A few months ago, I was seeing an elderly man in the hospital about a sigmoid mass seen on his colonoscopy that day.  He had presented to the hospital with fatigue and anemia and the long meandering workup eventually zeroed in on this malignant appearing mass as the source.  His daughter was in the room while I discussed the results, the likely diagnosis, treatment options, and anticipated complications.  She was very engaged with the conversation and seemed highly informed.  The questions she asked were advanced and sophisticated--- part Google search, part higher education background.  Her mien was that of an eager person interviewing for a job she really really wanted.  I liked her. She was earnest and serious about the situation at hand.  She  obviously loved her father.  He seemed to defer much of the decision making process to her.  He kept looking over at her with a faintly bemused expression.  I was recommending surgery and he just smiled.  What do you think, sweetie?  Should I get this surgery? He looked like a man who would do whatever she said.  He looked tired and worn down and it didn't matter about the cancer, all that mattered was doing what his daughter wanted.  His eyes gleamed when he looked over at her.  

I answered several of a series of her questions about the surgery proposed.  Laparoscopy vs open.  Potential complications.  Expected recovery time.  Need for radiation or chemotherapy.  We went through it all, thoroughly.  I was in there a good 45 minutes.  It seemed she was coming around to the idea of having her father cut open, the tumor extracted.  And then she said something that put me on my heels. 

"Now....you're just a general surgeon, right?  Will you be contacting a colon specialist to evaluate Dad for surgery?"  

I just sort of stood there for a second or two, bewildered.   But because this is not the first time someone has asked me this question over the years I quickly gathered myself.  Before, I may have answered defensively.  But not this day.  I told her:

"Mrs Smith, I am indeed a general surgeon.  And I appreciate your interest your father's care.  Your love for him could not be more apparent.  I assure you, that the surgical procedure I described for you falls well within the scope of my normal practice.  I perform a lot of surgery for colon cancer and diverticulitis.  And I think my results stack up with anyone around.  That being said, I understand where you're coming from.  There are some surgeons who do a fellowship in colorectal surgery after general surgery training.  Those that do tend to make that an exclusive focus of their practice.  I know several terrific ones here in town.  I could connect you with one of them if that is your preference.  I also would be happy to take care of your father's needs myself.  You would get my best. "

She ended up staying at our hospital.  The surgery went well and her father had a good outcome.  I am a general surgeon and I have always taken great pride in that identity.  Some days I have five hernias on the schedule.  This past weekend I took out four gallbladders and drained a breast abscess.  I see women with abnormal mammograms.   I get IV access and manage patients in the ICU.   I correct large diaphragmatic hernias.   I drain butt pus.  I  whack out rotten appendices.  I biopsy masses and see consults in the ER.  I cover trauma call and take out smashed spleens.  I operate early mornings and late at night.  It is the life I have chosen.  I knew what I was getting into.  

But I have grown to wonder if the term "general surgeon" means what it used to mean.  It started years ago when components of the general surgery repertoire began to fragment and separate from the main body.  In the late 90's you were just as likely to have a general surgeon perform your carotid endarterectomy as a fellowship trained vascular surgeon.  Nowadays, such a thought is risible.  Vascular surgery itself has sort of branched off into its own universe, leaving general surgery far behind.  Similarly, general surgeons have ceded much territory in the realm of endoscopy.  In many small towns and rural settings, most of the colonoscopies may be done by a general surgeon, but it's rare in a larger city.  Thyroidectomies are now being done by "endocrine surgeons".  Breast lumpectomies get referred exclusively to "breast surgeons".  Laparoscopic hernia cases get sent to the "minimally invasive fellowship trained" guy at the main campus.   Melanoma goes to surgical oncologists or "Moh's dermatology surgeons".    

