I have sometimes been asked, “Why do you post this stuff? Why expose yourself like that?” in comments about some of my more personal essays.

At least a small part of the reason is narcissism. I’m a writer and a certain amount of that comes with the territory.

A bigger reason is that it is therapeutic. A Facebook friend once commented on a post, “A burden shared is a burden lightened.” I post not so much to share a burden as to exorcise some demons through writing about them. If I write this stuff down and put it out there, it’s no longer running around in my head making me crazy. I don’t always want comments and I’m not looking for expressions of support. Confession can be a powerful tool for healing. The Wise Woman (my wife) tells me that owning too much, taking too much responsibility for things I can’t control, is itself a form of arrogance and narcissism. She’s right, but hyper responsibility is a character trait of all surgeons. We must find ways to live with it. Writing about it helps me with that.

Finally, I post this stuff to give others a glimpse of a world they will never see except on one of the worst days of their lives. It’s a world that my colleagues and I inhabit every working day. I work with some of the most dedicated and intelligent people that I have ever known. Most of them could excel at any trade or profession they choose. They could work in a job where they would have more free time, less risk and probably make more money at it. They choose to work trauma. It is an honor to be associated with them.

An Ethical Dilemma

Cicero once said, “Treat not with men who have no honor. You are both dishonored in the exchange but they have nothing to lose.”

What then is the proper course of action when confronted with a powerful organization that one believes is behaving unethically? The easy answer, the one that most people will give automatically (and somewhat self-righteously), is to refuse to do business with that organization.

But what if the organization is behaving in a perfectly legal and businesslike manner? What if, nevertheless, that behavior violates you own code of ethics, and arguably the larger ethical standard of ‘what is right and just’?

I find myself wrestling with that question right now. Many of my peers think I’m overstating the problem or that I’m being too idealistic. Many agree that the organization may not be a paragon of virtue, but they are scrupulously obeying the letter of the law, so there are no grounds for complaint.

The large hospital system that operates the hospital where I do most of my elective surgery (not the trauma center where I also work) has instituted a policy of requiring payment in full of that portion of the total bill for which the patient is responsible BEFORE any non-emergent surgery can be scheduled. In other words, if you have one of the 80/20 insurance plans sold under the ACA exchange, or if your employer provided plan has such a payment scheme, the hospital wants your 20% up front. They won’t waive it or let you finance it other than on a major credit card. The only exceptions are ‘emergencies’.

So far so good. I am a big proponent of individual responsibility. Patients are responsible for the deductibles on their insurance plan, and a prudent person puts money aside for that. I don’t have a big problem with such a policy for purely elective surgery such as the asymptomatic hernia or the elective hysterectomy or gallbladder surgery. But the hospital is taking a hard line on what constitutes and emergency. Specifically, an emergency is a life or limb threatening problem or one that will cause the patient irreparable harm if not treated immediately. The key word is immediately, as in today, not tomorrow or next week.

Recently I received word from yet another patient that she was unable to go ahead with surgery due to the policy of demanding payment in advance of her copayment of 20% of her anticipated hospital bill. I was asked if her surgery was an emergency. Usually for scheduled cases I do not certify them as emergent, but in this case I answered that it was. The patient had originally been scheduled for a laparoscopic cholecystectomy in a month, but came to my office urgently with crescendo symptoms. Her right upper quadrant pain had become much worse and was now almost continuous and required narcotics for control. I moved her surgery up to the next available day, 48 hours after seeing her in my office. She went straight to the registration area to set up her surgery and was told she would have to pay a large sum in advance based on her insurance plan. She did not have the money or the available credit on a credit card to pay. After I said it was an emergency, she was referred to hospitals Chief Medical Officer who reviewed her case and apparently her finances and somehow decided that it was appropriate for her to pay $500. Again, she stated she did not have that much cash and so she cancelled her surgery. I eventually did her surgery at the trauma center where I work and where there is no review of a surgeon’s decision that a surgery is urgent or emergent.

This is not the first time this has occurred. I and several other surgeons have had patients in need of cancer surgery have the same issue with respect to demands for advance payment of large sums prior to scheduling surgery. I have discussed this personally with the CMO and also with the Medical Staff President. While I understand the issue of bad debt resulting from patients failing to pay their share of their medical bills, I have little sympathy for the system’s pleas of financial hardship as a result of it. On any given day, thirty percent of my billing is bad debt. As a solo private practitioner, my ability to tolerate and finance that debt is surely more limited than a large organization such as the one that owns and operates my primary hospital. If this bad debt is so crippling, then how is this same hospital system able to buy hospitals all over the state and take over management of the state medical school?

I object strongly to having my clinical judgment as a surgeon over ruled by the hospital CMO, especially when he is neither a surgeon nor in the active day-to-day practice of patient care. I further think it is inappropriate for him to be making financial judgments with respect to a patient’s ability to pay. It is one thing to ask for advance payment for a purely elective surgery such as the repair of an asymptomatic hernia. It is both medically and morally indefensible to place financial considerations ahead of care in cases of cancer surgery or where a surgeon has declared that the surgery is urgent or emergent. To limit waiver of the advance payment to life threatening emergencies only may satisfy any legal responsibility, but such a policy compromises patient care in situation such as my patient’s. She did not have a life-threatening problem but was unable to function normally until her surgical disease was addressed. This policy needs to be changed. I know the satisfaction of a single patient means little to the hospital, but this particular patient has refused to have anything to do with the hospital, now or in the future. As more and more people experience similar treatment, patient satisfaction is sure to suffer.

