Healthcare

Welcome to the year 2022! I initially wished to summarize the year 2021, but then realized that my post “The Move” essentially accomplishes that. Today I encountered a very well-written critique of health care in the year 2021 by Paracelsus, which can be found here. My only criticism of this article is that it doesn’t go far enough. So, my blog site allows me to add all that I wish as I will now do. I strongly encourage you to first read the article by Paracelsus before reading this blog page. I noted a number of areas of concern that were not mentioned in the linked article, though I’m sure you all might add many more.

1. Loss of ethics
   I have written frequently about my concern that health care has totally lost its ethic, and I will not repeat what I have previously written. On the Feuchtblog.net site, one will find articles that I have written regarding physician assisted suicide and the abandonment of the Hippocratic Oath. Indeed, when I ask physicians as to what the Hippocratic Oath really means, I get nothing but jibberish. They don’t have a clue. Medical ethics has morphed into a creature from the Black Lagoon, something that destroys the meaning of medical ethics. If ethics means nothing more than a common consensus (and not transcendent law), then we are all doomed.
2. The purpose for hospitals
   The the 4th century, the Cappadocian fathers in central Turkey noted that the tradition in Roman culture was to put the sick and hopelessly infirm out into the woods to die, probably by being eaten by the wolves. They decided that a Christian solution was to reincoporate these people into society, and they provided the outcast what little healthcare there was, nurture, and community. Many of these folk died, but many survived. This was the start of hospital, springing out of monasteries, and providing to the sick perhaps nothing more than community and comfort in death’s hour. We’ve since removed hospitals from the monastery, and we’ve also removed the main objectives or purpose of the hospital from the hospital. Hospitals are now places where the sick go because they are a trouble to their family, where families are often forbidden to see their dying loved ones, where abandonment of the patient to a large impersonal system occurs.
3. Advertising in medicine-the commercialization of medicine
   Historically, it was considered unethical for a physician or a hospital to advertise. The American Medical Association stood strongly in opposition to physician advertising, that is, until the Supreme Court (sic!) in the 1970’s declared that the AMA was forbidden to forbid physician advertising. This opened up a can of worms. Physicians took to the airwaves and print. Hospitals everywhere, regardless of how incompetent they were, boasted of providing the best healthcare in the state, and drug companies promoted their latest elixers with elderly folk dancing across the boob tube, offering genuine lies regarding the miracles their latest, greatest, but unaffordable new potion. Medicine turned into a commercial industry, and agencies all the way up to the NIH lost their health care focus, and turned instead to profits as the highest good.
4. Research-blinded trust in science
   During my research years, Dr. DasGupta and Dr. Carl Cohen reminded me incessantly of the need for integrity in research. It indeed was a serious problem in the biological sciences world, the problem of fraud in research often being discussed by Nature or Science as critical issues, involving a large percentage of published papers. Since the 1980’s when I did my research, I can be reassurred that research fraud is more, and not less prominent. Publish or perish is a theme that has intensified in the academic and research world. Yet, we are asked to blindly “trust” science. Is fraudulence in research the reason why standard-of-care recommendations are so frequently changing? Is it why so often public experience doesn’t match the promises of treatment? Is it why prevailing paradigms are so hard to break, even when the paradigms don’t seem to fit reality, and that evidence contrary to the paradigms are soundly rejected simply because it offends the current paradigms?
5. The curse of statistics
   In the same vein as #4, statistics can be used even in valid research to support an illigitimate claim. I have seen it in cancer care, where a new, expensive but marginally better therapeutic drug (and often with significantly higher toxicity) becomes the standard of care norm. How do they do that? It’s all about how one does statistics, and (as the Paracelsus article above mentions), failure to present data focused on the individual survival benefit mislead the patient to the therapeutic benefits. If Big Pharma were forced to provide data which detailed the number of people required to treat in order to accomplish one favorable outcome, most drugs would go off the market as they would be rejected by patients as worthless. Big Pharma most often looks at surrogate outcomes, which are illegitimate in my book. As an example, statin drugs may lower cholesterol (surrogate effect) yet have minimal to no effect on actual deaths from hypercholesterolemia. True story. As an aside, in medical school, I had a community mentor (physician) who would be presented patients with unsolveable symptoms. His first action would be to stop all the medications that the patient was on. The physician noted that most patients would then proceed to get better. Statistics be damned; physicians are often making patients sicker.
6. The Flexner Report as a failure
   I am not promoting the Flexner report, as much evidence exists that it was an entire fraud. The Flexner report was produced early in the 20th century with the prolific rise of of medical schools in this country with widely divergent standards of training. The report was correct that many physicians lacked proper training and were devoid of any standard evidence of competence. The Flexner report attempted to provide some means of setting a standard of competence among physicians. I don’t have a complaint about that. My complaint is that our society has essentially trashed the impact of the Flexner report. We no longer require competence among many, and we have abandoned the used of the word “physician” and replaced it with “health care provider”. Nurse practitioners can now play doctor, and though they carry the word “doctor” after their name, it is from a mostly bogus “PhD” that they obtain by doing research substandard by any other standard, though legitimized by the nurse practitioner schools that now exist everywhere. Now, there are physician assistants which abound but who have very marginal training, yet serve the function of a physician in many settings. These extenders are offered standard of care flow charts that define their therapeutic agenda. Health care providers no longer think. Thinking, and personalized care has been thrown out the window.
7. Insurance debacle
   The insurance industry has a speckled history, starting as a means of providing for the most extreme emergencies in health care. After the insurance industry became self-focused, various physicians joined together to create the “Blues” system (Blue Cross and Blue Shield) to provide a more equitable system for the physician and the patient. Ultimately, what started as a protection against emergencies became the primary means of paying for health care. Costs meanwhile skyrocketed. In the 1950’s, the cost of a night in a hospital bed was commensurate with the cost of staying in a nice hotel room. Now, the cost of a night in the hospital would purchase an insanely luxurious and expensive hotel suite accompanied by servants and abundant frills. A week in the hospital without extraordinary care now will cost the price of an expensive Ferrari or a small home. Without the insurance industry operating as a giant Ponzi scheme, it is inconceivable that anybody could afford health care. I find it especially laughable when some argue about the importance of a free-market system. The free-market system was lost long ago to anybody but the most slickster physicians and a few of the independent family practice doctors. It is likely that independent (not-employed) physicians will soon become as plentiful roaming the earth as the Tyrannasaurus Rex. I realized when I first started a surgery practice that it was a joke establishing a fee for a service that I provided. I was told what I would be paid by the feds and by the insurance companies, who based their reimbursement in proportion to what Medicare paid. Private practice is nearly dead and in 10-20 years will be a historical novelty. The significance of this is that instead of receiving health care from a person, your health care is rendered by a corporation—a big, non-caring corporation whose corporate survival is more important than your survival.
8. Quacks
   Alternative health care has become a public reaction to the absence of trust in the health care community. During my tenure in a surgery practice, I have occasionally referred patients to chiropractors, and certainly feel that they are an important aspect of the health care community. These practitioners argue that they are scientifically based and are able to provide research papers justifying their practices, yet unbiased review by critical analysis shows weaknesses in the data that cannot be ignored. Because insurors will cover many alternative health costs, the pie of the health care dollar going to conventional medicine is greatly reduced. This might not be all bad, since conventional medicine has departed from its original objectives. Alternative care, regardless of the science, provides solutions that conventional medicine are unwilling or forbidden to explore, and is most fitting for certain types of diseases or as wonderful adjuncts for other diseases best treated in the conventional setting, such as cancer. Even still, alternative care has served as a confounding factor in rendering of health care, and mostly acts as a gadfly to conventional medicine in identifying how they have been deficient in providing true health care to their patients.
9. Legal issues
   The claim of the legal community is that lawyers are important in preserving the quality of health care. I would argue that the current malpractice environment massive drives up the cost of health care, while simultaneously driving down the quality of health care. This is a long discussion that I’ve discussed in detail in the past, though lost to the graveyard of digital ones and zeros. Suffice it to say that a true market system of health care would provide a much greater impetus for quality health care than the negative threat of a lawsuit.

I am most glad to be out of medicine, which now uses the euphemistic title “health care”. My arguments and those of Paracelsus indicate the loss of the system that once provided real (though sometimes ineffective) care of a patient. I would far rather die in the personal domain of a family, or on a mountain top, than to die in the sterility of a hospital with masked and gowned, over-worked and (often) under-caring physicians and nurses who provide for formulaic treatments of the signs and symptoms that my body happens to be expressing at the moment. Such repulsion of the health care system causes me to seek health care as minimally as possible, and to be as terse as possible when in the health care domain. As Paracelsus noted, the current COVID “crisis” serves to make clear how healthcare has degenerated into the impersonal beast, a henchman of the state, that does not serve the patient’s best interest. Though we can’t live without the healthcare community, it is becoming harder and harder to live with the health care community.

Why I am Leaving Medicine
Kenneth A. Feucht, M.D., Ph.D.
I formally decided to quasi-retire in October of 2016. This meant for me, getting out of the surgical oncology profession. My intention is to continue working until 31MAR2018 in an outpatient wound care clinic associated with the hospital in Puyallup, WA where I live. Remember that training in my profession consisted of 15 years past the 12 years through high school, so that I have completely identified myself as a surgeon, making my profession not easy to give up. I would have liked to continue practice until I was 65 or more, but frustration with medicine and the changes which have occurred since becoming a physician have led to my desire to leave medicine. This is not an easy decision. I have a deep love for my patients, and found the profession to be quite rewarding. It was particularly satisfying dealing with patients not only for the relief of their physical ailment, but also to help them psychologically and spiritually through a major crisis in their life, which is usually the situation when somebody is given a diagnosis of cancer. With my decision to retire a bit earlier than I had wished, I felt that chronicling the root causes for my decision would be appropriate. The list of my grievances with the health care profession is in no way intended to be comprehensive, but to cover the major areas of frustration for me as a surgeon. This is NOT an in-depth, heavily researched paper with references and documentation, but an off-the-cuff rendering of my feelings regarding the status of health care. Perhaps someday I will take the time to render a more academic version of this treatise.

Health Care Orientation

Hospitals began in the fourth century in central Turkey in a region called Cappadocia. At that time, the poor and destitute who were ill were abandoned by the community and sent away into the woods, where they were often eaten by wolves or other forest beasts. This allowed for containment of communicable diseases, but did not reflect well on the care of the ill patient. It was St. Basil who took these poor people and reincorporated them into a caring community environment. Thus, we get our word “hospice” or “hospital” from the latin word which would be translated as “hospitable”. Hospitals became defined as an agency that attended to and offered the patient an ability to return to the community of the faithful while under care.
Germans have two names for hospitals. The most common is “das Krankenhaus”, though they also use the term “das Hospital”. Translated literally, “Krankenhaus” simply means “sick house”. It is a vastly more fitting word for what we have today, and the term “hospital” should go out of existence. Hospitals are no longer places of caring, and they do not offer the patient a gracious return to the community, or hospitality. They are places where patients are treated with sterile rigor, where children dump aging parents once they have become a nuisance, where occupants are considered to be more work for already overworked nurses, where physicians rapidly fly by patients, knowing that they dare not say either too much or to little, but where everything needs to be documented in a complex electronic database, and where nurses spend most of their time making sure that those databases are replete with boilerplate (and thus useless) data to fulfill various government mandates over what needs to be documented. The entire orientation of healthcare is a narcissistic reflection on themselves looking past and ignoring the raison d’être for their existence, the patient!

