them without regards to cost. The clinical work both clinic and OR could be performed by residents. Trauma cases would be unsupervised while they continued to perfect their craft, either by writing or researching.

"In the mornin' I can smell cinnamon and coffee. The coffee is my mama. Grampa smells like cinnamon. I jump downstairs and try to rattle Gramma's china in the china closet, race through the room where no children are allowed, run into the kitchen and hop on Grampa's knee. Without a word. And I sit and watch him read the big black book. I know he's talkin' to God.
At many academy events, many academic physicians would present their research and speak in forums. There began to be a little shift with industry and some large group practices doing independent research away from the academic meccas.

The government reevaluated it's billion dollar insurance company (medicare) and realized that they should not pay twice for treatment of patients. "See we (government) pay residents already. So if only residents only perform the case, we will not pay and we will consider billing on those occasions fraud." This crack down place the academic and county institution under the spot light. It requires many people to adjust. They was more time to be spent directing are of patients and procedures and less time dedicated to research. "This was not that much of a problem I'll just do less research." For some, this was hard, but eventually they adjusted.

"Sometimes we take long walks and talk to trees and try not to step on cracks. Grampa tells me stories about the army ants that ate up a whole village of people. Just mowed down everything in sight. Millions of 'em. we sit under trees and wonder what they would say if they could talk."
In the position as educator, this physician had to educate both medical students, residents, and other physicians. This was part of their job. Many were baby boomers and had been trained under an iron fist and wielded their fist in the same manor. As political correctness came into fashion, out went much of the tolerance for the thrower and screamer. Write ups and visits to anger management discussing your feelings with your mother became more common. Resident physicians began to ask for the education. They want a handout with the lecture and they may ask why like a 2 year old child. Accepting what you say as gospel have gone to the way side. Learners actually want to learn from you and not just be a grunt. "Why can't they just do the work? It doesn't have to make sense, just believe what I tell you. Would I lie to you?"

"Grampa has two suits. One for Sunday. The other he never wears. he says he's savin' it for when he goes up in heaven to see Gramma a and have an important meeting with god. In the meantime he wears baggy overalls with lumpy pockets full of gum, his tobacco pouch, and a gold watch with a broken chain. She fusses about my overalls which are brighter and stiffer than grampa's and tries to put ribbons in my hair. I love Mama better than the honey apple raisin cakes from th bakery, but Grampa is tall as tress."
As times began to change, the pushes on the academic physician became worse. Cuts in insurance payments on basic procedures began to be noticed. The hospitals and practices began to reevaluate where money was being generated and were it was being lost. There began to be an encouragement to increase revenue by increase clinical flow. This again infringed on research time. At the same time that clinical practices were increasing, the amount of extended care providers and residents were not. The appeal for the academic practice began to decline. The politics within the university also was stifling. Creating more hassle than help.

"One night there was a big storm and the lights went out. It thundered and lightning and something bigger than Grampa shook the earth. Grampa said God was bigger than thunder and lightening and some people thought that when it stormed, God was angry. But Grampa said it was just his way of remind us that he is still here. Grampa says that God is old as dust, quicker than lightning, bigger than bears, and better than a bushel of honey apple raisin cakes WARMED WITH BUTTER."
In the private sector, things began to become more enticing. Specialty hospitals, surgery centers, and MRI scanners became a great money generator for the private physician. This made the financial difference greater and the attraction of younger physicians to the more profitable and less hassle private practice more appealing.

The government began to investigate the academic institutions for fraud. The restrictions for medicare and medicaid billing became increasingly tough. The possibility of a malpractice suit made the education of young minds more difficult. It require more supervision cause by the risk of malpractice and the restrictions governmental restrictions on billing. The physician who's life was once protected form many of the private worried by the academic system was now becoming more like a private practitioner without the financial rewards.

Learners, the residents, began to protest the previous work hours and ask for less hours. The ACGME placed restrictions on the resident work hour in response to the press and resident physician complaints. Educators where required to teach more and become more efficient at educating in less hours; as well as, increase the clinical revenue and produce publishable research. Why would anyone choose this as a life? There seems to be no benefit.