I suggest that first, the CMO actually discuss the clinical situation with the patient’s surgeon if he chooses to over rule the declaration of an emergency. Second, a third category of ‘urgent but not emergent’ needs to be created for patients such as mine – people who are not in imminent danger of death or complication but who still need surgery as soon as practically possible. Third, the CMO should be removed from any financial decision making about how much it is appropriate for a patient to pay if that is to be less than full payment. There are financial professionals who do that job all the time in the business world. The hospital needs to hire appropriate people to look at this issue the same way that a debt counseling service would. The current situation is unconscionable for an organization that professes to make a positive difference in people’s lives.

While the policy is unquestionably legal, adhering to the strict letter of the law, it is not, in my opinion, ethical. It does not support justice or do what is best for the patients who seek care at this institution.

So what does a lone surgeon do? I have written multiple letters of protest, brought the subject up at departmental meetings, and had conversations with the CMO and the CEO of the hospital, all of which have proven futile. Do I continue to bring my patients here and thereby tacitly support this policy? Do I resign from the staff? That would hurt no one but me. In fact, I’m sure the CEO and a number of administrators would be glad to have me out of their hair. Resigning would also inconvenience my patients, most of whom live near my office. There is no alternative hospital that isn’t owned by the same system within 15 miles.

For now, I will continue to protest this policy at every opportunity. But am I just being naïve? Is this the way of the future? The ACA has made the high deductible, 80/20 plans the industry standard. There will be more pressure on hospitals and patients both. But through all the argument over personal responsibility, bad debt, and the definitions of medical necessity and emergency care, we need to maintain or commitment to doing what is best for our patients. We need to continue to do right and seek justice.

“Thank You For Your Service”

I hear this often when people find out I’m a veteran. We all do. It’s become an automatic response for many people, like ‘have a nice day’. I’m not complaining. It’s certainly better than the indifference or outright hostility many of us experienced in the 70’s. But the statement is almost becoming meaningless as it is repeated so often and automatically.

The thing is, I, and most veterans I know, don’t want thanks. Acknowledgement perhaps, but not necessarily in the form of a thank you. I joined the Navy in 1973 for purely selfish reasons, not out of any sense of patriotism. I had been accepted to medical school and had no way to pay for it. The Navy offered tuition in return for military service and I took the deal. My time in service changed me. The Navy taught me to serve something greater than myself and the Marines taught me to lead, two lessons that have defined my life ever since. After 14 years, I was a very different person from the one I was before the Navy.

My wife, the wise woman, quietly accepts the thanks of others in the name of those who aren’t with us anymore. I try to do the same, but am more conscious of the mix of good and bad that went with my service. The costs were often high, and the rewards less tangible. My friends and fellow veterans will understand what that means. Those who never served cannot.

Making the Cut

I have wanted to be a surgeon for as long as I can remember. Despite that wish, I was incredibly naïve about the process of becoming one. I vaguely knew one had to graduate from college and go to medical school, but even as a high school senior had no clue how one went about getting into med school. There was an accepted premed track at the University of Illinois, but I blithely ignored it. Whether this was out of hubris or willful ignorance, I am still not sure.

My choice of college was constrained by financial considerations. By the time I graduated from high school, I was basically estranged from my family. The reasons for this are many and not terribly relevant anymore, but I was on my own from the age of 18. I had won a state academic scholarship that would pay tuition and fees for any state school in Illinois, and the U of I at Urbana was the only choice I considered.

I was a very good student in high school. I learned early on that academic success carried rewards and could be my ticket out of the chaos of my home life. I scored higher on the Advanced Placement Biology test than any other student in the state, and 99% of those nationwide. I qualified for almost a full year of college credit before I even registered at the university. 

My time in college was spent mainly in libraries and study halls. I had friends; I even joined a fraternity, although our house was full of engineers and mathematicians who thought complex technology based practical jokes were the height of humor. But at my core, I was a ‘grind’, a student focused on studying to the exclusion of almost anything else. What was lacking in my education were the usual liberal arts courses – history, philosophy, literature. I had a single introductory philosophy course and two semesters of a foreign language (Norwegian, which I have totally forgotten other than a couple of stock phrases) in order to fulfill basic requirements. Otherwise, it was all science and math. Everything on the prerequisite list for most med schools and a lot more physiology and biochemistry than necessary.

I studied obsessively. I took practice tests for fun. In the end, I finished a degree in physiology in just three years. I also scored highly on the Medical College Admissions Test. I thought I had it made.

Little did I realize that every other prospective medical student was working just as hard as I was, and most of them had a PLAN. They were carefully cultivating professional recommendations and research credits and extracurricular activities to round out an entire ‘package’ for an admissions committee. All I had was good grades and a high MCAT score. Both were a dime a dozen among medical school applicants.

I applied to seven schools, not an excessively long list but more than many and the limit of what I could afford. (Application fees ranged from $150 to over $1000). I was asked to interview at four, which in retrospect should have surprised me. I didn’t have the polished CV that many of my peers boasted. I suspect a couple of good recommendations from a physiology professor and a friend’s father, himself a surgeon, may have helped.  I was full of confidence that my medical career was in the bag.