In addition to the fragmentation of surgical practice into various specialties and sub specialties, alterations in surgical residency training programs have had unintended, undesirable consequences.  The 80 hour work week restrictions, implemented over the course of 2004-2008  have led to a scenario where graduating chief residents are unfit for independent clinical practice.  They haven't done enough surgery.  They simply haven't spent enough time in the hospital.  To wit:

• 80% of graduating surgical residents go on to do a fellowship
• 25% of senior residents report feeling unprepared for independent practice
• Surgical fellowship program directors note that 30% of fellows were not prepared for operative cases and 2/3 could not work unsupervised for extended periods
• Oral board exam failure rates have increased from 15% to 25% since work hour reform was implemented  

The American College of Surgeons is very much aware of this burgeoning crisis and has taken steps to try and rectify matters.  One idea is the concept of Transition to Practice (TTP) program.  In this paradigm, graduating senior residents would spend a year as "apprentice surgeons" under the tutelage of some older, experienced surgeon with a broad practice scope.  The hope is that this would help younger surgeons gradually grow more comfortable in a role as an independent practitioner rather than suddenly being thrust into the world without the necessary training or confidence.  Further, since so many surgeons do a fellowship simply because they feel unprepared for an independent career otherwise, it is hoped that the TTP program will incentivize more graduating residents to pursue careers in general surgery.  The impending shortage of general surgeons, especially in rural areas, would stand to be corrected by such an outcome.  Mid sized cities could also stand to use a few more general surgeons--- and a few less hepatobiliary specialists sitting around waiting for the rare big cases.  

I consider myself lucky.  I trained at a busy residency program in Chicago and I completed most of my training before the work hour reforms kicked in.  I graduated with a certain confidence that I would be able to step into a general surgery practice on day one.  For me, there was nothing else to aspire to than to be a general surgeon.  But with the way the training has evolved over the past 10-15 years I ought not be surprised when a patient asks me why I am not more. Perception is everything.  For some reason, the idea of a generalist has become a derisive term.  It wasn't always that way.  I see myself as the last of a dying breed.  I am a general surgeon.  There is no shame in that....       

A patient presented with 2 weeks of progressive right lower quadrant abdominal pain.   His primary doctor ordered a CT which revealed the above findings.  This was a very unusual case of cecal intussusception.  In an adult, intussusception is always an ominous finding---in colonic intussusception,  malignancy is the underlying cause in 50-71% of cases.   In children, most cases of intussusception are spontaneous and unrelated to cancer and usually do not require surgical intervention.  

This gentleman was admitted and a surgical consult was obtained.  By the time I examined him, his pain was improving.  We were able to perform a full colonoscopy which demonstrated a malignant appearing mass in the cecum.  The next day he underwent laparoscopic right colectomy.  Three days later he went home.  In some respects, he was lucky to have developed an intussusception as it led to incapacitating symptoms, expediting the discovery of a malignant tumor.       

JAMA published an opinion piece this month about the controversial issue of patients secretly recording their physicians during encounters.  We live  in the era of the smart phone.  Everyone has one--- soccer moms, teenagers, young kids who can't even read yet, elderly nursing home patients who can't safely feed themselves.  Everyone.  And these devices have amazing powers of audiovisual capability.  We all know this.  Anyone can film or record anything at anytime.  And most states have laws in place  that allow for the secret recording of conversations between two parties, as long as one of the participants consents to the recording.  The authors conclude:

Personally, I don't have much of a problem with being secretly recorded, either by a patient or someone else in the room.  I wouldn't feel violated.  I don't see it as undermining my relationship with patients.  In this era of less paternalism in medicine, I think patients just want to feel that they have understood the issues and are able to arrive at informed decisions based on the available information.  Medicine is complex and unwieldy.  Patients get overwhelmed.  In many physician/patient encounters, given the emotional content and the stakes involved, communication gets compromised.  Meanings are lost.  Words are misheard.  Opinions get misinterpreted.  And patients feel that by simply recording the encounter, all those issues will dissipate.  Of course, it isn't so simple.  Not much will be gleaned from re-listening to a garbled audio recording of a physician's thoughts.  At least not as much as just speaking with the physician one on one again, to reinforce ideas and clarify issues.  A physician should always be prepared to repeat himself, both within the context of the initial encounter, and at subsequent encounters, either on the phone or in person.  