"Then on day I woke up and didn't smell the cinnamon or the coffee. I ran downstairs and didn't even try to rattle Grandma's china in the china closet, race through the room where no children are allowed, and went into the kitchen to jump on Grampa's knee.

But Grampa wasn't there

In his chair sat my Mama holding the big black book and looking at me with tears in her eyes. She told me that Grampa was ready to put on his suit and go up to heaven with Gramma to meet God. She said we could see him one more time in a church with all his family and friends. She said he would be in Godsleep and be Godstill. That means that his eyes would be closed for a long time and that he would be still and stiller than I can sit on Grampa's knee after he says 'In a minute.'"
As the practice of working in a university setting become more restrictive, it will have to adapt. It is extremely important that the educational structure begin to change to accommodate the changes in the system. We have to balance the differences between academic and private practice. The work load has become equivalent. The benefits of having residents are decreasing and sometime can be somewhat burdensome. The prestige of a academic physician that may have once been there is gone and can easily be overcome by the financial gains in a private setting. With many of the restrictions that have been imposed, it may become more difficult to replenish the numbers of academicians who are retiring.

"Now I can ride my tricycle past the prickly bush, all the way to Mr. Hammond's house and watch him cut the hedges. Mama's going to get me a bicycle with training wheels. And they finally came to carry away the old Dogwood tree that fell in the storm.

Now I talk to God even when there is no thunder to remind me. I say, 'Thank you, God for Mama, and Grampa and Gramma, who are with you, and my new friend, Mr. Hammond. and my brand new bicycle with the training wheels. Amen.'

And if I'm Still - almost Godstill - stiller than when I sat on Grampa's knee after he said 'In a minute, Sister' I can hear grampa smile and say.

'Good mornin' sister."
In the end, I think things will begin to balance out. As long as there are people willing to inspire, there will be people willing to be inspired. With that inspiration, maybe they to will wish to become an educator. Despite all of the restrictions with in the academic practice, the reward of helping others learn the craft may win over.

“Courage is the discovery that you may not win, and trying when you know you can lose.”
~Tom Krause

Sunday, April 22, 2007

It seemed like a good idea at the time

hello all,

This is just a little post to get some comments started about things that you have done in medicine as a medical student, resident, and/or attending that "seemed like a good idea at the time." This is really more for the humorous comments. I am not searching for things that was harmful to patients.

Thanks all in advanced. I just got back from one of the always restful family vacations to the wonderful Disney world. The place were everything starts in a line and ends at a cash register. Yeah, the was one of the moments for me.

Wednesday, April 18, 2007

How do you know what you need to learn?

“The only thing that interferes with my learning is my education.”

~Albert Einstein

Over the past few weeks, I have been looking at a number of different blogs and internet forums. I do this in interest about what people are interested in and to find out what the "word on the street" is. A very common topic I have come across is about residency work hours and how medical training is inefficient. It has even be broken down to the amount of money made per hour if you work a 80 work week. There have been a number lawsuits against academic medical centers, as well as the ACGME and NRMP. People discuss how hard residency is and the meaningless tasks that they are made to do. Although I mostly agree with the sentiments about low pay and meaningless tasks, I ask how would someone propose to make the system different?

One proposition is that we get more mid level providers so that residents and medical students can get more "educational value" out of their time in the hospital. They would not have to do menial tasks such as discharge summaries and dressing changes. Then the residents could concentrate more on patient care and learning about disease processes. I wonder when they plan on touching a patient in this scenario. May be the attendings should do the work with a mid level provider and when we find an interesting case we can page you so you can watch how treatment is performed. This is a good way to learn because all of the patients follow the book exactly. Their symptomatology and disease progression is classic. The response to every treatment is the same for every patient and outcomes all the same. You know there have been many a board exam that has saved a patient's life. Hmm, let's try something else.

Another proposition is to decrease the hours to say a 40 hour work week. How about no call, no weekends, and no pager. That would be awesome. See as we all know, the human body only has problems are normal working hours and therefore, every physician / resident will get all of the experience s/he needs during the normal working hours. I have actually never seen a trauma come after 5pm or on a weekend. I have definitely never seen a code before 8am or after 6 pm. Hmmm, but may be there is another way.

