The discussion immediately began to focus on critical aspects of relations between physicians and 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. Tension between family, hobbies and work usually meant that compromises had to occur at work. About ten years ago, I stopped doing evening rounds. About 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 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 makes 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 doctor 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 the 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 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 happening 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 situation 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 the stable physician base, it can be challenging for hospitals to promote physicians on their team. 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 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.

The Emperor of All Maladies, A biography of Cancer, by Siddhartha Mukherjee ★★★★★

After having been in the cancer field for over 25 years, this book still was able to provide insights and stories in the “war” against cancer that I was quite unaware of. Dr. Mukherjee starts with a review of the most primitive and ancient treatments for cancer, which typically were to do nothing, or even worse, to attempt to do something. He does a masterful job of describing how the nature of cancer slowly has come to be understood over time. Mukherjee elaborates on the earliest attempts at surgery, followed by attempts with radiation and then chemotherapy for cancer. Occasional serendipitous successes often led to either skepticism or unbridled optimism regarding possible cancer cures. Mukherjee paints a masterful picture of interacting actors in the scene, including physicians attempting against the advice of colleagues in the first chemotherapy trials, colleagues outright rejecting too aggressive of researchers, drug companies hesitant to engage in the development of expensive new drugs, and public opinion spinners all interacting to generate the interest and then funds to permit cancer research to occur. Mukherjee, being a medical oncologist, definitely provides a serious bias towards the defeat of cancer through finding just the right chemicals, receptor blockers, and pathway interrupters. Though he writes with a conservative tone, one is still left with the idea that all we need is a short amount of time and another godzillion dollars and cancer will be in the past tense for everybody. I heard that statement at a major medical meeting from the head of the NCI in 2008, alleging that with the current progress, we would not see a cancer death after the year 2012–that leaves 9 months for them to find a cure.

I appreciate how Mukherjee refrains from being totally inclusive and chasing every possible storyline, but selects out the main channels, such as the driving forces for the development of the NCI and American Cancer Society, while omitting the development of such groups as the Susan Komen breast cancer story. He’s honest in noting that for the most part, we still remain in the primitive stages of finding the solution to cancer. His stories orient around the Sidney Farber Cancer Institute in Boston, and that is understandable. He beautifully paints a personal face to oncologic care through his stories of patients, both under his care and other physicians. This book can be understood by both physicians and lay alike, and a most worthy read.

Enjoy Every Sandwich; Living each day as if it were your last, by Lee Lipsenthal, MD ★

I read books or watch movies given to me by friends with great reluctance. Unless I’ve known you a long time, I typically find that the differences in world-view or likes tend to not mesh. This is an example of a book given to me by a friend who felt that it was most significant in his life. He felt this to be a great gift as well as source for meaningful conversation the next time we meet. It was a great gift, though I truly found that I could not connect with the book. Here is why.

Enjoy Every Sandwich is the autobiography of Dr. Lipsenthal, focusing mostly on the last two years of his life, when, at age 51, he was diagnosed with esophageal cancer, went through typical cancer treatment with the addition of some New-age medicine, only to die slightly more than two years later. Lipsenthal candidly expresses his thoughts from the last two years of life, and his desire to enjoy life to its fullest is appreciated.

Where Lipsenthal fails is in his ability to understand fully the nature of his experience. He describes his “battle” against cancer as his war on cancer, and his dying as simply fulfilling the Kübler-Ross stages of dying. The war metaphor for cancer I find especially troubling. We never speak of the war on flu, or appendicitis, or diabetes, or dental caries, and when the war metaphor is used, such as in political campaigns or the war on drugs, it is usually by a government entity trying to dupe the public into cooperating with their silly nonsense of creating a straw enemy that trillions of dollars could be wasted in order to “fight”. It’s as though Adolph Hitler and adenocarcinoma of the esophagus were comparable entities. Regarding the Kübler-Ross stages, that is total nonsense. The emotions that a person experiences when dying are multiple and far more expansive that Kübler-Ross describes, and the variability in the order of progression (stages) is as multiple as the Betz cells in her brain, though they might be few.