There is one caveat to this.  Any recordings of my role as physician would have to be done without my knowledge.  It would be essential that secrecy was preserved.  The minute you tell me that you are recording me, the encounter immediately gets transformed, irrevocably.  Suddenly,  it is no longer authentic communication between two humans, one of whom is trying to tease out the source of what ails the other.  Instead the encounter has become mere performance.   Instead of assuming my role as "doctor" seeking to alleviate suffering, I have become a man up on stage, microphone in hand.  If I know I am being recorded it would just make me self conscious and awkward and stultified, worried more about banalities of diction/syntax/voice timbre/modulation/how goofy i may sound upon repeated listenings etc etc.  An honest, authentic, meaningful physician/patient encounter requires a certain form of self-effacement, a losing of oneself in the moment.  Something happens when you truly and concertedly give yourself over to the hard work of listening to a vulnerable human who is trying to convey pain and suffering.  At some point, the gap between two strangers is bridged.  I suppose this is called empathy.  But it cannot be contrived or faked or staged.  For me, at least, recording that intimate encounter would ruin everything.  So much would be lost, just to preserve a few more words.

The other issue I draw a line on is as follows.  Patient may have a cousin in Idaho who is a pulmonologist.  The patient takes out cell phone, calls the cousin doctor as I begin my exam, and places said phone on bedside table.  "Do you mind?  My cousin is the only doctor in our family and he wants to hear everything you say".  I tell everyone the same thing.  I don't "do" conference call examinations.  What happens is, the person on the other end of the line can't hear what I'm saying and they ask me to repeat this or that.  So I'm always stopping and starting, shouting toward a faceless voice on a phone.  I have to turn my head away from you, the patient.  It gets annoying.  I lose my rhythm.  The whole encounter gets chopped up and fragmented.  It's unsatisfying on both ends.  I'd be happy to call your cousin as soon as we are finished and convey to him my exact thoughts via a private phone conversation.

Most patients are very understanding....

Well things are getting ugly in New Hampshire, of all places.  The state legislature just voted to end the ACA-derived Medicaid expansion (available as a federally funded option to all states) beyond the year 2017, thereby throwing tens of thousands of vulnerable poor citizens into the stressful chaos and financial uncertainty that defines being an adult in America without health insurance.  This quote from Republican state representative Dan McGuire was particularly uninformed and odious:

Those are just delightful sentiments, aren't they?  It seems that, in the world of Representative McGuire, the only acceptable excuses for being on Medicaid would include "Struck down by thunderbolt from the hand of Zeus", "Limbs gnawed off by sharks", "Earthquake destroys town", "Typhoon washes away all manufacturing employers in 50 mile radius" and "Abducted by aliens".   Mass unemployment, economic stagnation during the Great Recession of 2008-2011, and off-shoring of industrial and manufacturing jobs over the past 30 years are irrelevant, inconvenient details.  

I love how Mr McGuire seems to think that "having a job" eliminates all worries about health benefits.  I think all of our Wallmart and McDonald's workers forced to accept 25 hour work weeks would have something to say about that assumption.   It's as if the working poor don't even exist in his worldview.  Anyone qualifying for Medicaid must necessarily be a lazy, unmotivated, entitled slug who would prefer to sponge off more successful, more "authentic" Americans.  It doesn't even cross this guy's mind that there are plenty of struggling Americans working several jobs--50, 60, 70 hours a week-- but don't have health insurance, either because they are part time at all those jobs or the company doesn't even offer benefits, and they are unable to purchase individual insurance because it's far too expensive.   Furthermore, this bill they passed only eliminates the Medicaid expansion, i.e. those who incomes fall within 138% of the poverty line.  It has nothing to do with basic Medicaid itself.  This expansion only applies to those people who are already working but earn too much to qualify for regular Medicaid.  This has nothing to do with freeloaders choosing to stay at home and play X-Box stoned all day.  The whole thing is just about as disgusting and cynical and deceptive as you can imagine.  

The richest, most powerful country in human history.  That's not hyperbole.  And yet the provision of affordable health care for its citizenry remains an unsettled political powder keg.   It remains a dark stain on our collective moral standing....