OK, I got it. We will work in shifts. Like a tag team wrestling trio. We will do 8 hour shifts, just like the nurses do. Work never slows down during shift change. In the transition, information is never lost. There is never a slow down in services because someone has just come "on shift."

OK, I hope you can feel the sarcasm in my above statements. None of these systems are perfect. Training in the past was not perfect. It did provide the patient volume necessary to give a physician adequate experience from which to build upon. This volume was provided in true volume of hours in the hospital. There were/are inherent inefficiencies in the system cause by resident inexperience, attending staff not being present to prevent slow downs, ancillary staff who won't perform their duties because they know eventually a resident will do it. So how do we reach a happy medium.

Can resident education become more streamline? Probably, but there are somethings that we can't get around. In the surgical subspecialties, you will have to have a certain number of surgical cases to graduate. In the future, I do see that your credentials will be directly tied to your resident surgical experience. For example, you will have to do X number of total knee arthroplasties (TKA) in residency or fellowship to be credentialed to do a TKA in practice. As a surgical service, we are at the mercy of the patients. Sometimes the procedures come and sometimes they don't. I can't guarantee you will get to see 10 pelvic osteotomy cases. This is the ebb and flow of medicine and patient care.

Medical education is inefficient. As an educator, I am interested in increasing the efficiency of the resident learning. Unfortunately, the only thing that I have seen to this point that makes a difference is time and experience. The more time a resident has the better they are at incorporating new information. I have read a number of different points of view on this and hear many of the learners who feel that they "know" what they need to learn. This is like my 18 year old son who already knows everything. He knows exactly how to do things, I have no idea of what he is going through or what things he needs to accomplish to get where he needs to go. This is true, I don't know what the resident is going through. I am years from the end of my residency. What I can say is I know what mistakes, misjudgments, and errors I have made. In educating residents all I can do is lead you in a direction and hopefully you will not make the same errors. For all the learners, remember this, if your educator does something a particular way it is usually because of previous experience.

“Experience is the name every one gives to their mistakes.”

~Oscar Wilde

Wednesday, April 11, 2007

The beatings will continue until the morale improves ...

“If your actions inspire others to dream more, learn more, do more and become more, you are a leader.”
~John Quincy Adams

As I have written previously, and it is confirmed in one of the forums on the Student Doctor Forums, medical students these days are soft. I say this half in jest, but it does have some truth; otherwise, it would not make so many upset. From “my perspective” medical students and sometimes residents are not here to learn. They feel that we, the attendings, are making things to give them busy work. We are just giving you more paperwork to fill out, another dictation to do, or another patient to see. There is no medical relevance to anything you are asked to do, no education to be had. Everything must have some teaching value otherwise it is a waste of their time. They would rather study for the shelf exam which definitely correlates more with patient care that actual patient care.

This past week we have a medical student on service who is here to learn. She is a fourth year and this is her last rotation. She could cruse the rest of the way. That’s what most others do. “I am on month away from being a doctor, I have matched, why should I work so hard?” Hey, I am not knocking that mentality, it’s “senioritis.” We have all had it. What make her rotation interesting is she actually wants to learn. HOLY SHIT BATMAN, a medical student who want to learn about what we are doing. Yeah, we get the orthowanabes but they don’t count. Usually, those not going into ortho are really here to just have another elective. We are a surgical elective and we don’t require much of them. But, she actually wants to learn. Hmm, go figure. Isn’t this why we went to medical school or may be it was to be rich?

Why would this surprise me? Well, it is the interest. It makes me want to spend the extra time teaching. The extra time explaining why we do this or that. It makes me think. It reminds me why I am in academics. Sometimes all the other factors that many medical students and residents don’t see and these things can get you down. To have all the pressures of the powers that be and the top have uninterested residents and medical students as well will just frustrate you. (uurgh)

From the attending side, you are being pulled at multiple levels. From the upper level, administration of the hospital wants you to operate more and bring in more “business.” Residents want you to let them run free to operate and make decisions, as well as, get home at a reasonable hour; they don’t want to spend too many hours in the hospital, “we do want a life.” There are patient obligations. Patients call the office wanting to be seen right away for their acute intoeing consult. Other physicians want you to be available for consults so alleviate their fears of an acute case of “I can’t diagnose the cause of your pain” syndrome. Your partners want you to see more patients and operate more so that there will be more revenue for the practice as a whole. And if you are in a big university, the head of the university and/or medical school may have an interest in what you do. This makes your ultimate goal of patient care a little difficult at times. How can you dedicate your life to the education of the future medical providers without being disenchanted?