Then came the rejection letters. First Harvard, which was OK since I didn’t really want to go there. Then Stanford followed by Duke, Wake Forest and the Medical College of South Carolina (My girlfriend of the time had moved to Charleston. Not a good way to choose a school but I was in love). That left only the University of Illinois College of Medicine. In November, I got a thin letter from the admissions office. My heart sank. Thin letters meant rejection. Thick letters contained registration paperwork and meant you’d been accepted.

I didn’t open the letter right away. I wandered the Quad for a day, thinking, worrying, and trying to plan my next move. I decided I would remain an undergrad for another year and add biochemistry to my degree, retake the MCAT and try to cultivate some more professors for recommendation letters.

I went home and opened the letter, expecting the usual ‘thank you for your interest but . . .’ Instead, the first word was ‘Congratulations’. I was in. Registration information would be sent separately once I confirmed my acceptance of admission. I sent back the little post card enclosed with the letter confirming that I wanted to go to their school within an hour. I had made the first cut of my career.

First Duty

It was 1979 and I was sitting in a cold, noisy cargo hold aboard a C-141. Around me were twenty other men, all new transfers to Diego Garcia or to Naval Mobile Construction Battalion 5, my new duty station. We had been airborne for almost 8 hours after leaving Bangkok and before that had flown 5 hours from Clark AFB in the Philippines. According to the garbled voice over the aircraft’s intercom we were on final approach and this particular slice of hell was almost over.

This was my first of many flights on the venerable ‘time tunnel’ as the big cargo planes were called by those unfortunate enough to be passengers. The windowless holds were poorly insulated and indifferently heated. The temperature inside hovered a bit above fifty degrees, better than the outside temperature of minus 30 but still bone chilling after a few hours.

Half an hour later, the cold would have been welcome. Diego Garcia is a tiny atoll in the middle of the Indian Ocean. Eight degrees south of the equator, it is the very epitome of a tropical island. We stepped out of the still cold plane into blazing sun and ninety-degree heat. The humidity was within a soaking 95% and there was no shade for a mile in any direction, the native palms having been clear cut for the construction of one of the longest runways in the world. After a long half hour we were finally picked up by a trio of trucks for the three-mile trip to the Naval Support Facility and my new home.

NMCB-5 was the deployed unit responsible for new construction on the island. They had finished the runway before I arrived and were now involved in several major construction projects. There was the fuel pier, the new barracks and the infrastructure and utilities project. I was joining them as the new battalion medical officer.

Four weeks earlier, I had finished my internship at Bethesda Naval Hospital. I wish I could say it had been a good year, but that would be a lie. I was bitter and disillusioned. My peers and I had been regarded as temporary labor by most of our senior colleagues at Bethesda. We all knew that we’d be leaving for at least a year with an operational unit after the internship year and that only a few of us would be back. The rest would serve out their obligated service time as GMO’s (General Medical Officers) and leave the Navy to train in civilian programs. There was little attempt to encourage us to return and the prevailing attitude seemed to be that the only difference between a surgical intern and a cow pie is that no one went out of their way to step on a cow pie. On top of that, my brief first marriage of just eighteen months was over. My ex had emptied the joint bank account, diverted the household goods shipment to an apartment in Chicago and, rumor had it, had moved in with an old boyfriend. I was literally broke and everything I owned was in my seabag and a footlocker.

My intention was to serve my four years, and then get a job. I would save my pay and make enough money to buy a sailboat and sail around the world. It wasn’t a practical ambition, but I’d done the proper, conventional thing in order to get through college and medical school. Now, I was going to do what I wanted.

The trip to the battalion headquarters was short, but I was soaked with sweat by the time I reported to the C.O.’s office. The Captain didn’t seem to notice. He shook my hand and heartily welcomed me aboard. We made some small talk about the flight, and about Bethesda, where he had been a facilities engineer in the early sixties. He handed me off to his aid, a bored looking ensign who in turn handed me off to the Chief Petty Officer at the medical facility. Chief Harders was the first indication I had that this was real and I wasn’t in training any more.

“First,” he said. “We need to get you into a proper uniform.” I was in travel khakis and the uniform of the day was green fatigues. “We have a supply meeting with the S4 at 15:00. They’ve been shorting us on paper products and for the last two weeks, we haven’t had an officer to stand up that twit ensign over there and get us our full requisition. Then the Master at Arms has Petty Officer Race in the brig. He’s our only Public Health technician and if you don’t get him out, the reefer inspection won’t get done and you’ll have to shut down the galley until it’s certified.” He smiled at the stunned look on my face. “Don’t sweat the small stuff, Doc. I’ll run the clinic, you take care of the officer stuff. OK?”

Over the next two weeks, I got a crash course in running a battalion medical department. I had a budget of several thousand dollars to account for and responsibility for several hundred thousand dollars worth of equipment and supplies. I had a division of twelve corpsmen to lead, discipline, and supposedly mentor and counsel on everything from medical procedures to financial responsibility.

I quickly realized that the C.O. didn’t want excuses. He didn’t care that I had never done this before. If I didn’t know the answer to a question, the only acceptable answer was “I’ll find out, sir”.

I met the rest of the officers and was put in a berthing hut with three of them, all Lieutenants, like me, and all company commanders in charge of several squads of men. I found out quickly that they were all really smart guys. They had good engineering educations and had been in the Navy for five or six years. They knew their jobs and did them exceptionally well. Excellence wasn’t just a goal to them, it was a standard.