Defining “Healthcare”

What is healthcare? What is involved? What is health? What is wellness? How do you define something nebulous? The dictionary defines it as “the maintenance or improvement of health via the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in human beings.” This definition can be strewn out to as broad of meaning as life itself. Is my mental stress over an upcoming test in school a part of healthcare? Is my desire to become and identified as a female when I started out genetically and physically a male a part of healthcare? Is my carelessness in attending to my mental state when I accidentally kill somebody while driving a motor vehicle under the influence of alcohol actually a healthcare problem?
But, why do we even waste the time to precisely define the full nature of healthcare? Is it really important that we have a narrow versus broad definition of healthcare? From a personal point of view, the manner of defining healthcare is unimportant, but from a health care policy perspective, it is vital. The government promises that healthcare will be paid for, but exactly what that means is quite vague. In Germany, going to the spa for a week or two rest is covered. In the USA, the breadth of coverage constantly changes according to what is politically expedient. Oregon attempted to identify and rank cost-effective treatments to determine what might be covered. Since physician assisted suicide is very cost effective, it ranked quite high up. Is this proper? Assisting somebody in suicide seems to be counter to the entire goal of the medical profession, but nobody could doubt that much expense is saved by terminating the patient. If trans-sexual surgery is covered by government policy, why isn’t all cosmetic surgery covered, since it is aiding to personal well-being and how a person defines themselves? Why isn’t food free, since it is really taken to prevent healthcare problems? Why isn’t our housing and the cost of maintaining housing covered, since it all contributes to me maintaining and improving my health?
What about health itself? How do you define health? Is it just the absence of sickness? If so, then obesity would not be a health problem, or smoking, or any other dangerous activity, until it caused a problem. Some people choose to live through disabilities that would be viewed as insurmountable by others and refuse to identify their disabilities as an “illness”.
A frightening result of having an all-encompassing definition of healthcare that is provided for by government, is that they then must adopt the role of supervising our behaviors in order to maximize the government definition of health and well being. Does somebody really want the government telling them that certain activities are forbidden? Does anybody really want government prescribing exactly what you can eat and how much you can eat in order to stay healthy. When Michelle Obama attempted to regulate school lunches in order to decrease obesity, it was found that the children actually became more obese who were on the lunch program. When do we decide that decisions in our life become none of the government’s business? If we allow that government is responsible for health and well-being, we must realize that we are then completely giving away our freedom.
In reality, the public definition of healthcare is impossible and it would be best if we remove any attempt at defining the realm and coverage of what we think as healthcare.

Government interference

We are constantly being bombarded in the news that a new regime of politicians will correct the messes that former regimes have created in federal health care policy. I will speak of ObamaCare specifically a bit later, but here address specifically issues of government policy in health care. Over the course of the last century, we have gone from a situation where there was no government involvement directly in healthcare, to where government pervades virtually every aspect of the healthcare scene. Government first became involved in healthcare in Germany during the tenure of Bismarck. In 1883, he created a national healthcare system which provided insurance to all citizens. Many countries today follow the Bismarck model, though we do not in the USA. (ObamaCare seemed to be a model that attempted to simulate the Bismarck model though not utilizing many of the most important aspects of the Bismarck model.) Through the introduction of Medicare by president Johnson in the 1960’s, there has been a slow invasion of government into the healthcare scene. Government continues to fund increasing amounts of healthcare, and thus has taken an increasing stance toward controlling health care costs. At the same time, the innocent introduction of internal means of quality improvement (such as the JCAHO, which was started by surgeons as a means of voluntarily improving surgical quality across hospitals in the USA) has evolved into a beast that neither improves the care of patient nor the quality of healthcare delivered. More will be spoken on JCAHO later.
In times past, physicians generally took the Hippocratic oath on graduation from medical school. If not the Hippocratic Oath, then a somewhat similar oath (see article on the Hippocratic Oath, referenced below) was offered. In the Hippocratic Oath, three parties are involved, which include the patient, the physician, and the god(s). Glaringly omitted from the ancient oaths were the health care system, insurers, the government, and anybody else outside of the three mentioned. This is only right, and an article I’ve written on the oath covers why such an arrangement is so vital to the doctor-patient interaction (http://feuchtblog.net/die-veroffentlichungen/the-hippocratic-and-other-oaths/ ). Healthcare is now run by a multiplicity of bureaucrats and idiot savants who love to tell physicians and patients what is best for them without any knowledge of either the patient or physician. Government makes a cookie cutter mold that all diseases and persons are supposed to fit into. Diagnoses have a number assigned to them according to the ICD-10 manual, and no diagnosis will fail to have a specific number. Treatments and procedures also have their number, called the CPT code, with a one-size-fits-all mentality.
Government healthcare is run by bureaucrats. These are the self-serving policy wonks and bean counters that control the health care of all occupants of the United States, citizens and non-citizens, consenting and non-consenting, the sick as well as the healthy, the only exception being the politicians themselves. Most often, these healthcare pundits have been in the health care profession as either physicians or nurses, but are now removed from actually providing care, and thus not experiencing the consequences of the policies they implement. Being removed from health care, they may act with heartfelt concern for their colleagues in the trenches, but will never be able to properly address the constantly changing healthcare scene that affects healthcare delivery. In addition, their policies will fail to address all contingencies and variations in the disease process or patient goals and needs.
The government, since they intend on paying for healthcare, are obsessed with the cost of healthcare. Yet, they strangely seem to be the most clueless as to why healthcare costs so much. Perhaps healthcare costs are high because of government interference?
Two organizations from the federal government have been particularly harmful to healthcare, that of the food and drug administration (FDA) and the other the center for disease control (CDC). The FDA started as a well intentioned idea to protect the public from potentially dangerous drugs. The thalidomide incident in the 1960s is instructive. Thalidomide is a medication designed to decrease morning sickness in pregnancy, but was noted well after the fact to occasionally cause phocomelia, very short limbs, in some of the babies exposed to this drug in utero. I’m not sure that thalidomide babies could have been prevented even if the FDA was functioning as they do now, but a good crisis has not gone to waste by the government. It now takes many more years for a drug to go from creation to market in the USA as compared to Europe and other countries in the world. Drug development costs have risen to exceed a billion dollars to get an new drug to market in the USA. Yet, American patients are not safer than European patients, though we are denied rapid access to potentially useful medications.
While the FDA “protects” us against dangerous drugs, the CDC is here to “protect” us from various communicable diseases. I have less of a problem with the CDC than the FDA, though the CDC remains over-reaching in so much of what they do, and persist in trying to justify their own existence. The flu vaccine is a perfect example. It is close to impossible to predict which flu antigens would be dominant in any flu season, and the antigens of choice are made by “educated” guess. I know of no randomized trials that have proven within reasonable doubt that mass forced administration of the flu vaccine decreases morbidity or mortality from the flu. Health care personnel that work for hospitals are mandated to take the flu vaccine, and we have no other options. It matters not that we might have strong personal preferences against the flu vaccine. Another example, Gardasil, the vaccination against HPV, is sold to prevent genital warts, and thus cervical cancer, and is recommended for all males and females between 10-12 years of age. It is of value only for the sexually promiscuous female, but is strongly encouraged that all children receive this vaccine. Long term effects of the vaccine are essentially unknown. The CDC would love to have this vaccine mandated, and there is great pressure on all children to receive the vaccine, even from family physicians. This represents an over-arching hand that doesn’t allow for patients to make personal choices regarding their behaviors and actions, but assumes that all patients (or children) will be irresponsible and not have to take account of their actions. The CDC in effect takes the roll of parent, and displaces the biological parents as having a say in the behavior of your children.

ObamaCare Mess

ObamaCare is presented as the great revolution in healthcare, the solution to all of our problems, the defining policy that will allow all people in America to have adequate health care without obstruction from inability to pay. The health care bill was so voluminous that nobody in congress was able to read it in its entirety, and the proponents demanded that the bill be passed before one could discover what was in it. I won’t belabor the nature of ObamaCare because I have not read the bill, nor have any interest in reading the bill. What I will discuss is how it has affected physicians attempting to care for patients.
Obamacare wished to improve everybody’s access to healthcare, including that of illegal aliens. To do so, health care insurance was mandated to all. If you didn’t purchase healthcare, you were fined. You could either purchase private insurance, or the state would provide options. The rules were tightly defined for enrolling or switching health care plans. The presumption is that all people then had health care. Wrong! The cost of healthcare has continually escalated, and all plans had a copay for any service rendered. Copays were intended to prevent flippant and casual care. In actual fact, it has served to be more restrictive than anything to actual access to care. There are many patients that have turned down a proposed treatment plan for them simply because they could in no way afford the copay. In essence, care became more difficult to get.
ObamaCare also sought to assure that increased value was offered. This had multiple aspects, including patient satisfaction surveys, increased demands on providers to be fully “educated” through CME (more on this later), and increased demands of JCAHO. Patient satisfaction surveys were reported through what are called Press-Ganey scores. For employed physicians, bonuses were heavily dependent of the Press-Ganey scores. While Press-Ganey scores reflected how patients feel about their physician, it had minimal correlation with the competence of the physician. A physician that is the bearer of bad news, no matter how well it is delivered, will often be viewed with less favor than a physician bearing good news. Physicians oftentimes need to reprimand patients or cajole them into healthy behaviors, which is usually not viewed favorably by the patient. Some physicians are quite excellent, but do not have jovial personalities, which patients don’t like. Or, they have a jovial personality but are incompetent, something that a patient might not realize until it is too late. ObamaCare has allowed feelings to supplant honesty and truth, and the end-result will ultimately be disaster. Meanwhile, ObamaCare has flunked in its attempt to define quality in health care, and I’m not sure the ObamaCare act really cares about quality; they simply want the illusion that everybody is getting quality healthcare.
Are people truly having good coverage of their health care problems? The answer is complex, as there are a few people that have coverage that otherwise would have been out. Before government got involved in healthcare, most large cities and all counties had a county hospital that would take care of the indigent. Everybody ultimately received health care. Pharmaceutical firms were good about providing reduced rates on expensive drugs to the poor, and almost all people were able to survive. Now, coverage is actually worse, and many no longer have actual coverage of expensive treatments because they are responsible for a copay, which might be unaffordable. The only group of people who are better covered are those who should not have coverage, such as illegal aliens, or those who are mostly responsible for their own illness, such as burned out drug addicts.
Are the physicians getting rich? Definitely not! Over the last thirty years, physicians had to work harder and longer and more hours to make commensurate pay of the past. As a result, physician burn-out has become a true problem. The solution for physicians has been to become employed. I won’t belabor the problems of employed physicians, save to mention that employment essentially strips them of the definition of a true professional. They are nothing but expensive, sophisticated hired hands, and they will behave as such. People who serve administrative positions in health care are getting rich, and hospital CEOs as well the insurance companies are making out quite well. For the most part, physicians are getting poorer.
ObamaCare has not addressed the reason why healthcare is so expensive, and has diverted the attention from health care costs to health care availability. I am grateful that illegal aliens can receive the best health care in the world for free at my expense. In fact, I am waiting eagerly for anybody to provide an honest analysis of health care costs, and an explanation as to why health care costs in the US are much higher than in Europe or the rest of the world. I can think of many reasons, and simple explanations such as the absence of free markets deflects from serious analysis of costs, which has multifactorial roots.