It is when a young physician reminds you how interesting medicine is and what good we can do for patients. You are reminded about the differences you make in patients life everyday. This may be an idealistic view but reminds me of why I am here. I want people to aspire to be better, to understand disease processes, and find cures. I want to change the world. Ok, that was a bit much, but I do want to make a difference. So, the way I chose to do it is by one patient, one medical student, and one resident at a time. I will continue to try to spread the little knowledge I have with the hope that someday they will do the same.

"Courage doesn't always roar. Sometimes courage is the quiet voice at the end of the day saying, 'I will try again tomorrow'."
~Mary Anne Radmacher

Friday, April 6, 2007

If only I could hit the ball straight, I would be a great golfer ...

“If you don't know where you are going, any road will get you there.”
~Lewis Carrol

To those who read my posts, I am sorry I haven’t posted for a few days. I have been busy doing busy work. You know those pesky patients keep getting in the way of my free time. How dare they do that? I know I have residents and all. I really should have more free time. I’m told that I should be home at a reasonable time and getting plenty of rest working only 40 or so hours a week. Oh, sorry that was my dream from last night, welcome back to reality. It is summer and I am an orthopaedic surgeon, there may be a few long days.

For all those people who are commenting, I would like to thank you for you encouragement and your disagreements. It is great to get good and bad feedback. I look at this as a dialog. It is like I am welcoming you into my sometimes crazy thought process. I would like to put in a blog a comment that I thought was great. It brings up some major points related to some overall problems in medical care. To those who are residents and/or medical students, most medical educators do not teach you about the business of medicine. When you are in practice and taking care of patients, you spend about 50% of your time doing actual patient care and about 50% of your time dealing with the business of medicine.

This is a comment by Anonymous. (His comment is eerily familiar. I know this voice from somewhere in Ann Arbor.)

He (I assume) stated:

I've previously responded re: 80hr work complaints by the "old guard". I did read you reply carefully and notice you mention it in this post. The problem I have with the old guard is the mess they are leaving behind. Social Security is going to collapse. This is not an exaggeration or dramatization. The excessive medical spending of the 70-80's and the resulting sequelae will be the most important influence on how our practices are shaped financially. I can take complaints about only working 80 hours a week. I just wish I could get some answers.
This brings up great points about the old guard. You know physicians in the past lived the good life. Getting paid almost the same are what they billed. Life was good and the system may have been taken advantage of. Now we are dealing with the repercussions of the past. There is a backlash from medicare and insurance companies. Probable because we did not police our own very well, we allowed malpractice to become an issue. (This may only be part of the issue; most, I think, is a general sense that if something goes wrong, someone is going to pay for it.) Because physicians did so well financially, we did not pay attention to some of the significant changes in medicare and in other areas. We did not have a unifying voice and we allowed media to accuse us of being money hungry people. Because physicians were enjoying the good life, we fell a sleep at wheel and allowed some major things to change. Health Care Financing Administration (HCFA) came through with reforms dictating what needed to be documented to justify bills. Now, most physician practices get routinely audited (by in house people) to assure they are in compliance with HCFA. As stated above, some of these things were brought on by the “old guard” and are going to cause long term consequences, like the problems we will soon see with social security.

He also brings up issues of the stark laws (phase I and phase II).