And they treated me as an equal. I was a division officer, technically senior to them in the chain of command even though I was clueless.

About a month after reporting in and just as I thought I was getting a handle on my job, the embassy crisis in Iran geared up. This was just after the Shah had been ousted and a bunch of fundamentalists took over our embassy in Tehran.

The C.O. called an all officers meeting after getting a flash message from CentCom. We were put on Defcon 3 and orders were given to prepare the battalion for mount out. Which meant someone thought we might go to war. After an hour or so of readiness reports from the various line companies, the C.O. turned to me and said, “Doc, what’s our readiness plan for casualty clearing and evacuation.” Fortunately I knew the answer (the Chief had spoon fed it to me just before the meeting. God bless Chief Petty Officers). That’s when I stopped playing officer and really felt that I had become one.

My attitude changed after that meeting. I was determined to do the job to the utmost of my ability, just like the other officers around me were. And I was determined to go back to Bethesda and complete my surgical training. If I was going to be a combat medic, then I needed the best surgical training I could get.

In the end, Command decided not to send us into the Iranian desert to build an airstrip for a rescue mission. The logistics were too daunting and the combat power too uncertain. They did load the battalion onto an LST and float us around the Horn of Africa for two weeks before standing us down.

Although we didn’t see combat in the end, for those two weeks, the prospect was very real and I came away with a new outlook on my job and on life in general. I was serving something greater than myself. People had counted on me to lead them in a situation that might involve life or death decisions. It was heady and humbling at the same time, and the knowledge that I could do it changed the way I looked at problems forever.

Today I had a case to present at Trauma M&M. M&M is Morbidity and Mortality conference. It’s where surgeons bare their failures and take the heat from their colleagues. Cases for presentation may be chosen because they represent bad outcomes, near misses or outright errors. In short, I screwed up and this is where I confess to my colleagues. It’s a ritual of confession, acceptance of responsibility and a group discussion of where the error occurred and how it could have been done better. Surgeons can be their own worst critics and we tend to be frank and even merciless with our colleagues in these conferences. Everything is civil (after all, you may be up in front of the group next time), but pointed.

My case was a man who had been transferred from an outside hospital, a small facility, albeit one with a CT scanner. He was involved on a rollover accident way up in the White Mountains of Northern Arizona. He was seen initially in the small hospital up there and transferred down to us as a level 1 trauma. He had multiple rib fractures, a sternal fracture, difficulty breathing and a foot fracture. The CT’s of his head and neck from the outlying hospital were read by a radiologist there as being normal. I saw him in the trauma bay and his main complaint was chest pain and difficulty breathing. Given the report of a normal CT and no complaint of neck pain, I cleared his neck and removed his cervical collar. Big mistake. The next morning he had neck pain and weakness in his arms. An MRI at our facility showed a  C5 fracture with jumped facets on the right and cord compression. The neurosurgeons were called and took him off to surgery and placed him in a halo brace. Fortunately his exam is improving and there’s a good chance he’ll have no residual deficits.

Trauma 101 – don’t clear a cervical spine in the face of a distracting injury without reviewing the images yourself and controlling the other injury. He was distracted by the sternal and rib fractures, short of breath and not able to give me a reliable exam. I got complacent and violated the protocol. I was appropriately grilled, filleted and skewered. And I rediscoved first principles yet again. The protocols were developed for a reason and no matter if nine out of ten times you can ignore them and go with your gut, that one in ten is why even experienced surgeons need the protocol.

There’s a great book that dissects the M&M process and provides incite into how surgeons handle error. It’s FORGIVE AND REMEMBER, by Charles Bosk. Originally published in the 70’s, it’s still the best analysis of this process and how it teaches us to learn from mistakes that I have ever read. I recommend it to anyone with an interest in failure analysis and frank discussion of error.

Nostalgia

Faulkner said, “The past is never dead. It’s not even past.” Nostalgia steals into your thoughts like an old song. When the song was fresh, it was vibrant and alive and full of meaning. Once forgotten, it can return as a haunting melody that tries to pull you back into a world that might have been but never really was the way your memory recorded it. Sometimes it’s bittersweet. An old remembered pleasure, a memory of innocence and a gentle longing to return. But sometimes the gulf between who you were then and who you have become is too great to be bridged. The pull of nostalgia becomes a deep pain the resurrects all the might-have-been’s and brings back the events and the deeds that changed you from what you were to what you are.

Baseball and Hope

It’s spring and Baseball has started. I went to the Arizona Diamondbacks home opener last night and found a gentle renewal of hope. Even though they lost, blowing a middle inning lead in the sixth, the rhythms and optimism of the game, especially the first game of the season, were invigorating.

For me, spring baseball has always been about hopeful expectations. Your team may have ended the season in the cellar, but each new season brings new hope. Maybe this year we’ll win the division. Maybe we’ll top .500 for the season. Anything seems possible.

I’ve had a tough couple of months lately at work. I worked harder for less income last year and the winds of change coming out of the ACA and the insurance industry don’t look friendly to the individual practitioner. We’ve had a run of tragic and difficult cases on the trauma service and I’ve lost some of my usual objectivity in the face of it. Things are changing in the hospitals were I work, and not for the better, but I can’t seem to do anything to reverse or stop it.