Physician Regulations

The state has deemed it vital to make sure that physicians are competent. In order to define competence, the state has had to set some sort of prevailing standard, which is an amalgam of current practice and best practice recommendations based on the latest research. This assumes that best practice can be codified and then enforced. It assumes that current prevailing practice is the standard for all physicians and all patients,  and that our knowledge of disease pathology and physiological processes for disease are correct and well understood. Sadly, history is replete with countless times where the medical profession has been wrong and has had to eat their words. It is no wonder that much of what I had learned in training had to be unlearned as simply wrong. Medical practice is in constant change, and not necessarily in the correct direction. One dares not fight the system if the system is going in the wrong direction.
The state needs a way of making sure that physicians are keeping up with the latest and greatest developments in health care. The current standard is to require physician recertification, usually every ten years. The other is the requirement for continuing medical education, or CME. There are serious problems with both of these systems. For recertification, the physician needs to be placed in a box that defines who they are. These boxes are the selected specialties that the physician identifies with, whether that be in family practice, pathology, internal medicine, general surgery, or a host of other specialties. But, these specialties are too vaguely defined, such as in my specialty of general surgery. I am a surgical oncologist, and the American Board of Surgery only recently created a board specific for surgical oncology. Surgical oncology itself is heavily fragmented, between melanoma surgeons, breast surgeons, hepatobiliary surgeons, sarcoma surgeons, and a smattering of other organ specific surgeons. Within the last 20 yars, surgical oncology has essentially lost head and neck surgery, endocrine surgery, thoracic surgery, and colorectal surgery. True, one would like their surgical oncologist proficient in all aspects of cancer surgery, yet reality states otherwise. Regional referral patterns and practices also affect a surgeon’s expertise. Certain diseases are just more prevalent in some areas as compared to other areas of the county. In Chicago, I saw much pancreatic pathology. In Seattle, there is very little pancreatic disease, but a proliferation of other diseases. The truth is that as a professional, one is always reading and educating oneself, and each individual physician will develop a differing broad area of expertise. A simple test imposed by the state is not capable of defining what only the test of real life scenarios can clearly define. Recertification has become a horrid pain to take. I’ve re-certified twice, have done well in my re-certifications, but swore on the last re-certification that I would never do it again, ever, for any reason. Most physicians reach the same conclusions as I have, and the net result is to drive out the aged but experienced physicians. The only exception is in academia, where the surgeon is somewhat protected.
Keeping up with CME is a pain. It is not enough to simply subscribe to various specialty journals and read them on a regular basis. Now, one must answer sets to test questions to assure that you’d acquired the information attempted to be taught by the article. The Journal of the American College of Surgeons would do this for four articles each month, and I dutifully answered their questions for a number of years. About 2 years ago, I realized the stupidity of most of the questions, and how they were usually completely unrelated to my field of practice. The questions were intended to quiz whether you had read the article, but often assumed you had knowledge well beyond that of the article; thus, there was no education of the physician, and failure to judge whether I’ve read and learned from the article. The problem is compounded when articles relate to my own specialty, since I usually read into the question the controversies involved and uncertainty about the information in the article. The multiple guess questions really fail to assess my true knowledge of a subject, yet is mandated in order to assess whether I’m actually staying on top of my specialty. CME updates are demanded by the American Board of Surgery every three years, and I will be letting the next update slide.
Increasing surveillance of physician behavior is happening. This relates to both social behavior, as well as practice outcomes. Hospitals are simply not turning a blind eye to behaviors that would be publicly unacceptable. There has been a change from historical norms, where previously the physician acted mostly without accountability. This is a good thing, and physician antics with the treatment of patients, colleagues or nurses must be now accounted for. The only problem is that it is the hospital that is performing most of the policing, and they have a very strong bias for protecting themselves. Thus, there is predictably unfair judgement against unemployed physicians, and usually it is by someone clueless. I recall, for instance, being reprimanded by the chief medical officer at my hospital for not responding in person to an emergency room call, even though I was in the middle of a case in the operating room. I informed the CMO to no avail that it would be considered unethical and immoral by the American College of Surgeons for me to leave a patient open on the table to attend to another person. Such madness has only gotten worse under ObamaCare. Physicians are still held liable as “captains of the ship” yet are not given the power or authority to maintain that captainship. We are constantly being told to alter our behavior or practice in the most minute ways that have no real bearing on patient outcomes or hospital well-being. The focus has turned from outcomes to process, without any evidence-based data to suggest that behavior changes would be good.
The discussion of “captain of the ship” bears more intensely on issues of hierarchy within the hospital structure. Traditionally, physicians were the main drivers for hospital decisions, dominated the board of directors of a hospital, and were held as primarily responsible for the success or failure of the hospital. Now, responsibility falls to the CEO and his minion of subordinates, most of whom are not physicians, though they might be nurses, pharmacists, physical therapists, or simple business types with no training in medicine. Because of the increasing commercialization of medicine, spread sheets and the color of the bottom line have become the most vital aspect at determining the survivability of a hospital. The physicians have silently gone from being the leaders of the hospital to being nothing but another cost center to be dealt with.

Documentation/HIPPA issues

Until recently, documentation was performed in paper charts, usually a combination of typed text and handwritten notes along with printed reports, lab work, and outside information. Marginal notes would be made in the chart to facilitate jogging the memory of the physician. A typical note would take a few minutes to write, but would be highly effective at documenting an encounter. With the rise of third party indemnification (insurance), the desire to have confirmation of services rendered demanded improved documentation. The saying, “If it isn’t documented, it wasn’t done” became the hallmark message for mass documentation. This led to automation of means of documenting, including boiler plating encounters and procedures. This naturally led to the reverse problem of the past, in that much “documentation” might not have ever been performed. Because boilerplating made possible getting information quicker into electronic format, and with the rise of improved databasing and need for distribution of data, the electronic medical record (EMR) saw its rise. What was once a convenience became a mandated necessity. Many payors no longer accept handwritten charts, and the federal reimbursement systems require EMR for full reimbursement. EMR systems are very expensive, not only to implement, but also to maintain. They solve the problem of a plethora of charts and storage of these charts, as well as issues of lost charts, and the need for multiple simultaneous access to these charts. The down side is harder to see but more destructive. With a combination of requirement for increased documentation, and through the use of boiler plating, excess information now exists, and it is quite challenging to quickly identify the relevant information on a patient. Because of multiple sources for input to the EMR and restricted ability of access users to correct faulty information, the EMR slowly becomes less and less reliable. Errors become quite plentiful, from basic patient information, to diagnoses, medications and treatments.
Meanwhile, privacy of the data has become a greater concern. Physicians were instructed not to talk about patients in the elevator with outside people present, or to share patient data with people outside of the immediate family, unless given permission by the patient. Now, privacy has become a fanatical issue. In the past, I would walk onto a ward, and at the nurses station, a chalkboard list of all the patients and their room number was present. At the door of each room, the patient(s) name(s) were again posted, allowing for re-identification of the patient. This doesn’t happen any more, all in the name of patient privacy. The problem is that it is now easier to confuse or mix up patients, and more errors occur because of that.
Privacy in electronic data is a greater issue. The need for highly secure servers to manage patient data has become the norm, all mandated by HIPPA (federal policy). Yet, the skill of hackers has not been thwarted from obtaining any private patient data that they wish. True privacy is a myth, but the expense that we go through to maintain this illusion of privacy is astronomical. Indeed, true privacy is impossible. Perhaps all patients should present themselves to the physicians office or hospital in full covering like a Burqua or KKK outfit? Yet, the one area where privacy is zilch is with the government. They now know EVERYTHING about you. I fear the government more than I fear some stranger knowing that I happen to be on a β-blocker or some other medication. Yet, the feds have access to every aspect of my health care record.

Big Pharma

I don’t view big pharma as an intrinsic evil, and much of their perceived evil comes from government and legal policy imposed upon them. There is no doubt that the large equipment and pharmaceutical firms have vastly improved the quality of healthcare in our country, as well as throughout the world. It is without a doubt that drugs exist and are available today that never would have been possible without these large companies. But, the large pharmaceutical and equipment firms comes at a terrible cost to all of us.
The large pharmaceutical firms must deal with a host of regulatory agencies, the FDA being the largest of them. One would think that big pharma would be fighting the FDA tooth and nail, yet the opposite is the case. The pharmaceutical firms have seen the FDA as a wonderful means of keeping out smaller competition, which is why you don’t see small pharmaceutical firms in this country. The assistance of the FDA in the assault on the nutritional supplement and vitamin industry is shameful. Big pharma has relished the protection to their industry by the FDA, leading them to become even more powerful at controlling the drug market. Concomitantly, we see larger firms buying up the smaller pharmaceutical firms, and thus becoming ever more powerful.
A secondary problem is created when insurers pay for medication costs, so that the consumer never sees those costs. This becomes problematic if a patient is unable to perform a cost-benefit relationship to determine whether a drug is worth taking. A perfect example are the statin drugs to lower cholesterol. I wait eager to see any statin demonstrate improved survival over the best alternative therapies out there. Statins have a high chance of significant side effects, yet has never been shown to be significantly effective at preventing death from atherosclerotic heart disease. And, they are expensive drugs. Too often, the patient assumes that the physician is using critical judgement in determining the need for a drug, yet the greatest determinant tends to be how good of lunch the drug representative brings to the doctor’s office.