1. Who is responsible for the offences that necessitated Stark
I&II and Antikickback legislation -the majority of which resembles and was modelled after attempts to combat organized crime?
Stark law I (1989) basically prohibited only self-interested referrals for laboratory services. This was updated in 1993, Congress broadened to Stark II which include referrals of a broad array of "designated health services” Stark I and II had changes again in 1995 and 1998.The final Stark II Regs are substantively different in a number of respects and provide physicians and other contracting parties more flexibility than originally anticipated under the Proposed Regs. Due to significant changes from the Proposed Regs, the Stark laws were issued in phases. "Phase I," which includes the Stark II Regs issued on January 4, 2001, restates or modifies definitions used throughout the Stark law. "Phase II addresses the remainder of Stark II including additional exceptions to the law, and clarifies the application of the Stark law to the Medicaid Program. These laws really affect people who are business oriented and want to expand their ability to increase revenue by investing in their own practice and ancillary services.
Anonymous also makes a statement about my beloved program and a publication that I had also had some questions about.

2. Who can explain to me pg2687 of the December JBJS-A? Plastic surgeons at a traditional "old school" program, U of M, "the U" have essentially been given distal radius fractures by orthopaedics (they put volar locked plates on 161 IN 2 YEARS and Ann Arbor isn't exactly a dangerous place). I've looked into it minimally - it came down to ortho attending level surgeons not wanting the call responsibility.

Will this be a change in thinking? Will we give up services because we don’t want to work that hard? Will residency have to suffer because we are not willing to teach? I don’t know, but it does bring into questions the heart of my fellow attending surgeons. May be we should all go home and let the patients take care of themselves. That is how some people see the future. Peer into the mind of the future.

Anonymous finally begins to discuss a topic that I have already seen to be a problem. It has been discussed on 60 minutes. Should we protect out position or should we allow other providers and countries do what we could do better? Or may be we can’t do better so they are better off going to Podiatrists and to India to have their total knee arthroplasty.

3. Why has industry in recent years so readily embraced overseas providers and non-physician providers? The most common response is physicians pricing themselves out of the market. A recent AMA newsletter detailed non-physician providers gaining authority to offer services through THEIR OWN BOARDS. Of course the podiatry board will be willing to certify their members for knee arthroscopy and pilon reconstruction. In many states it is becoming a legislative issue. Who let this get away? Why is there another report every month about elective hip and knee arthroplasties in India and China? The common response by American surgeons: well we'll band together not to take care of their complications when they are back in the US. It won't be a problem, it will probably be cheaper to keep flying the patients back and forth. None of these employers or benefit plan administrators will even have a list of local providers around the office - nor will they miss it. Non-physicians and their boards Why doesn't the public care?"
In the times where money was plentiful, we opened “specialty hospitals.” It increased our bottom line and lined our pockets. But, it is now catching up with use. There is a moratorium on building specialty hospitals. And larger hospitals are complaining that the specialty hospitals are cherry picking cases, bringing there financial practices under review.

Some Hospitals Call 911 to Save Their Patients" is the title of a 4/2/07 NY Times article detailing a mortality in a surgeon owned specialty hospital. This topic is on its way to legislation (AMA News 3/26/07) NY TimesAMA about specialty hospitals. They are given plenty of reason not to trust us.
Whenever I hear about the "old guard" commenting on something such as the 80hr wk I wish they would just ask them how their generation is leaving the world of medicine? I wish everyone who came out of medical school with less than $100k of debt would take one step back. The time of a national plan is coming it will be generations before "pay for performance" critereon are reasonable and actually based on meaningful medical performance measures - no one reading this in 2007 will see that day. The old guard lived fat off the system. They'll never admit it but SSA isn't going to collapse because they worked a few extra hours a week during residency and that extra work cost Medicare. We're going to be at the mercy of the system that results while they are retired in some house on some beach I'll never see. I just wish instead of the grief, they'd just say "sorry for the mess," and leave us to see what we can sort out.
Anonymous was exactly right in stating that medicine is not what it was in the past. We will never be rich. We will live relatively well. I do see in the future that our practices will be driven by hospitals and insurance companies. This is already occurring. Insurances are telling you that test is not indicated based on a list of criteria that they have on some piece of paper. Hospitals are telling you what implants you can and can’t use based on contract that you have had no say in negotiating. Malpractice companies raise your rates with no provocation and you have no way of changing because the other company is even worse. Patients don’t appreciate the all the hard work you just put into their case; they just want their pain medication and their FMLA form filled out.