Chris Borland, a linebacker for the San Francisco 49ers, announced his retirement from the NFL this week.  Borland had a reasonably productive rookie year and was expected to play larger role in the team's defensive schemes this coming season.  Most analysts expected he would be one of the team's starters.  So why would an otherwise healthy, productive, up and coming player walk away from such a once in a lifetime opportunity?  Apparently he got his bell rung during training camp last August but didn't tell anyone because he was a rookie trying to make an impression.  Afterwards, the experience gnawed at him and he did a little private independent research on repetitive head trauma in NFL players.   A portion of Borland's statement:

So yeah.  On the cusp of stardom, his dream job in hand, the dude walks away because he didn't want to end up like Junior Seau and Dave Duerson and Jovan Belcher and Justin Strzelcyzk and Terry Long and Chris Henry and Andre Waters and Mike Webster and Tony Dorsett and Ray Easterling and John Mackey and Gene Hickerson and Ted Johnson and Owen Thomas and 17 year old Nathan Stiles and on and on and on.  The now well-described ravages of Chronic Traumatic Encephalopathy (CTE)  gave him pause, and he justifiably flinched.  And he walked away while he still had the cognitive wherewithal to do so. 

The NFL responded as follows: 

This is a deeply misleading, cynical statement.  The consensus opinion of scientists and doctors is that CTE represents a chronic degenerative brain injury that occurs after the accumulated effect of repetitive head blows, both minor and major.  Whether the traumatic event qualifies as a concussion or not  is irrelevant to the pathophysiology of CTE.  And the NFL knows this.  The NFL is a craven, exploitative, multi-billion dollar monopolistic industry that spits out broken shells of men when they have out-lived their usefulness.  But at least we have been entertained.....

  

Like most of my age cohort, I was brought up to believe that the Great Satan threatening to undermine the bloated American healthcare system was our broken-down, antiquated, self-interested model of reimbursement for care provided called "fee-for-service".  Being a professional who, to the best of my ability, tries to maximize the value of the care I provide to my patients, I subscribed wholly to the notion that the cause of our exploding healthcare cost conundrum is driven entirely by me  and my physician brethren.  We order too many tests and perform too many procedures.  We do this because we are motivated by greed and profit.  The financial incentives to do more,  to pad our bank accounts, to renovate the spare bedroom in our Cayman Island vacation homes, to rip out the tiles in our master baths and replace it all with gold embossed marble, to book a window seat on the next Space X shuttle to Mars, to become minority owners of professional sports teams, simply drives us to do more and more and more, whether our patients need it or not.  Ask not if the patient needs a new Stryker mechanical joint, rather ask "does the patient have knees".  We have been told this time and again.  Battered over the head like the self-obvious cudgel it ought to be.  To wit:

Kaiser Family Foundation:  "Most insurers — including traditional Medicare — pay doctors, hospitals and other medical providers under a fee-for-service system that reimburses for each test, procedure or visit. Coupled with a medical system that is not integrated, this encourages over-treatment, including repetitive tests, the report says"

Robert Wood Johnson Foundation:  "Accordingly, reimbursement under a FFS model generates a strong incentive for a high volume of tests, procedures, inpatient stays and outpatient visits, including those that have questionable potential to improve health.   The incentive to generate income by performing more tests and procedures is exacerbated by having the costs typically paid by third party insurance, masking the true cost to consumers. "

Ron Wyden: "Pay-for-procedure or fee-for-service reimbursement rewards doctors and hospitals for volume - not keeping patients healthy or being efficiency. Pay-for-Performance is clearly one tool that can change the incentives to reward quality."

CBS News: "A systemic driver of high costs is America's fee-for-service healthcare system, in which providers are compensated for each procedure, not for the outcome of care. This system provides providers an incentive to pad their bills by performing as many services as possible, while providing no incentive for patients to decline unnecessary procedures"

Center for American Progress: "One of the key reasons for the high level of health care spending and its rate of growth is the predominance of the fee-for-service payment system, which rewards quantity over quality, especially for high-cost, high-margin services"

Atul Gawande:  "The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.” 