Insurance

A system of third party payment for health care has created the worst possible solution for healthcare. It is a serious misnomer to title health insurance as such, since it does not operate like insurance, but simply as a mode of funding. Insurance supposedly should be most active when there is an acute need, such as with a car accident or a heart attack or a new diagnosis of cancer. Instead, it covers every possible aspect of health care, including runny noses in kids to health maintenance examinations. Under ObamaCare, health insurance is not an optional decision, but mandated by the state. In such a situation, you would expect the health care insurers to making out quite well, and for the most part, they are, with executives of the major insurance companies making exorbitant profits. Yet, there are strains on the system. Insurance is not able to reign in the ever-rising cost of health care, and can only raise premiums and copays to a limit before the system breaks. And, the system is about to break.
Ultimately the big winners in todays system are the insurance companies, but that is a bittersweet win, as they continue to merge with other systems in order to survive. Time will ultimately pass a severe judgement on insurance companies.

Legal Aspects

If you read the popular press, they would suggest that legal issues are a small portion of what’s “broken” in medicine. Whenever malpractice tort reform becomes a subject of referendum up for vote for the public, the advertisements and press attest to litigation being a small part of costs for doing medicine. Yet, those most entrenched in the health care system and actually paying attention what is going on realize that legal aspects of medicine are probably our worst enemy, and that politicians and lawyers who know little of the actual functioning of healthcare are essentially orchestrating how things should be done in the health care world. If a physician suggests changes in the legal world, lawyers tend to attack the physician as ignorant, befuddled, or clueless as to how law actually works. Perhaps outsiders see the legal world a little more clearly than lawyers? Yet, it is most true that lawyers and political meddling in the world of medicine have only left medicine far worse off.
When a physician attends conferences, there are numerous sessions offered on how to avoid or deal with lawsuits. It is made very clear that the physician should understand that everybody gets sued, and that a lawsuit often is the “luck of the draw”, and that a physician should never take a lawsuit personally. Yet, in court, it is presented as just the opposite, and the claim is that there is something wrong with the physician that caused the medical “error”. I place the word error in quotes because it is too often that an error is not an error at all but simply the course of the disease. The lawyer presents a disease process as an entirely controllable phenomenon, and that good outcomes will happen when the standard of care is closely followed. Of course, they will deny this mentality until they are in court, where acts of “nature” serve to reward the lawyer quite generously. In public referenda regarding tort reform, there are usually two most serious claims. The first is that bad physicians need to be punished in order to improve the system. This goes contrary to all evidence yet seen. The second claim is that the tort system preserves patient rights. In actual practice, it does just the opposite, and patients end up with less options and choices in their care because of the malpractice climate which physicians and hospitals have to work in.
Whenever a referendum for tort reform hits the public, the claim defending current practice is that malpractice claims are actually decreasing and that malpractice premiums continue to be less expensive on the physician. Especially after a referendum, this is briefly the case, until the public forgets about matters, after which lawyers come back in force, hungry for more litigation. The malpractice situation has not improved, but remains a crapshoot, where a physician remains highly likely, no matter how excellent they are as a physician, to get sued and lose. The tragedy is that physicians can oftentimes see colleagues that truly are dangerous and yet manage to avoid suits. Cases that hit the public scene are often the most revealing. A few years ago, the leading transplant center in the USA made an error in typing an organ, leading to a hefty lawsuit. But, to what avail? This transplant center defined excellence in care for their service. Does human error necessitate lottery type outcomes for the lawyers and unfortunate patient? That is what happened in the transplant error to a distinguished center of excellence. There are many more similar stories.
What about if the legal profession is eventually proven to be wrong? Do they refund their ill-gotten gains then? I recall the colossal sums won against Dow Corning for the silicone breast implant lawsuit. Not very long later, it was proven beyond doubt that the manufacture of the implant or the nature of silicone did not lead to the alleged autoimmune diseases that the lawsuit purported to have happened. In this situation, the funds should have been returned, at least in part. This only shows that truth and justice are not served in courts of law, and the legal system has no interest in pursuing what is right.
My claim that litigation raises cost of everything is quite easily supported. Think about matters for a brief second. When you stay overnight in the hospital, with minimal attention rendered to you, you could expect a bill for upwards from $20K. I cannot think of any but the most exclusive hotels in the world that would even approach a fraction of that cost, even with servants and the most lavish attention. Why does it cost so much? Medications that are sold for veterinary use typical cost under 10% of what they charge for exactly the same medication with adults. Why? Medical equipment tends to be quite unreasonable in cost compared to similar products in the non-medical market. Oftentimes it is absurd, from a simple little staple gun costing several hundred dollars which if sold as a non-medical item would be several dollars. Why? Incorporated in those costs are both the higher cost of development for the human market, and the potential for litigation. Cows don’t sue, but people do. Yet, there are other subtle cost drivers. Physicians assuredly often act against their best judgement by over-ordering tests and x-rays, and over-treating, all in an effort to protect themselves against litigation. The patient is not given a choice in the matter, or allowed to assume risk. This is because with informed consent, it is still assumed in court that physicians should know better and not have offered choices to the patient if one choice was not assumed to be “standard-of-care”. The physician can’t win, and so plays the game by following the rules, even when the rules are wrong or don’t make sense.

JCAHO

This actually belongs in the “government interference” paragraphs, since the JCAHO is a government organization. Yet, it is so pervasive to all aspects of healthcare, with such overreaching influence on the way medicine is practiced, that it deserves a category of its own. As I write this, my hospital is currently undergoing a JCAHO inspection, and the anxiety of the administration is sky high. They have come by, and declared how various improvements must be made, how there are defects to the system which has so capably served patients. In essence, they are fixing “issues” that are not problems, never were a problem, and never will be a problem. Typically, the fixes are expensive, time consuming, but also require extensive documentation to prove that the fix is actually implemented by the hospital.
One of the most troubling changes in recent years has already be discussed, which are regulations imposed by HIPAA in order to preserve patient privacy. Sadly, HIPAA has failed to recognize that if somebody wishes to bust into the system, it can be done regardless of how intense the security measures are applied to the electronics of the system. The result is the physicians can no longer speak easily with each other about a patient’s care, and the detriment is ultimately to the patient.
JCAHO has long filled any possible useful purpose for itself. Yet, it has become a burgeoning business that must be sustained at all cost. Thus, they have sought desperately to find ways of justifying their own existence. They have accomplished that by creating new and novel regulations each year which they impose on hospitals. They will review hospitals every third year, and if sufficient inadequacies are found, will return a year after their visit to review the hospital for correcting their “mistakes”. During the triennial visit, they will disclose the new regulations, holding the hospital immediately responsible to correct their behaviors and adapt to the regulations. This causes a fleury of anxiety, panic, and hasty development of new hospital policies to match the new regulations. One year, they decided that if a patient was placed in restraints (usually in the ICU), then the order for that had to be renewed weekly. This had never before been a problem, and when there were restraint problems, they were of a nature that a policy would not fix. Another year, it was decided that used instruments or laundry could not be transported to their appropriate destiny in an open environment but had to be completely enclosed. One could hypothesize that bacteria could be spread with these instruments and laundry in open air, yet there has never been an instance where this had ever been a problem. The fix is indeed costly, and must be done in order for a hospital to continue operations. But, the hallway transportation rule defies notion that the hallway itself or the patient room could be transmitting disease between patients. Perhaps the entire hospital needs to be systematically sterilized between patients?
But, JCAHO will continue to work their evil deeds. Health care will become more complex, impersonal, and expensive, and ultimately, less safe. JCAHO is an organization that holds others responsible, but submits to nobody else’s authority. It is a true creature from the black lagoon.

Commercialization of Healthcare

It used to considered immoral for physicians or hospitals to advertise. Pharmaceutical firms were forbidden to advertise prescription products to the public. The American Medical Association held policies forbidding their members from advertising, as found in their code of ethics. The goal for these rules was to keep medicine out of the realm of commercial enterprise. All of that changed in the year 1975, when the federal trade commission considered the AMA policy as an illegal restraint of trade. The AMA rolled over dead. What was immoral one day was considered right and proper the next day. Advertising among health care emerged slowly. Early in my private practice, there was a rule that physicians in our community would not advertise, or even to have their name in bold print in the yellow pages. That disappeared slowly. Soon, one could see a plethora of drug advertising, with elderly patients in perfect health dancing vigorously across the tv screen, proclaiming the miraculous benefits and health giving effects of a medication with multiple side effects and toxicities. A few little lies won’t hurt, would they?
The end result of healthcare commercialization is that it has caused anybody and everybody to seek for a portion of the health care dollar. The highest paid person in a medical community is often the CEO of the hospital. While hospitals still designate themselves as “not for profit”, the non-profit hospital has gone the way of the dodo bird. Quite often, the most vigorously trained physician taking the greatest risks and responsibilities get the least cut of the health care dollar. The pharmaceutical and medical equipment suppliers are making massive profits unheard of in yesteryear.
One could argue that commercialization has led to improved competition and desire for innovation. Yet, competition has always occurred in health care, and innovation has also taken a great toll on our profession, not commensurate with the benefits offered. The most heavily advertised physicians are oftentimes the most marginal physicians. It would be hard to argue that patients are truly better off with advertising. For the reader interested in a erudite discussion of this issue, please read this article… https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2563279/ .

The Flexner Report and its Evil children

The Flexner report was funded by the Carnegie foundation, supporting Abraham Flexner in a review of the existing medical schools in the early 20th century. The report was published in 1910, and intended on promoting standardization of medical education and the removal of marginal medical schools. We now see the evil children of the Flexner report, with regulation of the health care professions at an unprecedented level. The net effect we have had on physicians is increased regulation and requirement for continuing education, which was previously discussed. It has restricted the number of physicians in the health care community, and medical schools have not been able to keep up with the demand, especially in an age where increasing numbers of physicians retire early. It is difficult to just build more medical schools, since the cost of medical education is prohibitively expensive, and the state has had to bear part of the burden of these costs in order to keep the supply of physicians at adequate numbers.
There have been several ways in which the health care community has met the demand. First is through the influx of ever greater numbers of foreign medical graduates (FMG’s) from countries where health care education is not so aggressively monitored. The second is the rise of alternative providers, which include physician assistants and nurse practitioners. Both of these groups of providers have much shorter training periods, which would fail the current minimal standards for medical school training as defined by the results of the Flexner report. In essence, the Flexner report has forced its own extinction, and bred an alternative to the physician.