Medicine is not what it was. The great physician is now a paper pushing mule. The glory days are over. We are basic blue collar shift workers. It really isn’t about patient care; it is about what I can get from the system. Since the system is not going to provide me with adequate reimbursement, screw the patient.

I am an optimist and I will continue to try an inspire people who are training under me to do the “next right thing.” Many of the things I do, there is no financial benefit. I still love medicine and the smiling face on the patients that to appreciate what you do for them. I guess it is like when I playing golf. Most of the time my shot is 50 yards off to the right, and if that was always the case, I would never go back; but every once in a while I hit the sweet spot and it reminds me why I keep coming back for more.

“A dreamer is one who can only find his way by moonlight, and his punishment is that he sees the dawn before the rest of the world.”

~ Oscar Wilde

Tuesday, April 3, 2007

You are only as good as your last case ...

“If I have seen further than others, it is by standing upon the shoulders of giants.”

~Isaac Newton

Last week was a tough week, I understand it is part of the job, these weeks happen. For the pediatric orthopaedist, the summer is filled with elective cases and trauma. I understand that like most things you have good weeks and bad weeks, and as the saying goes, "this to shall pass." If you put your head down and continue to work, the next thing you know is that your done. So, long days usually don't get me down. The thing that can really be a downer on a day is when "that" patient comes in to the office. The patient that you remember like yesterday. You can remember every nuance of the patient. You remember the time, date, and room when you first met the patient. If not all then most physicians will have a patient or patients that they remember the name, medical record number and the specifics about the case. These are the patients we call our albatross. I think when those patients come into your office it can be worse than the hardest work week, because it brings back all those past memories.

There is nothing like follow-up to ruin your good surgeries. In orthopaedics, we follow our patients for years, especially pediatric patients. Sometimes the problems won't display their ugly faces until 6 months or more later. You may have one of your perfect surgeries fail; or maybe you missed a diagnosis when you first saw someone and now they require surgery. Regardless of what the cause, it causes your heart to race when you hear the name. You may loose your appetite while eating your favorite meal. We all have those patients. So how do you deal with them?

As a resident, except when I was truly wrong with a reduction or treatment in the ER, etc., I don't think I ever felt the sick feeling that you get as an attending when a problem occurs. Residency gives you that attending protection. If you are in a case that was over your head, you always have (or should have) someone to back you up. There should be an attending with the experience to prevent any major error and correct any minor deviation. But, as an attending, not so much. There are times when I am in the middle of a big case when I look up and wish someone would make the pain stop; "take the scalpel, someone, anyone. Ah, but alas, there is no one." Residency and fellowship protects you from the albatross. Usually, you are not on the service long enough to see the final outcome. Yes, you may remember bad cases and it will effect the way you approach patients and surgical cases; you will see cases at M&M and remember the specific problem; but you don't "own" them.

Over the last few years, I have learned from many of my partners experience and support. The most important thing that I have learned is not to avoid a problem. As a resident, one of my chiefs said to me, "if you think it is infected, you have to prove it is not." This was in a particular case, but it holds true for most of what we do. Each surgical case is like your child and it is very hard to see you own child's flaws and defects. So, you have to be truly honest with yourself. Phone a friend (partner) to give you an honest opinion and listen. There was a nice article written on Neurologic Risk Management in Scoliosis Surgery. It made some nice statements on dealing with the family. There are several points that are important. When you deal will patients with complications you should have honest communication with the family, see the patient frequently, document clearly, and consult others (or spread the base). When you are having problems in clinic or in the OR, these are principles to use.

Every physician has an albatross. Maybe it is an ego issue or maybe we genuinely feel for the patient and family, regardless of the emotional cause of our discomfort, you still have to treat the patient; you have to answer the calls; and you have to see them in clinic. In the end, you should "do the right next thing" for your patient. Do not let your ego get in the way of proper treatment of your patient. In the end, if you are open and honest with yourself and ask for help when you feel you are over your head, you will be a better physician. We take an oath to do no harm; don't let your shortcomings prevent you from keeping your oath.

“I claim to be a simple individual liable to err like any other fellow mortal. I own, however, that I have humility enough to confess my errors and to retrace my steps.”

~Mahatma Gandhi