What I found even more disturbing with this book is the authors’ absolute obsession with himself. He is one of the most self-absorbed narcissists that I have ever read. There is no dimensionality in his life, and the cancer doesn’t make him progress as a person. Such moments as when he threatens to leave his wife if she didn’t start connecting with his alternative medicine – New age medicine thinking was typical of his overwhelming self-importance. All that really mattered was himself. Lipsenthal doesn’t end life with notions of higher aspirations, or the feeling that the impact of his life gave others a fuller meaning, other than dragging his family and friends into the inexorable hell-hole spiral where he was headed. Following Buddhist thinking, he could give no meaning to his pain and suffering, and thus had to form a “universe” in which the pain he was experiencing was not actually real or of value. Then I think about the person Lipsenthal, he is exactly the person I would avoid, and choose not to befriend. His inspiration comes from rock music, sports, and himself. His world had no meaning and had no dimension outside of himself.

Yet, it is his advice on health care alternatives which are the most disturbing to me. Lipsenthal generates an amalgam of native American spiritism, Buddhism and spiritism, new-Age thought, mysticism, and Wiccan thought into a form of “spirituality”. True, Christian religion was mentioned, but his thoughts on Jesus and advice from scripture were most in line with what the Scripture uses to describe Satan and his lies. Indeed, Lipsenthals paranormal mystical experiences prove only that there is something out there beyond what science itself can discover. It fails to show that there are contesting “spirits” in this spiritual world, good and evil, and that evil is a true oncologic entity, not just something that the Buddhist can wish away into non-existence. Lipsenthal is most worried about happiness, which only makes sense if you conclude that there is no such thing as truth, true meaning, redemption, or morality. His second to last chapter is on love describes a love that is alien to my thought on true self-sacrificial love, as well-described in I Corinthians 13. His love is a narcissistic love, a love for self, and the warm fuzzy feeling that perhaps others also love him, and that he loves them in return.

I remain at a total loss as to how mankind can give up the eternal truths of the Holy Scriptures, and buy the rubbish of the new spirituality. In a sense it is no wonder, because Scriptures remove your focus from yourself and places it on God alone. Christ makes impossible demands on you, yet gives you the strength to live right, and forgiveness through his death (substitutionary atonement) to allow the triune God to treat you as though you did nothing wrong in His eyes. All that you must do is believe in Him. So simple. So true. But, it is so contrary to our very human nature that wishes to do the work for our personal salvation, to merit God, to become intrinsically good, to be a “self-made” person, and to honor ones self as god. For the Christian, our duty is to glorify God and enjoy Him. We give Him glory in our health and also in our sickness, as we trust Him as an all-loving God, the embodiment and ontological definition of true love. Though He has ordained all that comes to pass, we find meaning in our lives by orienting our lives, and the lives of those we come into contact with, in a worshipful relationship with our creator God. Sickness and death are a great evil, but God uses the evil that comes upon us in a meaningful way. Life in its totality becomes a joyous experience  as we live it coram deo. I  offer only one alternative author, C.S. Lewis, in his two books A Grief Observed and Surprised by Joy, autobiographical accounts that give an alternative view of the world, our existence in it, and suffering. As a cancer doctor, I can give countless examples of seeing both miserable deaths and meaningful deaths. Of the meaningful deaths, the death of a Christian holding fast remains the most overwhelming. Lipsenthal has offered a cheap imitation to the truly significant life. I pray that readers would find the shallowness of his thinking and discover the true riches of life and death as found in Christ alone.

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 is 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 unto 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 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 goes 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 pyschomotor 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 on-line 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 it’s 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.

Several years ago, tort reform became the cry of the medical profession. We felt that our profession was being destroyed by a litigious culture which 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 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 for 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 URI?s, 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 on a case. Auto-doctors remain to be invented.

5. Which leads to brutally serious question…why have auto-doctors not been invented yet? Autopilots work because one can “figure out” most the systems 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 any more in the health care industry. In fact, our pay would either remain stagnant or cut, in spite of 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 error 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 operational systems will be helped by check-listing? Does he have evidence for that? Newly enacted checklists tend to eventually breed familiarity, that 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 checklisting 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 sources 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. Which is why “teams” are probably more important than check-lists. 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 ego-istic 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 check-list. Yesteryear, that made you a good physician. Now-days, 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.

Many people have asked me about my views on ObamaCare, and what I would offer as a reasonable fix to the healthcare “crisis” in our country. I have no hope that our wonderful government will be able to fix the mess of healthcare. This is why I support the Obama health care plan. If it goes through in its entirety, it will destroy medicine. Then, we could start over. Maybe. Unfortunately, too many conservatives blame the government for the health care problems of the USA, while the liberals wish to give the government everything. Neither makes sense, because neither side takes the time to ask what is really wrong with American medicine. My final answer is that everything is wrong. There is no party or group that doesn’t stand innocent of our mess. Specifically, finger pointing must include all parties, including government, the lawyers, big Pharma and the health care industry, physicians, hospitals, insurers and third party payors, and patients themselves. I will be very brief in how each party is making a mess out of medicine.