Conclusion

I am not unhappy that I ever became a physician, and feel that it has been a rewarding career. I am very unhappy with what has happened to medicine. It is like a public good has been stolen and no hope for recovery.
I am particularly sad that most people do not identify root causes for problems, but continually ask for immediate, self-serving, quick fixes to the health care problem. It is a truism that until congress and all of government has to live under the same health care plan that they impose on others, there will be no hope for improvement. I wouldn’t count on it ever happening in my lifetime.
Ultimately, health care will kill itself. It is unsustainable. It has lost its soul. Its original driving force was a Judeo-Christian Weltanschauungen, specifically, the belief that all people, young and old, born and unborn, of all races and creeds, were created in God’s image and of intrinsic value. Humans were not viewed as the accidental product of the primordial slime. Human relations were viewed as important as health itself. Suffering had meaning, which oftentimes led patients to delay in seeking a remedy. Pleasure and euphoria (feeling good) were not considered goals of worthy pursuit. Among health care professionals, the pursuit of “health” and prolongation of life seem to be more in line with personal challenges and a game to be played, the chance of honor for a great discovery, rather than the sympathetic concern for the whole person, body and soul. Purpose and meaning in life are oriented around maximizing pleasure and minimizing pain and suffering. Healthcare is the agent responsible for restoring maximal pleasure, either to the individual or to the community, when things go mentally or physically wrong. The greatest creed of healthcare, the Hippocratic Oath, provided the framework for practicing our profession. Without either a framework or a direction, we flounder. Healthcare, rather than being a true profession, becomes the utility of the state to maintain function and order, rather than the pursuit of a higher good. We have lost our soul in medicine. I am leaving medicine because my profession no longer is a profession of Hippocratic orientation. I have no interest in being a duped servant of an evil state.

Several days ago, I was asked to attend a meeting put on by the hospital in conjunction with outside consultants, seeking ways to improve the working environment in the hospital. The focus seemed to be directed at the operating rooms and surgeons. The consultants were ex-Air Force fighter pilots who now work in the private airline industry flying jets and running this consulting firm. The theme of the discussion was that by utilizing various organizational and procedural methods, the airline industry has been able to significantly cut back its accident rate, implying that the same methods can be brought into the health care industry to reduce the number of mistakes.
The discussion immediately began to focus on critical aspects of relations between physicians, nurses, and techs at GSH. There was a prevailing notion that the old behaviors and attitudes of surgeons would no longer be tolerated, as it was destroying the ability of nurses and techs to work constructively and contribute to the well-being of patients. Surgeons, so it is said, do not listen, and operate under behavior patterns that assure that mistakes will happen. Procedural techniques to fix this problem include creating pauses before cases and having debriefings after cases. During regular operations, hostile relations will be sought to be removed in order to allow the free interchange of information among all parties involved in patient care.
There is much good to this model. It realizes that the surgeon is not God and cannot have command of all aspects of things in the operating room or on the patient floors. It appreciated that various other disciplines such as nursing, dietary, physical therapy, and others have contributions that should be considered in the physician decision-making process. This model realizes that when there is a breakdown in comfort among various groups interacting in a hospital, mistakes are going to be made that were otherwise preventable. I raise absolutely no objection to these ideals and feel that GSH needs to recruit assistance from outside themselves to correct these relational issues. Yet, there is something missing from the discussion noted by the surgeons but nobody else. To that, I will address.
The grass was never greener in the past. Yet, it seems like the hospital is now trying to fix something that they spent the last twenty years destroying. I am not sure that the airline industry and the plethora of consultants have a grasp as to what is really broken. I recall the years when I would make rounds twice a day. During these rounds, I was usually accompanied by either the patient’s nurse or the charge nurse. Ideas were exchanged, thoughts on patient care discussed, and then some social exchange occurred. I knew the name of all the nurses on the surgical floor, as well as their hobbies, family situation, and length of time that the nurse had been at GSH. None of this occurs anymore. It’s not just the nurses’ fault. With declining reimbursement, I had to be busier to maintain a solvent practice, meaning that more surgical cases had to be performed, leaving me less time for other things. The tension between family, hobbies, and work usually meant that compromises had to occur at work. About ten years ago, I stopped doing evening rounds. At that time, nurses also stopped rounding with the doctors. Because the hospital had to cut back on employee costs, nursing aides were the first to go. This meant that nurses had no time to round. Then, electronic medical records came into being, which meant that nurses had not only less time with the physician but also less time with the patient.
Meanwhile, inappropriate behaviors by physicians had become of increasing importance to hospitals. All it takes is one mean-spirited, demanding physician in a bad mood, or, perhaps a kind but incompetent physician in any mood, to make life miserable for everybody in the operating room and on the ward. Oddly, throughout the 20 years of my time at GSH, there has ALWAYS been one or two physicians under extreme fire from the administration. Somehow, when one naughty physician is appropriately silenced or removed from staff, another physician rose to take their place. Often, this was a physician who may have had just slightly inappropriate behavior in the past, but then received the spotlight, which assured that the intensity of maladaptive behaviors would increase. The physician might have been sent to anger management training (no comment on that, watch the movie Anger Management!), or worse yet, sent to Seattle for psychological investigation and therapy. Should a hospital need to appropriately remove a physician from staff, lawsuits could be expected, unless the hospital had adequate documentation to support their claims of persistent and enduring physician misbehavior. Thus, the evolution of incident reports. Incident reports are written now for every possible behavior that might be interpreted as maladaptive, including walking onto the wards with crossed eyes. Any joke, any statement, any reference that might be overheard and misinterpreted by the hearer would lead to an incident report. When a real incident occurs, then the hospital will enquire of all employees as to comments or statements that might have been uttered by the doctor producing the incident. These are all kept in files outside of the purview of the physician. Oddly, the only person in this grand production that was not writing incident reports was the physician, regardless of the misbehavior of the employee toward that physician.
Not surprisingly, the ultimate result of this has been a widening rift between physicians and the hospital. Those physicians who are most dependent on the hospital, the surgical specialties, and OB/Gyn, have had the hardest time adapting. Surgeons have complained bitterly in the past about the widening rift between the surgeon and the hospital employees, but this has fallen on deaf ears. Thus, when the hospital shows an interest in correcting the alienation of surgeons with the rest of the hospital community, it represents a favorable move that hopefully is not too late in coming.
I had mentioned that surgeons and surgical subspecialties have been defined as having the greatest behavior problems at the hospital. What is it that is different about surgeons that make them bad boys? Is it that it takes a certain greater amount of ego and ambition to be a surgeon than other specialties of medicine? Only a select few wanted to go into surgery in the past since the training was extreme, and the risks that the surgeon would take were extreme. I saw many bright young doctors drop out of surgical residency in order to go into a specialty that possessed a tincture of sanity. The few that survived residency often went into fellowships, which were even more demanding on the person. After about 5-9 years of abuse in the training program, the young surgeon would be spit out onto the community in order to practice their trade. Their ability to do brutal things to a patient and yet have them survive could for the most part be attributed to ingrained habits, routines, and developed skills that occur automatically. Success in the operating room is possible when the techs and nurses mesh with the particular style of the surgeon. Of course, this is far more critical for large, complex cases than for small routine procedures. The stakes on complex surgeries tend to be huge, and the ultimate responsibility rests upon the surgeon to get the patient through. It is known that post-operative care is just as critical as intra-operative care, and so similar demands are placed on the nurses and ancillary personnel on the floor to perform commensurate with the expectations of the surgeon.
What happens when the system breaks down? Complications occur, patients die, and fingers get pointed in all directions as to responsibility. Physicians become angry, nurses and techs become frightened or despondent, and further disruption of the system into a fatal spiral occurs. The hospital responds with checklists and policies. Niceness is enforced. Feel-good sessions are enacted. The root problem is ignored.
The surgeon used to be considered as captain of the ship. The airline pilots who were consulting for GSH acknowledged the importance of having a captain on an airplane. The pilot of the airplane has sole responsibility and is allowed the final decision for matters of concern that occur on an airplane in flight. Because of the breakdown in relations between surgeons and nurses/techs, there is no captain of the ship in a hospital. Decisions are made during my meetings and multiple consults. Everybody deserves an equal say in the decisions. If a nurse or other employee feels the physician to be in error, they have the hospital support to correct that decision and change the physician’s order or not fill the doctor’s order. This has happened to me many times and has happened many times to other physicians that I know of. To respond in an emotional manner would generate an anger management recommendation to the doctor.
The airline equivalent is appropriate here. In order to keep things totally safe, we should spend the rest of our life taxiing our airplanes around on the tarmac. The stewardess (now called flight attendant) would have a chance to drive the plane on the tarmac once in a while. Everybody will feel warm and fuzzy.
It is hard to compare the world of the airline pilot and that of the surgeon. The example of following protocols is often given of Captain Scully landing the AirWest plane in the Hudson. It was a tremendous decision. Oddly, he didn’t call a case management conference. He didn’t hold a discussion of options. He didn’t worry about offending the co-pilot, who happened to be flying the plane at the time. He immediately took total control of the plane. He would have not tolerated a stewardess protesting his decision and might have even acted in anger if the stewardess had the audacity to do such a thing. Surgery is always operating under an adverse event. Things are never normal, which is the reason for surgery. Much is not predictable. The human body is not a finely tuned aircraft whose every part and function is known. If we really had to compare the airline and health care industry, then we should force the Airline industry to operate mainly in inclement weather, with a 30% unreliability placed into all the instruments. The pilot could never totally trust his instruments. I really don’t think we’d see the same industry-wide track record for the airline industry. We might see more pilots forced into anger management classes for failing to respond properly to extreme stress.
Physicians used to be the orienting factor for quality health care. Many of the great clinics, such as the Mayo Clinic, Oschner Clinic, Cleveland Clinic, Virginia Mason Clinic, and others were created around a single surgeon who attracted patients. These physicians set the tone of excellence for the entire clinic. Today, hospital advertising tends to promote first-class facilities and techniques such as laser surgery or robotic surgery. Doctor names are rarely ever mentioned. When doctors are illustrated, it is typically a room with either a team of physicians and nurses and ancillary people or a group of physicians together. In a sense, this is understandable. But, it is like advertising an orchestra while focusing on the second violins and never mentioning the conductor. The second violins are vital, but nobody really cares who is playing second violin if the conductor is von Karajan.
The old paradigm of private practice medicine tended to keep the physician stable in the community. Now, physicians tend to be employed by hospitals or large physician groups, and their life situations tend to be far more mobile. As an example, hospitalists have been at GSH for at least 7-10 years, with 10-15 physicians in the group, yet only three of the hospitalists now at GSH have been at GSH for over 2 years. It becomes hard to build functional teams when most of the physicians and employees on the team are transient. Worse, without a stable physician base, it can be challenging for hospitals to promote physicians on their teams. Thus, the public focus is on things that do not promote quality, such as new hospital buildings, new computer informatics systems, and new gizmos in the operating room.
My solution to this whole problem was somewhat novel and required a Sabbatical to realize. After returning from Sabbatical in 2009, I decided that the safest solution was to never, ever do a complex case again. My patient outcomes at GSH historically have been superlative for thoracic cases, hepato-biliary and pancreatic surgery, gastric and esophageal surgery, and complex oncologic cases. Regardless, with a system that I viewed as broken, I was uncomfortable having my patient risk the hospital experience under my responsibility. I do not feel that the hospital has yet allowed surgeons to be the lead driving force for quality improvement. Therefore, I have advised complex surgical cases to go to the university for their surgical treatment.
The system is broken between physicians and the hospital and its employees, and I’m delighted to see the hospital taking a preliminary move toward identifying the problem and trying to fix it. I do NOT want to be misinterpreted as implying that this is a problem limited to my hospital. It is a problem that exists in most hospitals in the US and represents the changing culture of health care. For my hospital, it is most vital that they respond quickly to an ever-deteriorating condition of dysfunctional relationships. Thus, my strong support for bringing in an outside agency to help restore a workable dynamic in the hospital.