I really needed a night out, and Opening Day was perfect. The grass was green, the uniforms were crisp and white, the beer was cold and the dogs were hot and all seemed right with the world. At least for a few hours, there was hope. Batter up!

Mother’s Day
 
Mother’s Day is always a bittersweet occasion for me. On the one hand, my wife, the mother of my two sons, deserves recognition for the amazing mother that she is. She is the glue that holds us together and her strength and unconditional love for her sons has always been a safe haven for them.
 
My own mother committed suicide when I was in high school and had not been emotionally stable enough for several years before her death to provide that kind of love to my siblings and me. At fifteen, I thought I was beyond needing a mother and soon left home altogether because of the simmering hostility between me and my father. I regret that decision now, as I abandoned my brother and sisters in the process.
 
Over the years, there were several stepmothers who tried to fill the role my own mother had abdicated, but I never felt a strong connection to them. The closest I have come to a mother figure in my life since then has been my mother-in-law.
 
I know, weird. Mother-in-law jokes aside, she has always been a strong presence in my wife’s life. It’s a traditional Italian family and holiday gatherings, the traditional Sunday dinners, the daily phone calls, have been a part of our lives for thirty years now. It doesn’t hurt that in her eyes, I can do no wrong. (The down side is that in her eyes, my wife can do no right, so there is some strain there) She has always gone out of her way to make me feel loved and wanted in her home.
 
So although my own mother is long gone, I celebrate my wife for her devotion to our own children and my mother-in-law for her role in making my wife the wonderful person she is today. Happy Mother’s Day to both of them.

PTSD and the Trauma Surgeon

Over the past week I’ve experienced increasing sadness and a feeling of futility. It began with the chance discovery of an obituary for the father of an old high school girlfriend. He had a surprisingly big influence on me, although I was only partially aware of it at the time. He was the kind of guy who was good at almost anything he tried. He had 4 kids and his family, at least from my outsider’s perspective, seemed supremely stable and happy. He clearly loved his family and made times with them special. I was included in some of those times and was impressed by his quiet acceptance, gentle discipline and self-control and above all, his sense of fun. It was such a contrast to the chaos of my own family life that I found I wanted to be part of it. My girlfriend even gently chided me at one point about the ‘courtship ritual’ and how the guy in the relationship was expected to take his girl out on at least a few dates. All I wanted to do was hang around her house with her family. As early life relationships often do, ours ended when we moved to separate cities, separate schools, and I’ve heard nothing from her for close to 40 years. But her father’s example of what a family man could be stuck with me and I realize now that it had a lot to do with how I tried to be a good husband and father myself.

Why would such a discovery touch of feelings of futility? Perhaps because of a world that I once dreamed of that never came to be. Don’t get me wrong, I don’t regret my life, and I love my wife and family as dearly as life itself. But in reading about his life, its successes and the obvious success of his children and grandchildren, I felt as if my own efforts had come up wanting.

I have been so focused on my work and on a constant drive to be the best I could be, that I think I forgot that life is supposed to have a generous measure of fun in it.

Yesterday while driving home, I got a call from the hospital about a routine matter on a critically ill patient. As I was talking to them, my youngest son called as well. I quickly settled the question with the hospital and switched calls to my son, expecting some crisis or another. He just wanted to remind me to stop at the store for some things he wanted. This was the third time he’d called that afternoon with the same message (autistic kids do things like that) and I lost my temper with him since I’d already told him twice before that I would stop. I hung up after the call and was suddenly overwhelmed by a rush of shame, despair and a feeling of loss so powerful that I had to stop the car and cry. Images of dead and dying patients flooded my head for reasons that I still don’t understand. I felt as if I had wasted most of my life pursuing an illusion and that the cost to my family and myself had been too high for too small a gain.

We all have regrets about our life choices, even the good ones. I know that. But my reaction to the regret I felt and the flood of memories of all the times I failed to save a patient was completely over the top and frightening. Somehow my worth as a person has gotten all mixed up with my worth as a surgeon. There seems no separation or balance anymore. I still haven’t recovered my equilibrium.

I have never placed much credence in PTSD as a disabling condition. I know it is a real response to traumatic events and that people may be profoundly affected by those experiences, but I always felt that one recovered by soldiering on and drawing on ones strength to learn from the traumatic event. I have often felt helpless and inadequate when faced with a patient who was so ill or injured that I could do nothing to help. You learn to deal with it, to put it in a box and learn what you can and move on. Yesterday the box opened and dumped a load of pain on me. I’m still struggling to understand it.

2/14

Gun Control and the Real World

A high school acquaintance and Facebook friend who regularly comments on Huffington Post recently posted a heartfelt essay on gun violence. (see http://www.huffingtonpost.com/lorraine-devon-wilke/forget-any-other-argument_b_4598274.html?utm_hp_ref=fb&src=sp&comm_ref=false#sb=1468893b=facebook). I responded in my usual fashion with statistics and legal citations. Others responded and even suggested I view a YouTube video of people talking about the personal effect of the violent deaths of their loved ones. As if I didn’t ‘get it’.  I am posting this response on my own wall rather than hers in part because it is long and in part because I don’t want to spark further confrontation on someone else’s domain.