1) Government. Government would love to control medicine. It is intrinsic in government to have control of the people, whether that government be a democracy or a totalitarian regime. Our constitution was established to restrict the power of government. Now that our constitution has become a “living” document, it may be interpreted and changed at will, usually to the effect of offering the government more power, and us less. I cannot think of a single government in the world and throughout history that I would trust my body and my life to, yet, that is essentially what we are asked to consider with the health care plan of St. Obama, the patron saint of the infirm. Medical ethics will become what is good for the masses, rather than what is good for the individual, since government will always seek global, rather than individual solutions. Decisions will be made that are most politically correct, and not what is most morally correct, or what maintains the highest dignity and honor to the individual. It has been argued that health care delivered by government would be less expensive and more efficient, yet, I cannot bring to mind any federal agency that delivers efficient services without graft and corruption. A simple look at pure government health care systems, the Veterans Administration and military medicine show highly inefficient and expensive systems with shoddy health care delivered in a haphazard fashion, always at the whim of an incompetent and fickle congress. One only need to pause at the countless ways in which the government has made physicians lives currently unbearable, including ever increasing and expanding agencies to regulate and control health care. Need I mention JCAHO and the totally ridiculous demands them make on hospitals, or Medicare and its “fraud” provisions on honest and hard working physicians. To the feds I say, no thanks.

2) Legal. Many conservatives have argued hard for legal reform, feeling that it is the legal system in most part which has destroyed American medicine. Arguments have returned from our legal colleagues of the necessity of our system to safeguard and protect a vulnerable public from increasingly greedy and immoral physicians. In fact, conservatives refuse to look at the breadth of the source of problems of our current health care debacle, and lawyers refuse to accept that we need more protection from increasingly greedy and immoral lawyers than that of physicians. Estimates that suggest that the current legal climate drive up the costs of medicine by 40-50% or more, are off by about 1000%. There is no longer any bang for the buck; the health care consumer has discovered that it is cheaper to fly to India for major heart surgery, and yet receive reasonably equivalent safety in their health care. The lawyers have not protected us, but instead, have stifled creativity, autonomy of physician-patient relations, and made health care unaffordable. Every drug that I purchase, and every medical device that I use, has a cost that tends to be 10x-1000x more expensive than non-medical or veterinary equivalents. Malpractice has driven up the cost of practice of countless physicians who have chosen to switch trades, retire, or sell their soul to an employment situation rather than endure unsustainable malpractice premiums, regardless of whether they have ever been sued. Lawsuits themselves have no correspondence with the personal competence of a physician or hospital. I see quite competent physicians occasionally being sued because they choose to manage riskier cases, and incompetent physicians that have never been sued. Somehow, lawyers don’t connect. When a surgeon goes to trial, they usually try to avoid a jury trial, only in that they know that a jury will be another form of wanton injustice, since juries will always sympathize with the party that can generate the most tears, rather than the party that claims the moral high ground. The practice of our trade lacks absolute control-biological systems, being overwhelmingly complex, can have only partially predictable behaviors. Since physicians can only know limited facts of any given medical case, there always remains the possibility of things going wrong, outside of our control, regardless of how careful we happen to be. The legal system simply cannot correct that. Efforts to build in increased safeguards in hospitals have only served to sweep problems under the rug, and no serious study has ever shown a hospital to be safer with the use  of recently enacted safeguards over those hospitals that do not exercise those safeguards. The driving factor for all this madness is the accusation of the legal system that health care needs to clean up their act. The legal system remains clueless about the true nature of medicine, and will only make healthcare problems worse rather than better with their well-intentioned efforts.