It has been uncommon for me to write commentaries of late, in part because there seems to be minimal feedback from the internet community. In my earlier years of web blogging, I used iWeb and it facilitated readers adding comments for feedback. I would never wish to go to a social networking type style, such as with FaceBook, in that it tends to breed short, abrupt thought processes that do not have premises, reasoning, and conclusions demonstrated. It is meaningless prattle. No, even if I love you, I’m not interested in your kid graduating from pre-school, or where you went out to eat last night, that is, unless these events have a significant meaning in your life, and you offer an explanation as to how these events were significant life-events.
Hope. It is one of the three Christian virtues. Faith, hope, and love. Just as we don’t wish to ever cause another person to lose love or faith (in Christ), we never wish to cause a person to lose hope. But, hope in what? I am on rare occasions accused of causing my patients to lose hope. Generally, I try to tell the patient the exact truth. If I don’t, they’ll get it over the internet. I feel that integrity is a foremost virtue for a physician. I have heard many doctors argue otherwise. Dr. Lauren Pancratz argues vehemently that if a lie (deviation from the whole truth) contributes to the betterment of a patient, then we should lie to our patient. I disagree entirely. Truth must be presented graciously and skillfully, but it must be presented all the same.
I see many patients that come from other doctors, mostly medical oncologists, who were never told the significance of their cancer. For many medical oncologists, hope in “the system” must be preserved. Perhaps much of this is self-serving. I find that only 5% of patients do not wish to know the truth of their condition. Most patients welcome it, often are relieved, and are happy that they can better understand their condition and make long-term plans with better knowledge of their condition.
There is a balance that physicians struggle with. If there is a reasonable expectation that the health care system can significantly improve their condition, then I will strive to be positive, even if the short-term outcome is expected to be dismal. In one sense, there is always hope, but that hope depends on the objectives of the physician/patient encounter. If the expectation is to prolong life no matter how miserable that life might be, the treatment options are going to be different than if the objective is to simply offer comfort measures. Both contain hope that the therapy will work, but the outcome expectations are different. Thus, in a real sense, hope is never lost.
The source of hope is my greatest concern. Patients usually do well or do poorly in spite of me. Health care professionals have less control of a situation than they would like to believe. To trust that the health care professional will provide health is a misdirection of one’s trust. It is always a pleasure when a patient comes to me, realizing that only God can give them hope, and trust in Him is of greatest value. It is a pity that so many devout Christians have a seriously displaced hope, trusting entirely in the physician, and not seeing that even the best physicians have feet of clay. Balance is important. To ignore the physicians that God provides is unwise. To expect that physicians always know best is also unwise. Many Christians run to Hookey-Pookey medicine (Chiropractors/Naturopaths) feeling that they are more “natural” or “Christian” than mainline medical practice — that is also highly unwise.
We don’t want our patients to lose hope. We wish for them to have the correct source for their hope. We wish them to have realistic expectations. We wish them never to give up. We wish them to be able to change expectations when the facts suggest it. Mostly we wish them to maintain the three Christian virtues, faith, hope, and love, up to the very last breath that they take.

I’ve written about this before, but the topic doesn’t go away and I’m growing weary of it. Hospital regulatory agencies in our state, and in most states, are being instructed the way in which the airline industry has become safe was through the use of certain regulations and imposed rituals. Especially being pushed on the medical community are the use of checklists, similar to what is used before and after a flight to assure that all procedures are carried out correctly. Our state is now instituting a checklist standard with 100% compliance by hospitals in our state and celebrated by meeting at the old Boeing plant in Seattle, Washington with an author of a favorite book detailing the use of airline safety procedures in health care industry.
I’m all for airline standards, but not in the “pick and choose” standard that is being shoved down our throats. There are too many other airline industry differences that are simply ignored, at the patient’s peril. I’ve discussed many of them in the previous post. Let’s re-hash a few of them.
1. Airline personnel work hours. The airline industry, as well as the government, has strict standards on the amount of fly that a pilot can do, or work that a repairman can do before exhaustion leads to inefficiency as well as mistakes. Nobody would ever dream of climbing on an airplane, where the pilot has been up the last 24 hours and is now exhausted. I have personally called for reform in this area with deaf ears listening. It is hard to imagine that a truck driver in our state is forbidden from driving his truck for greater than 8 hours straight, and yet physicians frequently work for 48-96 hours straight with nary a comment from the state about the dangers that this is imposing. I’ve asked both the medical society as well as state legislators to consider this problem, and it is swept under the rug. Yet, if there are any actions that could be taken to eliminate errors in medicine, this is certainly the most important. Even airline pilots, on long flights, have replacement pilots in the plane to prevent the pilot from having to fly for over 8 hours.
There are 2 main stresses on an airline flight, that of taking off, and that of landing. True, decisions may need to be made in the air, but the main stresses are the start and end of the flight. In medicine, the initial patient consult, the care during a moment of extreme instability, or the trip to the operating room may be likened to the takeoff and landing stresses. The period that physicians spend on call sitting by their beepers could be likened to the time in the air. It is similar, since the physician is still being called, and must make consequential decisions. Many of those decisions are made when awakened from sleep, and more often than not, a night on call will rarely give more than an hour of straight sleep in a night. Yet, we not only have to make significant decisions during the night but must show up at work and consult on new patients or operate the next day. Would anybody feel comfortable flying on an airplane where the pilot had no sleep in the last 24 hours? Thankfully, most patients have no clue how much sleep their surgeon had in the last 24 hours! Comparable to the airline industry, it would be like saying that the only legitimate work-time for the pilot was the time on takeoff and landing, and then who cares how much time is spent in the air since flight time is a low stress.
2. Co-pilots. It used to be that almost all surgical cases had two doctors in the room. For smaller cases, it was the surgeon and a family doctor, and for larger cases, it was two surgeons. Nowadays, it is almost impossible to get two surgeons both in the room at the same time. It is economically unfeasible, and we’ve been forced to adapt. This has mostly been to the greater risk of the patient. Two surgeons on a case always go quicker and better than one surgeon alone. It could be compared to the airline industry deciding that a co-pilot is too expensive to maintain and thus eliminating that position. Maybe it’s time to return to the co-pilot in surgery practice?
3. Retirement – My pilot friends tell me that the airline industry bumped up the age of mandatory retirement from age 60 to age 65. Frightening! Pilots need to go through more rigorous psychomotor testing to assure that they have good reflex timing as they age. Why aren’t they doing this for doctors, especially those who do procedures on people? We are required to take ever-expanding CME classes and tests to prove our mental competence, though it is dubious that either accomplish their intended task. At the same time, we are required to take courses in things we never intend to see or would not manage even if we encountered such a situation, since courses of themselves are absolutely no replacement for real-life experiences. I recently took a mandated pediatric trauma online course in order to maintain my ability to serve our hospital. I felt like I was in the military–dotting all my “i”s and crossing all my “t”s, yet realizing that I had not acquired any true competence at pediatric trauma. We don’t have simulators that can exactly match what a flight simulator can do for a pilot. There are no surgery simulators that will spray blood in your face and give you AIDS if you screw up.
At this time, I have no recommendations for the medical profession, but pray that it soon die the same death that all its patients will eventually experience. Physicians are unwilling to defend their profession from external abuse but complain bitterly about the loss of their profession. Medicine – R.I.P.