I realize that my initial response was wrong. The essay wasn’t about real solutions to gun violence. It was an appeal to emotion, to a common sense idea that if the gun were taken out of the equation, the personal confrontations that had resulted in a death would have been less lethal. The idea is indisputable – guns escalate the potential lethality of any situation.

And believe me, I ‘get it’ when it comes to the personal devastation of a violent death. I’m the guy who has to tell a family that the gunshot wound their father/sister/brother/son inflicted on themselves was fatal and that they are gone forever. I’m the one who has to tell the parents of a 16 year old that his brain has no reasonable hope of recovery and ask if they’ve considered organ donation. I’m the one who is up to his elbows in someone else’s blood at two in the morning trying to staunch the flood from a severed aorta. I am an intimate participant in our nation’s dance of violence and death.

I am also a realist. ‘What if the gun weren’t there’ is little more than wishful thinking if it doesn’t lead to a solution. The only real solution to the impulsive use of a gun in a confrontation or in a suicide is to remove guns from the general population. And that is simply unrealistic in this country, at this time in history. Blame whomever you like. I don’t care. There is simply no way that guns will go away any time soon. Bromides about mental health screening and background checks are feel-good measures. They will likely stop some really bad or crazy people from acquiring a gun, but that is a tiny minority of the people who use guns on their fellow humans. Most are regular people who succumb to a moment of rage or bad judgment or despair that is then made tragic by the easy access to a deadly weapon.

I don’t offer a solution because I don’t believe there is one; at least not one that is palatable to most people. Gun control? Sure. Gun confiscation on a national scale? Um, wait a minute. And make no mistake, in order to stop all impulsive acts of gun violence, that’s what it would take. If there is a solution, it will come through hard-bitten realism and careful analysis of the roots and possible cures for what has become a public health problem. Not through emotional appeals to a national conscience that is fleeting and inconsistent and abdicates it’s responsibility to nameless government functionaries.

2/9/12

The Obama ACA Mandates

The stupid and poisonous attacks mounted by Rush Limbaugh and Patricia Heaton on Sandra Fluke following Flukes Congressional testimony have invalidated any reasoned opposition to the women’s health mandates due to go into effect this year. Which is unfortunate, because the mandates are problematic in their implementation and represent a major expansion of governments reach into the delivery and quality of healthcare.

At the risk of arousing the ire of many of my female friends, I will attempt to discuss how we got here and outline some of the real problems with the mandates issued by HHS which will define what services must be offered by health plans in order to comply with the provisions of the Affordable Healthcare and Patient Protection Act.

So how did we get here? When the Affordable Care Act was passed, it included considerable attention to preventive care, for the first time stipulating that new private plans cover a wide range of recommended clinical preventive services to plan holders without cost-sharing. Specifically, this section of the law (2713) requires that private plans cover services that receive a strong recommendation from the U.S. Preventive Services Task Force (USPSTF); vaccines recommended by the Advisory Committee on Immunization Practices (ACIP); preventive services for children recommended by Bright Futures guidelines for pediatric preventive care; and “with respect to women,” new services that will be identified by the Health Resources and Services Administration (HRSA). No specific mention is made in the law to contraceptive services. In 2010, the Department of Health and Human Services (HHS) requested that the Institute of Medicine (IOM) convene a committee of experts in women’s health and prevention to identify gaps for women in the current preventive recommendations.

The IOM committee identified eight new preventive services for women, including screening for intimate partner violence, well woman visits, breastfeeding supports as well as the inclusion of contraceptive services and supplies, including all methods approved by the Food and Drug Administration. These recommendations were adopted by HHS in August 2011. Contraception is also recommended as a part of health care for women by the nation’s leading health care professional associations, including the American Medical Association, the American Congress of Obstetricians and Gynecologists, the American Academy of Pediatrics, and the American Public Health Association.

So far, so good. The Institute of Medicine is the medical advisory arm of the National Academy of Science. It is generally a respected source for determining best practice guidelines and comparing the safety and effectiveness of different therapeutic measures. They offer several levels of advisory documents ranging from ‘letters’ which are brief consensus statements about one particular device, treatment or approach to a problem, to ‘recommendations’ which are their consensus statements on the correct approach to a large medical or public health problem. The Institute doesn’t claim to be completely free of bias, but is independent of any government agency and is funded through donations and the sale of their consensus papers. They nevertheless carry great weight with healthcare organizations many of their guidelines are standards of care for the problems they address.

That said, the recommendations made to HHS regarding women’s preventive healthcare are groundbreaking and depart significantly from previous guidelines and recommendations. There are two issues with the eight preventive services identified by the IOM. First, there is little data or experience to suggest the recommended services will have the desired effect. They make intuitive sense, but many things that make intuitive sense turn out to be impractical or even unintentionally harmful in their implementation. Most recommendations issued by the IOM, at least those that deal with clinical guidelines, identify the source material on which they are based. The studies are classified as Level 1 (derived from controlled randomized scientific trials) Level 2 (derived from clinical studies with historical controls or non-randomized linear studies) Level 3 (generally accepted practice supported by long-range outcome data) or Level 4 (expert opinion). Support for the eight specific services recommended the HHC for women’s preventive care range from Level 2 data (recommendation 5.1 – screening for gestational diabetes; and 5.2 –screening for HPV) to Level 4 (5.3 – counseling on STD’s; and 5.7 – domestic abuse counseling). The assumption is that these measures will have a positive effect is reasonable but has not been validated or studied.