And of course this:  Obama on Surgeons and Amputations

It seems clear enough.  Physicians collectively have betrayed their constituents.  We, as a professional guild, have yielded to crass, craven materialistic pursuits.  The way of the future is the "Accountable Care Organization", an amorphous hive-mind of specialists and sub-specialists who act in concert, an intellectual symphony of elegantly intertwined collaborators who then split up the paltry reimbursements like Trappist monks dividing the fall harvest for winter sustenance.  Further, the dawn of of the Age of  "Value based Purchasing" is upon us.  Remuneration will become 80-90% "outcomes-based".  Are you opposed to paying only for quality?  Then you must agree that it is immoral, heinous, unconstitutional even, to pay for a medical intervention or treatment if the outcome does not lead to complete restoration of optimal health within 30 days.  You must.  This is not debatable.  There are bounds to the limits of what is considered acceptable discourse in the realm of health care reform.


Sure there are inconvenient facts that only seek to cloud the One True Perception of what is wrong with American healthcare.  Facts can be propagandized.  Truths outside the parameters of "TRUTH" will not be tolerated.  The following will be used by the undesirables to bolster claims of innocence and cynically direct one's attention to other targets of cost-containment:

• Reimbursement for general surgical procedures, like inguinal hernia repair, have gone down 20-30% (in nominal dollars) over the past 15 years 
• Hospital charges quadrupling surgeon fees for outpatient procedures
• The robust profit margins (15-25%) of Big Pharma, Medical device makers, and the biotech industry
• The bloated growth of hospital administrator bureaucracy compensation  (six figure salaries for mid level community hospital VP's of Quality Assurance or whatever)
• The fact that 30% of Medicare spending occurs in the last 6 months of a patient's life
• The opacity of the "Hospital Chargemaster" and variability in reimbursements from state to state, town to town.

Disregard all the above.  It only serves to distract from the true villainy occurring every day in individual physician offices and operating rooms.   The true test of a physician's character depends on his or her willingness to forgo personal remuneration for services rendered.  All compensation ought to be contingent on the final outcome.   Only by disconnecting the physician from any tangible financial benefit will we enter the Utopian era of Value Based, Collaborative healthcare provision.   After all, the rest of the economy functions along similar lines.  No one pays their plumber to come out to their home for a leaky faucet.  That's absurd.  We all pay a set, reasonable premium every year for "Household Expenses" which covers your plumber, heating and cooling guy, roofer, various approved handymen, contractors, etc.  And if another pipe, in the other bathroom springs a leak within 60 days, well, that plumber shows up upon demand to fix it sans additional charge.  This is how we control costs.  we simply stop paying for services rendered.  Because physicians are only out to get into your wallet.  They will not stop.  Without an aggressive counter-attack they will continue to bill you for that 4AM appendectomy, for working up your chest pain, for diagnosing your breast cancer.  The world has moved past such depravity.  We have arrived at the precipice of disaster and, looking over the edge, a Paradise extends interminably before us.  I see a world with only healthcare "providers" rather than the unnecessary hierarchical declination from "doctor" to "midlevel practicitioners".  I see bundled reimbursements and capitation.   It is a Brave New World of "Patient Centeredness" and "Accountable Care".  Physicians must fall into place and accept their role as interchangeable pieces, like ever so many Ford workers on a modern assembly line, contributing a small widget to the glorious whole.  The new way strides forth with ineluctable momentum, with or without us.... 

An elderly lady presented to the ER with sudden severe RLQ abdominal pain.  A CT scan was ordered because of concerns for acute appendicitis.  Did she have appendicits?  No she did not.   That amorphous, dark glob you see is actually the patient's gallbladder, down below the level of her anterior superior iliac spine.  We corrected her INR and took to surgery.  Asleep and anesthetized on the table you could feel the firm mass down in the right lower quadrant.  "You'll have to stick one of your ports in her upper thigh", my assistant quipped.  