Below is an article that I wrote several years ago, that is now more true today than when I wrote it. At the time, we had a flamingly incompetent Chief of Staff (called Dr. Bigshot, since he remains very prominent in politics at our hospital) and the staff of our hospital was all given an article by Dr. Guwande from the New Yorker regarding the virtues of checklists in saving lives. My apologies for not being able to give you the exact reference for this article, as I threw it in the wastebin. I have no problems with checklists. I have a serious problem with assuming that checklists are what saved the airline industry and that people would be saved if only we used checklists. So, I re-post my article. The next post carries on with the same theme, now written contemporarily. BYW, Dennis, I found most of my grammatical errors, but feel free to inform me of others.
Several years ago, tort reform became the cry of the medical profession. We felt that our profession was being destroyed by a litigious culture that was strongly supported by a government that seemed to thrive off of a healthy legal industry. We lost that battle. In return, the law industry laid claim that the health care industry was careless and did not attend properly to quality control or error reduction. In turn, we responded with multiple programs. There were state and national programs that were initiated, such as the 100,000 lives campaign (I await eagerly the 250 million lives campaign). Even in Pierce County, our medical society invited various quality control pundits to speak to us. The rallying cry was to become like the airline industry. After all, did not the airline industry take an intensely complex system, and produce methodological algorithms (such as checklists) to eliminate human error? As I learned in flight surgery school, the number one cause for airline fatalities was a loss of situational awareness on the part of the pilot. Checklists helped to reduce routine operational error, thus, decreasing the one aspect of a fatal error.
The article by Atal Guwande in the New Yorker further fosters this idea that if only the health care industry model itself after the airline industry, then error reduction would significantly fall, and lives would be saved. I certainly agree with Dr. Guwande that checklists can serve some useful purposes in our profession. Yet, I also see certain problems with what he proposes. The first problem discusses differences between the airline industry and medicine, that disallow the airline model. The second details the evidence that Dr. Guwande himself provides claiming that checklists can solve many of our woes.
First, what are the differences between medicine and the airline industry? There are a number of issues that I can list.
1. We can’t control the circumstances. In the airline industry, if bad weather hits, the airlines shut down. We can’t do that. We “fly” in any circumstances. If a patient arrives in immediate need of surgery when the operating rooms are already filled and the patient already has multiple system organ failure, we aren’t allowed to “stop all flights (surgeries)” and wait, in order to get control of the situation.
2. We don’t aim for 100% survival. Ultimately, all of our patients will die, which is 0% survival. Unlike airplanes, we have a poor means of predicting personal survivability. We can quote population statistics, which do not apply to a given individual. Checklists or not, eventually everybody will die on us. In fact, we have very poor means of measuring when we are actually successful in medicine, as it is not necessarily survivability at low cost without complications.
3. We cannot set the circumstances for surgeons or health care personnel like we can with pilots and flight attendants, airline mechanics, etc. I would love to have the same working circumstances as a surgeon as a pilot usually lives. There are strict controls of working hours, and time that a pilot is allowed in the cockpit. We have no such controls. Yet we know that human error is our biggest source of health care error, just like situational awareness is the biggest problem in the airline industry. Establishing mandatory retirement ages, mandatory work-hours, mandatory spontaneous drug testing would kill the industry. I have operated countless times high on antihistamines in the symptomatic treatment of seasonal URIs, yet such drugs would have grounded me in the airline industry. Are we willing to have our health care personnel subjected to such demanding regulation as the airline industry has done? Why not? The object is to eliminate human error, and such airline regulations would accomplish that.
4. Human systems back-up cannot compare. A pilot has not only a second backup (the copilot) always at his side, but also the capabilities of autopilot. Generally, we virtually never have a second physician (with the same expertise) simultaneously participating in a case. Auto-doctors remain to be invented.
5. This leads to a brutally serious question…why have auto-doctors not been invented yet? Autopilots work because one can “figure out” most of the system’s issues and expected problems in the operation of an aircraft. The “machinery” (the human body) that we work with is infinitely more complex than the machinery (the airplane) that the airline industry works with, and the expected problems vastly greater. While Dr. Guwande tends to disparage the “art” of medicine, heralding the virtues of scientific medicine, it remains without question that the complexities of medicine demand both intuitive as well as methodological decisions, and the intuitive decisions cannot be check-listed. An equivalent comparison would be to devise an airplane that is so complex, the ground support personnel never really understand how the airplane works, or exactly what the proper procedures are to repair. The pilot could never be sure whether pushing the joystick to the right would move the appropriate wings or flaps in the proper direction, and would be told that any control panel action would have only an 80% or less response rate, as well as a highly unpredictable nature of whether all the monitors or gauges on the control panel were ever monitoring the correct information. Yet, we live with this all the time in medicine.
6. The economics are different. If the airline industry is asked to institute an industry-wide change, they would raise rates to passengers to pay for that. We cannot do that anymore in the health care industry. In fact, our pay would either remain stagnant or cut, in spite of the elimination of error.
7. Training and retraining. We call retraining CME, yet CME only remotely pertains to our practice of medicine. A flight simulator has never been invented for the health care industry, probably for reasons explained in #5. Our expertise comes solely from experience, coupled with the maintenance of an innovative mindset. When we increase physician educational demands and demonstration of competence through increased testing, the net result is not increased competence among physicians, but a decreased number of physicians, who drop out rather than re-test. This doesn’t mean that we can’t learn from the airline industry. It only means that we need to be very cautious in selecting what methodological algorithms we acquire from the airline industry, and then be highly selective in exactly which circumstances or activities would be well served by these algorithms. It is possible that some systems in medicine would actually be harmed by blindly applying the airline industry methodology of error prevention.
What about Dr. Guwande’s claims that checklists can significantly reduce errors in medical care? Dr. Guwande discusses his thesis with unbridled enthusiasm. In a most unscientific manner, he fails to discuss multiple variables that should have been examined, especially since his thesis of the virtues of checklists are now being mandated throughout hospital systems in the USA. Which variables did Dr. Guwande follow? Survival? Costs? Turnover rates of health care personnel? Patient and family satisfaction? Days of hospitalization? His studies of checklists were limited to highly specific and controlled circumstances, such as the management of central lines. This is a relatively non-complex system compared to many systems seen in medicine. Does he propose that all operating systems will be helped by check-listing? Does he have evidence for that? Newly enacted checklists tend to eventually breed familiarity, which in turn lead to loss of effectiveness. Dr. Guwande has only short-term follow-up of his check-list system, so it is not surprising to see short-term improvements. What do you suppose we will see after ten years of check listing and familiarity itself leads to error? I suspect it will lead to even more detailed check-lists, probably orchestrated by a computer program, rather than a human, such as the nurses that Dr. Guwande used in his catheter study. This in turn will not only drive up the costs of medical care, but also the depersonalization of medical care.
Outside of checklists, the failure to communicate has been identified as the other great source of medical error. There is a great amount of truth to this, and check-lists certainly serve the function of forcing a brief episode of communication among the team, many of whom often don’t even know each other’s name, let alone the most rudimentary facts about the other people on the team in the room. But, we don’t dare tread on that. We must remain scientifically impersonal. Yet, when I work with a team that has known me for years, typically, minimal communication ever occurs about the patient or medical care we are rendering, save for occasional teaching points for the team (we do talk about other things!). We know how each other does things, and we expect things to be done that way. This is true for nurses and techs in the OR or recovery room, as well as experienced nurses on the wards. Sadly, regimented communication cannot fix the problem of operational harmony, something that only time and experience with each other as a team can fix. This is why “teams” are probably more important than checklists. Another communication issue, handwriting, was fixed thirty-some years ago with computer-order entry, quite the norm in Chicago, IL where I trained, but still unknown in these parts.
Dr. Bigshot comments that resistance to checklists is an “ego” issue. I doubt it. True, there are ego issues when one has a nurse policing the doctor. Not even the airline industry has stooped that low, having a stewardess tell the pilot to push the rudder right rather than left when the airplane is going down. But that is exactly what is happening in medicine. You can escape hierarchical disorientation by being independent, which is exactly what Dr. Bigshot has done. Hospital-bound doctors like surgeons and intensivists don’t have that luxury. Is it egoistic to ask questions pertaining to the efficacy of checklists? I don’t think so. Many of us could have easily gone into research rather than clinical medicine. Our training teaches us to ask questions, look for alternative solutions, explore the unthinkable, to agonize over a solution that doesn’t exist in a textbook, journal article, or on a checklist. Yesteryear, that made you a good physician. Nowadays, it makes you a non-team-player, radical, disruptive, or perhaps, worst of all, egoistic.
We will turn to checklists. We will love them with religious devotion. The Joint demands it. We will comply. Yet, it feels like we are driving just another stake into our coffin. R.I.P.

Dr. Mike Brown was the anesthesiologist, and we got the team together for a photo of my last elective case at St. Samaritan Hospital. I am still performing smaller procedures at our surgery center, but have refused to take any further hospital call at GSH and so am restricted on performing elective cases at the hospital. That’s okay with me, but their underwhelming friendliness and willingness to accommodate to my particular issues induce a reluctance on my part to ever return. Who knows? There are always locum tenens, the Franciscans (another hospital group in our region), or possibly focusing primarily on mission work. Meanwhile, it is a little slower at work since I am not taking on the huge cases, and elective hospital cases that I see in the clinic are fed to my partners so that they are busier with paying cases.
 
I’ve been saying goodbye to many patients and will miss them. One patient had a total esophagectomy by me, followed by a major colon resection, and is alive and well ten years later one of my miracle patients. He used to drive a beer truck, and would always ask me for a beer. His first comment whenever I’d walk in the room was “&*^#@!, hurry up, I don’t have all day!” So, the last visit I gave him a few brews to take home.

 
Bicycles… Another Mike Brown is my bicycle consultant, and he has ordered my Steelman bicycle. I am waiting anxiously. I will probably get a cheap Rennrad (road bicycle) in Düsseldorf in January to get around with. Perhaps later in the year, I could return to do the Rhein or pop down into France and do the Alpes d’Huez (yea, mon!!!). Meanwhile, I did the almost unthinkable. I always thought that I would be totally safe with my bicycle mounted on the trainer in the garage. Well, three weeks ago, for some unknown reason, the back wheel flipped out of the trainer, and completely wrecked the back wheel. I had to completely replace the back wheel. Schade!  So, I am back pumping on the cycle. I must be the only person to ever have totaled a bicycle while on a trainer!
 
I’m ready for the year off. I can’t wait to touch base with Herr Doktor Herbert Feucht in Krefeld. I’ve always enjoyed visiting him. Hopefully, I could be a little more independent in Düsseldorf and thus be forced to speak German. With Herbert, he usually talks English to me and spoke about matters when we were out. So, I’m cramming my German right now, while also teaching myself the Sanskrit of the Bengali language (much slower progress!) and a few Bengali words. Bengali definitely is an Indo-European language, and I can see similarities in many words, such as numbers.
 
Our (Betsy and I) only significant activity was a trip to Maui for a Wilderness Medical Society meeting. I didn’t really enjoy Maui. It’s expensive and crowded. I find that it is hard for me to just lay out on the beach and get any serious reading in. So, we didn’t lay on the beach or at the pool even once. We did get around the island a bit, and that was enjoyable. While in Maui, we learned that we now have a little Commie Pinko freak as president. I wasn’t really crazy about McCain and so voted for neither McC nor BHO (I wrote in Ron Paul), and do not feel that mine was a wasted vote. But, I was still a little disappointed about the election. BHO’s presentation at the Democratic convention would most appropriately be called the apotheosis of BHO. Later, schoolchildren would sing songs worshipping him on television. Older folk of all intensities of skin pigmentation on television would lapse into trances of rhapsody for their savior and redeemer from the capitalistic pig, a behavior is more fitting for a Pentecostal church service than a political rally.  It really seemed like BHO was competing with the Almighty as #1 of the Universe.
 
I was even more dejected by the vote in our state to approve physicians’ ability to help a patient commit suicide. You don’t need a physician to do that. Any dimwit can figure out how to kill themselves swiftly and cheaper than a physician. It just isn’t our role to assist in killing. So, I am a bit leery about even practicing medicine in our state anymore. Now that we have seen the death of Hippocratic Medicine, I am left frightened by what will take its place. Medicine no longer has a definition as to its goals. Is it to simply prolong life? Is it to maximize the profits of the pharmaceutical firms? Is it a means of giving the State control of the most personal aspects of our lives? Is it entirely a utilitarian function of maintaining maximal functionality of the States’ citizens?
 
I am left thinking about St. Basil the Great. Basil the Great of Caesarea (in Asia Minor) was one of the Cappadocian church fathers in the 4th century, one of the brightest theologians ever of the church, who also started the first hospital. Sick people were left out in the woods to die by getting eaten by wolves—certainly a convenient way of dealing with the sick! Basil decided to re-incorporate the sick back into society through the use of hospitals.

Kudos to St. B. Is it no wonder that Christianity took the world by storm, without force and without might, but rather by its’ adherents simply being obedient to Christ and being servants of others? Lord, give me both the wisdom and caring heart of St. B.
 
Finally, thanks to Dr. Middelmann for noting some German grammatical errors on the blog site. I’ve hit the one-year mark for my blog/web page. My children, who inspired me to start a blogsite, are no longer diligent at maintaining their blogsites. Facebook has kind of stolen the show. What next?

This week, I received the shocking news that one of my special mentors in Surgical Oncology passed away. Dr. Michael Walker was a fellow for the year that I did my internship, and then stayed on as an attending, and serving as an advisor for me. He was one of my favorite attendings, and very influential in getting me to go into surgical oncology. A quiet and private person, he was patient, kind, with excellent bedside manner, very bright, and most exemplary as the kind of doctor that I myself wanted to be. Michael was quite physically fit, ran all the time, and never had much fat on him. He worked hard, and that got him a position at Ohio State. It was an e-mail from Dr. Das Gupta that informed me of his death. My heart goes out to his wife Lee. Dr. Walker will always be remembered with pride by me.
 