Why is that important? After all, these sound like good ideas that would be of benefit to many women. The problem is that these are not guidelines – standards that are recommended and that most insurers and practitioners would try to abide by. They are mandates. Once HHS adopted them wholesale, they had the force of law. Whether they are effective or not, whether they can be practically implemented or not, they MUST be done in order to qualify for Federal funding and certification.

Which leads to the second issue: Implementation. Even good faith efforts to meet all of the recommendations will likely fail for lack of resources. For instance, recommendation 5.7 requires screening and counseling for interpersonal and domestic violence. Sounds good, important even. Domestic violence is the leading cause of death and injury for women 21 to 30 years of age. I see and deal with this every day as a trauma surgeon. We try to refer victims to counselors and social workers to get help, to get out of their living situations. But there aren’t enough counselors or social workers to deal with the demand. Waiting times for counseling appointments may be several weeks. Space in shelters may take even longer to find. Increasing demand simply cannot be met with current resources and there is no funding in this bill to train more counselors. Mandating a thing doesn’t necessarily make it so.

An examination of each of the eight recommendations reveals serious issues with many of them.

5.1 Screening for gestational diabetes No major controversy here. Most prenatal clinics do this anyway. This is supported by both Level1 and Level 2 studies and is the standard of care for primary care and OB-Gyn.

5.2 The addition of high-risk human papilloma virus DNA testing in addition to cytology testing in women with normal cytology. This is state of the art testing but is of unproven benefit. There are Level 1 studies suggesting earlier detection of high-risk patients and more frequent screening for them may detect cervical cancer earlier, but right now this is unproven. We thought routine PSA testing for prostate cancer would be useful, too, but it hasn’t proven to be of enough benefit to justify the costs.

5.3 Annual counseling on sexually transmitted diseases for sexually transmitted diseases. Again not much controversy, standard of care, as long as you document it.

5.4 Counseling and screening for human immunodeficiency virus (HIV) on and annual basis for all sexually active women. Really? This seems to recommend annual HIV testing for every sexually active woman in the country. That at least is the generally accepted meaning of ‘screening’ in the medical community. If they mean something else (asking “Are you engaging in unprotected sex with multiple partners?” for instance,) they should use another term. I actually believe that annual testing WAS the intent based on supporting documentation in the full text of the report that states ‘there is a bias toward gay men in the routine testing for HIV exposure that discounts the risk of unintentional exposure in sexually active women”.

5.5 The full range of FDA approved contraceptive methods, sterilization procedures, and patient education and counseling for women with reproductive capacity. This is the ‘contraceptive mandate’ that has caused much of the controversy. More about that later. The problem with this recommendation that is overlooked in the shouting is its sweeping generality. No other healthcare mandate requires that ALL methods of providing a particular type of care be provided. Not cancer care, chemotherapy, cardiac care, treatment of hypertension nor diabetes has such a sweeping mandate. Why was this aspect of women’s health singled out for special treatment? At its most literal it can be interpreted as requiring health plans to offer every contraceptive medication in the formulary plus over the counter methods at no charge to their insured. At the least it will require a representative drug from each class be offered as well as every IUD, sponge and implant made. Sweeping and unprecedented.

5.6 Comprehensive lactation support and counseling and the cost of renting breast feeding equipment. A trained provider should provide counseling to all pregnant women and to those in the postpartum period to ensure successful initiation and duration of breastfeeding. Again, a sweeping mandate showing the bias on the part of the authors against bottle feeding. This is based in good science showing the superiority of breastfeeding but goes way beyond current standards and assumes that all women want to breast feed their infants. Further, there is no training standard for these providers. A boon to the La Leche League and similar groups but not a practical mandate.

5.7 Screening and counseling for interpersonal and domestic violence to include solicitation from women and adolescents about current and past violence and abuse in a culturally sensitive and supportive manner. This is a wonderful idea, but not the job of primary care or OB-Gyn providers. As medical professionals we do not have the cultural of sociologic training to deal with these issues. This is the purview of social work and psychology. Putting this burden on healthcare providers is unfair and as likely to elicit resistance as cooperation. And there are not enough trained counselor and psychiatric social workers now to do this job.

What emerged from the IOM report is a sweeping change in the role of government in mandating specific healthcare measures. These recommendations were adopted without debate or discussion and will be imposed on the medical community this year. We will be required to document compliance with these measures for each and every patient; an additional burden in record keeping a separate reporting that will cost time and money. And if studies show the recommended interventions are ineffective, it will be a cold day in hell before they are changed.

Government mandates are not new in healthcare. For the past four years, for instance, the practice of surgery has been under a set of mandates called the Surgical Care Improvement Project (SCIP). These mandates require specific antibiotics be given for certain procedures and specify the timing of when they are started and when they need to be stopped. Other mandates require the routine use of low dose anticoagulants to reduce the risk of deep vein clots and pulmonary emboli (clots that travel to the lungs). They also require that urinary catheters be used only for specific problems and be removed in a specified period of time. An 85% compliance rate was required or Medicare and Medicaid funds will be withheld. Two large longitudinal studies published this year looking at several hundred thousand patients have proven that the mandates are ineffective. There has been no effect on the rate of surgical infections and the number of DVT’s has been reduced by a whopping 0.5%. Pulmonary emboli have not been affected at all. Compliance has cost hundreds of thousands of man-hours in documentation and implementation and an unknown amount of money (estimated by the VA to be in the millions) for no gain. So what does CMS, the government agency that runs Medicare,. do? Do they rescind the mandates? No, they increase the compliance requirement to 95% so we can waste more money complying with irrelevant mandates.