3) Big Pharma and the health care industry – There was an epoch in American history where physicians and health care industry was not permitted to advertise. Physicians felt that advertising would degrade their profession with distraction for economic gain from medicine. Indeed, for the most part, this has happened. With the combination of appeal directly to the public, and government regulations that supposedly protect the public but more importantly protect the mega-health care industry from competition, and protect markets, it is not surprising that big Pharma has erupted into a multi-billion dollar industry. We see how this has led to major corruption, such as the Martha Stewart shady investments in Erbitux, a drug that cost well over a billion dollars to develop and bring to market. Big Pharma naturally has a lot to loose, should a drug like Erbitux suddenly be discovered to have untoward unforseen side-effects, or if it proves to be less effective than originally believed, or less useful than other drugs on the market. Naturally, such pressures would be overwhelming for a large corporation, and easy fudging of the numbers (many ways to do that!!!) tends to protect great investments. In the end, we are all hurt. Are we much better off with Erbitux? Perhaps a little bit, as it is a useful drug in many circumstances, such as in head and neck cancer. Yet, patients truly are not living too much longer with as compared to without the drug. Big Pharma continues to appeal to the general public. You can see elderly people dancing across the tv screen in a proverbial retirement paradise, all thanks to Viagra or Flomax or Arimidex, or etc., etc.. The message is conveyed that the drugs bring a fulfilled life, happiness and joy, peace and prosperity. This advertising is an overt lie, and the advertisers know that. I do not wish to indulge into Big Pharmas’ cozy relationship with Big Government, and their desire to overwhelmingly protect themselves rather than the patient. Notice how little they protest the FDA or the legal climate in the US, even though those two factors so steeply drive up the costs of new medicines. I don’t believe Big Pharma really cares at all about you and me.

4) Physicians – I wish I could say that physicians were not a part of the problem, yet we are as much of the problem as anybody else, but for differing reasons. First, physicians have not stood up to their oaths of morality. The Hippocratic Oath is no longer used anywhere in the US, but entirely replaced by Oaths, sadly, including the Christian Medical and Dental Society Oaths, which focus more on population and societal ills, as a focus on the patient themselves. Physicians are not politicians–we have in our care only one patient at a time, and our morality evolves around that patient. We were historically bound to patients by covenants. The legal binding now is a contract, which in turn diminishes our profession into an occupation similar to that of a garbageman or plumber. Our major Medical societies have rolled over dead when reprimanded by government, rather than standing up for what is right. I refer specifically to government forcing rulings on various drugs, forcing the AMA to remove their restrictions on physician advertising, and forcing the health care community to accept and comply in the murder of unborn children. Now,we are even complying with the murder of the elderly. We have lost our morality, allowed medicine to be turned into a business rather than a high profession, allowed government and Insurance companies to intervene between us and the patient, and then we scratch our heads wondering what went wrong. We did it all to ourselves.

5) Insurers and Third party payors – In the eyes of some people, it is the health care insurors who receive all of the blame. Certainly, Michael Moores’ movie Sicko seems to cast much of the blame for America’s health care woes on the Capitalist pigs that govern the major insurance companies. This might be the only theme in Sicko that Moore has partially correct. Contrary to Moore, it is the act of third-party indemnification, whether that third party be a “capitalist” insurance company, or a government, that creates serious problems. First, it places a fourth player in the game of the covenant between doctors-patient-God, as defined by the Hippocratic Oath. It removes much decision making from the patient, and gives it to the insurance company or to the physician. The patient assumes minimal responsibility on an economic basis for the health care decisions that they make, especially if the funding for the patients’ health care came from an employer insurance policy, to which they paid nothing (save for lower wages). In reality, health care insurance no longer functions as an insurance plan, except for those plans that are high deductible or catastrophic. The contracts that and insuror makes with the patient loose their legitimacy when a patient demands high expense procedures, such as transplants or major cancer therapy, and insurors often are forced to comply regardless of the contract. In some states, there is no “pre-existing” clause, so that patients may obtain insurance whenever they wish, without penalties. Insurance companies have sought for survival, but usually at the expense of higher premiums to all, rather than fighting public and government insanity in court.

6) Patients – I love most of my patients, and so I must be quite careful about what I say about them. All the same, in our state, it was over 50% of my patients that voted against tort reform, even though they deny that in the exam room. It is many of my patients that demand free or almost free care. Co-pays are greeted with disdain. It is many patients that expect me to be available 24 hours a day, 7 days a week, 365-366 days a year, and never make a mistake or error in judgement. It is many of my patients that live a life of wanton self-abuse, and then are angry at me that I can’t miraculously fix them in a day or two. It is many patients who lie to me, abuse me, take advantage of me, expect perfection of me, and have no qualms at suing should an opportunity arise. Ultimately, it is the greater than 50% of patients who allow government to get away with murder, vote in idiots such as Obama and Reid and Pelosi, and demand free health care for all. It is the same patients who are so severely protesting ObamaCare, but who refuse to admit the serious problems in the current system, especially with Medicare. I am grateful to God that a good number of my patients see the problems that exist in health care, though they remain powerless to enact a change.