The only person that ranked higher than Mike, in my opinion, was the professor, Dr. Das Gupta, who still remains the greatest doctor I’ve ever worked with, ever, and there were many greats.
 
Of all of my mentors in Surgical Oncology, Dr. Henry Briele remains the most quoted. Cut! Cut! Cut! Today! were repeatedly screamed at me in a sharp, staccato fashion, with me gasping in frustration, worried about cutting the wrong place or the wrong thing. We always used these large blades that looked more like sabers, which I continued to use until they became unavailable.  I still say Cut! Cut! and Today! to others in the operating room, and there are countless techs that have heard of Dr. Briele, even though they have never ever met him. Another favorite quote…I’ll have the electrocautery turned way up, and then say, “If they didn’t want it to go that high, they wouldn’t have made it go that high”.
 
Well, I can go on, but I’d do a disservice to my real hero, Dr. DasGupta.  I don’t quote him much, except something he told me when I was taking too long to close a mastectomy, “If you keep up this pace, you’ll never make it downtown”. Dr. DasGupta will be proud to know that my average modified radical mastectomy with sentinel node biopsy (and completion axillary dissection) rarely takes more than 60-90 minutes. I’ve gotten faster, but also much more precise in my surgical technique.
I decided to do surgical oncology research since the surg onc docs seemed to be the most intelligent and caring surgeons in the residency program. When they criticized, it wasn’t just to make you miserable-they were actually trying to teach you. On the very first day of research, Dr. Das Gupta sat Dr. Tate and me down in his office, asked Peggy the secretary to turn off the phone, broke out a very expensive bottle of Port, and offered Dr. Tate and myself a good cigar. We were his boys. He was our boss. We called him “the Boss”. The only other thing we ever called him was “Scooby”, from what a patient called him once. Dr. Das Gupta once was asked by a patient whether he was German since his name had “Das” in it. I believe that his response to the patient was something like, “yes, I’m from VERY east German!”. My favorite quote of Scooby was to let a patient know that they got better “in spite of us”. Dr. Das Gupta was, more than anybody else, responsible for me getting a Ph.D. He has always been my superior, but also my friend. It is nice to be able to occasionally still ask him for advice or direction. A few years ago, Dr. Das Gupta made the news because he apologized to a patient after making an operative error. The national news lauded this as a unique and unusual form of behavior for a physician. Yet, this honesty and forthrightness were taught to me by him from my first day on service with him.   There is no person in all of Surgery that I would be more proud to call my mentor than Dr. Das Gupta.
 
The lead photo is of a surgeon from Cameroon who was visiting Puyallup. I shall be spending some time next year in Bangladesh, so am now actively trying to teach myself Bengali. It’s hard. I may also spend some time in Africa with Ngoe in Cameroon. My hope is to find the best fit for myself or be able to be available so that I could spend 3-6 months every year overseas.
 
I am unfortunately persistently agonizing over the absence of respect that is given to the older surgeons by our hospital. I keep getting the feeling that they want to get rid of me, yet, when I give them a firm statement that I really, really am leaving, they come running like lapdogs, trying to make amends and promote unity. Today, the Lord Grand High Executioner informed me that I cannot go on courtesy privileges, finding of any loophole possible within the text of the hospital bylaws to refuse me courtesy status for two months while I cover my service but not actually take hospital calls. He finally agreed that he would pay me for call, but, my price is not cheap. I am not a well-worn whore. Several days ago he send me a letter reprimanding an order I placed in a chart. I had a patient on whom I did major and serious abdominal surgery, and she remained with an unusually prolonged ileus. Finally, one day, I walk into the room, and, rather than vomiting on me, she begged me to get her an iced Cappuccino. YES! She opened up! I promptly ordered “Iced Cappuccino, i po qh prn”. Two months later, I get this lengthy reprimand stating that the hospital simply could not provide the cappuccino, so I made the hospital look bad. Oddly, nobody ever spoke to me, or called me to inform me that the order was unfillable, but that alternatives were possible. I would have personally walked over to the hospital and purchased her an iced cappuccino. Unbelievable paperwork was generated by nursing, dietary, and then administration over an iced cappuccino order. Dudes, this goes on all the time. It’s sad to see the “caring” profession to be the least caring people of all, especially those that try to protect the patient from the “uncaring” doctor.
 
I fixed the “comment” device, as it wasn’t working well. Please feel free to leave comments. I’ve also included reports of some more bicycle rides, movies, music, and book reviews. Sometime soon, I’ll leave more detailed note of our future plans.

A little over a year ago, I was having stents placed in my coronary arteries. Thirty pounds of weight loss and lots of exercises followed, as well as a focus on stress reduction. I purchased my bicycle (a Novara Trionfo) in early September and found that I could only do about 10 miles before becoming exhausted. But, I decided in October to do the STP this year (an annual Seattle to Portland bicycle ride). It was a wonderful feeling to do 203 miles at a reasonable pace and yet never feel really drained. I’m already thinking about doing it again, hopefully in just one day. We’ll start a little bit earlier in the day, before daybreak. My main problem is the mistuning of the bicycle had the chain coming off. My bicycle worked perfectly well until I took it in to be tuned at REI several weeks ago. I have never had such a bad time with chains coming off. Fortunately, we had no flats on the trip, though my tires look rather chewed up, and in need of replacement at the end of the trip. I hope that son Jonathan would be able to do the STP with us next year. He’ll have to get riding a bit. I also hope that Ara could make it out next year. Start riding, dude! I’ve learned to tune my own bike, and feeling comfortable about riding long distances, I don’t anticipate any problems next year.
 
Today is Bastille Day! Vive la France! J’adore le Français. Our family is relishing the wonderful freedom we have from our revolutionary forefathers. That is why we try to suppress the spirit of revolution because it’s already been done for us. Now, our benevolent and all-caring politicians will supply our every need, big or small. If your name is Freddie or Fannie, and you just somehow squandered 3-4 trillion dollars, hey, no problem, Uncle Sam will bail you out. Freddie and Fannie might get a slap on the wrist, or be given a few additional regulatory orders, but that’s it. The kind and ever gracious benevolence of our dear politicians also wishes to provide for your’s and my healthcare. They will make the rich pay. The rich are anybody that is not buried six feet under.
 
When I put on my libertarian Ron Paul hat, I demand that the health care system be as far removed from government as humanly possible. There are several problems with that. 1) The feds require that health care be provided for all. Though the emergency room is only for emergencies, eventually every disease will become an emergency, in which you can go to an emergency room and demand care for free. 2) The feds have imposed massive rules on health care that make it nearly economically unstable. These rules are most prevalent in hospitals, governing the most inane items, such as initials that have been used for orders since the development of medicine, and are uninterpretable only to the clueless, like lawyers. 3) The legal profession has defined an ethereal standard of care that forces maximal possible care in all situations and makes you guilty even when right. 4) The feds have defined pricing for all but the most elective procedures, such as plastic surgery and dermatology procedures. This means that we have absolutely no control over overpricing. We take what we can get, and rarely is it comparable to other highly professional services rendered and always without the extreme risks that are assumed by the physician. 5) The feds have removed value from the cost of medicine, forcing costs to sky-rocket. 6) The third-party payor system has removed cost impact on the health care consumer, thus removing any sense of value to any drug or procedure performed. How much is an appendectomy worth? What about a perforated appendectomy in a 500 lb diabetic smoker with heart disease that stays in the hospital for 2 weeks. Under medicare, the surgeon gets about $400 for any case of appendicitis, slightly more if the appendix is ruptured. That is barely enough to cover overhead costs. Medical care no longer has value, and the public expects it for free. 7) Our current system was based on a historically previous better economic arrangement for physicians, which allowed them to often render services for free, such as caring for indigent patients or offering their time as “community service” to the hospital as call. With the loss of any margin to health care, most physicians (especially surgeons) can no longer freely give of their time, creating extreme tension between physicians and hospitals, with physicians now demanding to be paid for their hospital service call and hospitals insisting that such care continue to be rendered for free.
 
The only difference between the current US health care system and most European health care systems, such as that in Great Britain, is that the socialized system in the US is funded mostly by entrepreneurial private dollars, while the socialized system in Great Britain or Canada funded by public funds. In reality, we are giving the feds a very foolish deal. They can carry on the most asinine regulatory actions, pretend to offer tort reform, offer grandiose promises to the public, and act truly sincere about caring for the health care provider. They reluctantly save the health care system at the last moment after doctors throughout the nation have kissed the derriere of their local politician with begging and pleading not to enact Medicare cuts (which still is a cut, since current inflation is estimated at between 3-16%) thinking that we should be ever grateful for them. As a response to decreased Medicare reimbursement, private enterprise is trying to become increasingly creative about making a profit. Historically, our response to decreasing reimbursement was simply to work harder. Now, we are working as hard as possible in order to maintain financial equity. Several years ago, a colleague announced that he was going to take a week a month off since that would then give him the equivalent of an eighty-hour work week and provide some sanity to his life. Several months later, his revenues plunged to not even supporting his overhead. He is now back to much less time off, and making a modest profit, though his investments are probably more financially rewarding than his profession itself, and he rarely ever seems to be happy or enjoying himself at work.
 
With all of this under consideration, I have several proposals. 1) Private enterprises quit funding federal health care programs. We should back out of investing in health care, whether it be for our own private offices, or for community-driven ventures. 2) We should encourage medical care to go to a purely socialized venue like Canada. This will force the feds to live by the insane rules that they create since they will be creating them for themselves. This will also not allow for “boutique” practices, which is healthcare that tries to escape from the “system”.  3) We should quit funding the entire bureaucracy through taxes. The state is currently sucking us dry. If you count all the taxes that we are forced to pay, including Medicare, income, property, sales, telephone use, vehicle, and many other taxes, all but the poorest are paying over 50% of our income into taxes. Stop working. Retire. Go on Medicare. Leave the country. Find another profession. Live off the inheritance you were planning on giving to your children. 4) The final solution (Enderlösung!) is to find a system whereby the hospital or state assumes all of your overhead, and truly pays you on a per-hour basis that is commensurate with your skills and level of training. This would also allow you to work as much or as minimally as possible without incurring major debts through massive overhead. Sadly, such a system doesn’t exist. If physicians would uniformly refuse to continue funding the system and allowing to hold us in forced servitude and quit, go on strike, shut down, or terminate virtually every state and third party payment, the system might be forced to correct itself. Until then, the fed is going to be content with letting private enterprises fund their health care follies.
 
With all of this under consideration, it would be best for me to get out of medicine altogether. Yet, I continue to look for alternatives, with less stress and fewer work hours. I will not be a sacrificial lamb to the state.
 
Vive la France!

Dennis, if you comment, please keep it short, and mention something about your celebration of Bastille Day.