This is my greatest concern with this new set of rules. Many sound laudable in intent. But they are sweeping in scope, may cost millions to implement and document and as yet have little data to back their efficacy. Past experience with similar mandates has shown that once they are in place, documentation of compliance overshadows actual performance of care.

8/18/11

Who Speaks for Me?

Our country is not a democracy. By design, the Constitution set up a representative Republic, not a pure democracy. The framers of the Constitution, for all their talk about the rights of the individual, understood that freedom without the discipline of careful reflection is the path to chaos.

We have a system where our Representatives in Congress are supposed to speak for us in the seat of power and look after the rights and interests of their constituencies. Despite Washington’s warnings about the dangers of factionalism and the establishment of political parties (I’m talking about the man here, not the city), by the end of his second term a strong two party system of political power had emerged.

Flash forward two hundred and eleven years and we have an increasingly polarized Right/Left political division. It’s not the first time in our history that the divide between the major parties has been this sharp, nor is the current division any more acrimonious than say the split between the Whigs and the Democrats in the days of Andrew Jackson, or the Republicans and Democrats in the years before the Civil War. We perceive a more acrimonious atmosphere because of the 24hr news cycle and the relatively bland politics of the preceding 20 years. The period from the early fifties through the late eighties was unusual for it LACK of political acrimony.

So who speaks me in our Republic? I’m a white middle-aged male professional. You might say I need no one to speak for me since I’m clearly one of the privileged elite. I’m  one of the people who run things, right? Except I’m not. I’m asked to pay for a lot of stuff, but have little say in how the money gets spent and on whom.

Given my demographic, the conservatives should speak for me. But I have little use for the religious right. I am not a religious person and don’t believe that theology has any place in politics. Morality may have a place but morality is not dependent on theology. I am not an atheist, even though I don’t really believe in God. An atheist actively denies the existence of God. I simply don’t know nor do I care about God’s existence. The universe functions quite well on its own without Divine intervention. As long as the ‘conservative’ party in national politics is help hostage to the religious right, I have no place within it.

I must therefore be a liberal, right? Not really. I believe in VERY limited government. I support social liberalism as far as the freedom to choose one’s sexual preference, lifestyle and personal habits is concerned and don’t believe we can or should legislate personal morality. I believe abortion should be safe and legal, but not necessarily free. I believe in personal responsibility and the concept of accepting the consequences on one’s choices without expecting to be bailed out or helped if that choice was wrong. As long as the ‘liberal’ party in national politics believes that government has the duty to intervene in people’s lives whenever misfortune or (more often) stupidity causes them suffering, then I have no place in it.

The libertarians offer no voice either. They appeal to my sense of individual liberty and responsibility, but I don’t believe that private ownership of everything is a practical way to run a country and isolationist foreign policies have never worked in a world where others wish us harm.

So where do I turn?

I believe our government is out of control and no longer acts in the interests of the nation. I believe that ALL spending should be discretionary. There should be NO ‘entitlements’. Social security, Medicare, direct payments of money or services of any kind from the government to citizens should be renewed yearly. All spending should be sundowned at a specific time, no more than two or three years.

I believe the War Powers Act should be repealed. Military commitments should be made only when there is a clear and present danger to our country and should require a formal declaration of war. We need a robust and all volunteer military, but it should be used by people who understand war and killing, not by politicians. We are not in the business of ‘nation building’. Humanitarian interventions are not the business of the military. We should go to war only when out security is threatened and then with overwhelming force. Once the threat is removed, we should get out and come home. We are not the world’s police force.

I believe that who you love and who you marry is your own business, not the government’s. Same sex marriage, at least in the civil arena, should be a non-issue. The government can’t compel churches to change their doctrines, but anyone should be able to go to the local justice of the peace and get married.

I believe abortion should remain safe and legal. But I also believe that we should recognize that abortion kills a potential human. We can agree that the mother’s rights trump those of the fetus until the age of viability, but the decision to end a pregnancy is not morally neutral.

I believe that income tax is inherently unsound as a fiscal policy. It penalizes savings and investment, skews the responsibility for payment to a smaller segment of the population and pits those who pay little or no tax against those who pay the bulk of the taxes. A tax on consumption is fiscally sound and necessarily limits the power of government. Income tax allows the politicians buy support from interest groups through tax breaks and handouts. Consumption tax is blind. It doesn’t care who spends the money, so can offer no advantage one way or the other.

I believe in a strict interpretation of the Constitution. The tenth amendment is just as important as the first and should not be forgotten.

I believe that the government exists to make war, coin money, build and maintain infrastructure, grant patents, ensure basic clean water and food and support public health. Other interventions into public interactions or private lives should be viewed with healthy skepticism and should have limited and specific goals.

I currently have no use for either political party. They are two sides of the same coin pandering to an electorate that is too easily swayed by emotion and demagoguery.

We have forgotten our history, we ignore the lessons of civilizations that went before us and live in a perpetual adolescence where the penalties for stupid behavior are regarded as ‘misfortunes’ or ‘disadvantages’.

Who speaks for me?