Upon insufflation we encountered a massive, gangrenous gallbladder just sort of floating around on the right side of her abdomen.  Completely unfixed from the liver it seemed, as if someone had already been by to remove it but forgot to extract it at the end of the case.  With a little manipulation I was able to detorse the rotten sac and flip it over the liver.  It had twisted around the axis of the cystic artery.  I placed a couple of clips on the the important structures, bagged it, and drew it out of her forever.  90% of her gallbladder was completely untethered to her liver bed.  

Gallbladder volvulus is a pretty rare phenomenon.  300 or so cases have been described in the literature.  You can read your little heart out here, here and here.  Most patients are elderly thin females.  The pathophysiology under girding the disease is a poorly fixated, completely peritonealized gallbladder.  Most of the time, a large percentage of the back wall of the gallbladder is adherent to the liver.  This seems to fixate the GB pretty well and prevent unwelcome contortionist maneuverings. as above.  In the elderly, loss of fat and general atrophy of tissues may contribute.  The lady felt much better afterwards.  She went home in a couple days, albeit unhappy about the hospital food.  The fry had been dry.  Who doesn't know how to cook fish?  

This was an older guy who presented with mild, vague upper abdominal symptoms and the above CT scan.  What you should note is the air-density structure located anterior and to the left of  the liver that, believe it or not, is a long redundant loop of sigmoid colon that had meandered behind a laxly fixated cecum, up the right paracolic space and behind a band of omentum above the transverse colon.  The pneumatosis is obvious on the above lung windows.  

Although the guy had a relatively benign abdominal exam, I took him to the OR for laparoscopic exploration based on CT findings.  His sigmoid colon snaked behind his floppy cecum and twisted like licorice as the decompressed proximal and distal limbs curved around the hepatic flexure and came to a cul de sac behind the transverse mesocolon.  It took a little work identifying the ends and reducing the dilated loop but I was ultimately able to get the entire redundant sigmoid into the wound.  The dilated terminus of the loop had obvious, visible pneumatosis in the muscular wall, as if someone had inserted bubble wrap just under the serosa.  It was very weird to palpate.  Strangely, the bowel looked entirely viable.  No ischemic change.  Nothing to suggest vascular compromise.  Somehow, though, despite the chronic volvulus, he had been able to have bowel movements and avoid a complete colonic obstruction.  I ended up performing a sigmoid resection to eliminate some of the redundancy and prevent future occurrences.  He did well.  When I first saw him I was fairly unimpressed; soft, non tender belly.  But the radiologist talked me into it.   

Today in the NY Times there is an article questioning the utility of the 30 day mortality as a valid quality metric in cardiac surgery.  In some states, hospitals are required by law to publicly report 30 day mortality rates after cardiac procedures like valve replacement and coronary bypass grafting.  The article presents a case study wherein a 94 year old patient underwent aortic valve replacement and, unsurprisingly, suffers multiple post operative setbacks and complications.  Ultimately, discussions of palliative care and withdrawal of aggressive support were delayed until she reached the magical 30 day milestone.  On day 31, she was made DNR and expired shortly thereafter.  

The article makes valid critical points about the arbitrary nature of "30 day mortality rates".  Specifically, that surgeons may be reluctant to pursue aggressive care in certain patients for fear of hurting their "stats".  In addition, there is a real concern that palliative/hospice care may be delayed even when it becomes obvious that the situation is futile, thereby subjecting the patient to weeks of unnecessary suffering hooked up to ventilators in an ICU.  

These are good points.  But the lede has been buried.

The real question ought to be:  "Why the hell would you perform aortic valve replacement on a 94 year old patient?"   Simply choose to not put such a patient on the operating table and you don't have to worry about keeping her alive for 30 days.  And if surgeons feel increasingly dissuaded from performing high risk surgery on poor surgical candidates, then so be it.  Maybe that wouldn't be such a bad thing.  I like the idea of total transparency in surgery.  I like published mortality rates.  I like the idea of comparing hospitals using hard cold data.  And I think Americans ought to have a right to  access information that may impact decision making in terms of where an operation is performed.  This ought not to be all that controversial....