So, I return to my original statement. I hope that ObamaCare succeeds, since it will destroy medicine. Maybe afterwards, a better system could resurrect. Maybe not. Ultimately, our trust is in God, and not doctors. As I grow older as a physician, I realize how powerless I am to add time onto a patients’ life. It still seems to remain entirely in Gods’ hands. Too heavy of reliance on physicians seems to do as much harm as too little reliance on them. But for now, I simply do not foresee any viable fixes to the healthcare crisis, unless the entire system, from the patient to the government corrects. I doubt that that will happen. To attempt a fix of only one aspect of the health care problem will only make the entire health care crisis worse. I don’t wait with hopeful expectation for a solution.

Following my heart procedure and then subsequent Sabbatical, I’ve had time to think about medicine and what is different about my profession from when I began as a private surgeon in 1992. The opportunity of being away from medicine for a year has been especially helpful in delineating what seems to bother me about the “New” Medicine.

1. The feminization/effeminization of medicine: The percentage of physicians that are female have sharply increased, so that in many medical schools in this country, there are now a majority of females. This is especially true in surgery, where the shift toward female doctors have taken a sharp upward turn. As a female, different expectations are held toward the profession. It is often the activity that conflicts, rather than supports family life. The female psyche of being more a nurturing person changes the approach to the patient. Oddly, this feminizing effect on medicine has affected even males. They are no longer supposed to be aggressive. They must be gentle and never lose their temper or raise their voice. They must now approach their patient as an advocate, friend, sympathizer, rather than as the authority and aggressor against their illness. As we have seen the effeminization of male movie stars, who previously were masculine and tough, Clint Eastwood types, but are now boyish girly men, male doctors have had a tendency to become girly men in the ways mentioned above.

2. The foreign-ication of medicine: I will be the first to comment on my absence of objection for foreign doctors. I believe that foreign physicians stimulate thought and provide wonderful new perspectives to American medicine. My favorite doctor of all time ever, Dr. Das Gupta remains a role model and mentor, though he was born outside of the USA. Yet, I can’t help but think that there is a problem when greater than 50% of our physicians are foreign medical graduates, and not necessarily assimilating into the American cultural belief systems. Besides religion, they differ in such drastic things as how they view the nature of science, medicine, and life itself. Many come here, assuming that wealth and lifestyle will be an automatic given, and often end up frustrated or disappointed when that doesn’t happen.

3. The accelerated gentrification of physicians: we see both an effect on the older physician, and a response that older physicians are giving to their profession in this gentrification. First, modern technology demands rapidly changing practice patterns in order to keep up on the latest-greatest. This often results in ping-ponging of management, that is, certain techniques or management methods are forbidden, then encouraged, and then later forbidden again. Otherwise, newer technologies or treatment plans come in that are often demanded by the patient, but offer no distinct advantage, are far more expensive, but take seemingly forever to discover the errors in their thinking. We see physicians retiring early, or, as soon as possible. They simply don’t wish to put up with the arrogance of younger doctors and competing technologies that seem to be more hot air than distinct helps to the physician or patient. We also see a loss of respect for the older physician. They tend to be out-dated, not with it, hopelessly lost in the past. It takes years to make the best physician judgements, yet these older physicians are no longer respected. A most functional medical community would allow the older physicians to slow down, and work with younger physicians to help them develop skills. This is not happening, and an increasing generational gap happens between younger and older doctors. In times past, the older doctors were able to hone their practice to allow for their decreased ability to be as physically agile or supple as the younger doc. It is more difficult to stay up at night, to have great physical strain in caring for sick patients, yet, there is no reprieve for the aging physician. Thus, for an aging physician, it only makes sense to get out asap.

4. Economic and legal dis-incentivation of physicians– The cost of medicine continues to rise. Prices on medical commodities continue to inflate at standard or accelerated rates, rent and employee costs continue to rise, taxes fail to go down, all of this eating away at physician profitability. Meanwhile, reimbursements continue to fall. When one subtracts costs from reimbursements, you get a number that is essentially your profit. If you divide that profit by the hours that you work, you get an essential pay rate. Currently, when accounting for inflation, I made more as an apprentice typographer than I am currently earning as a physician. Ultimately, physicians will deem the effort not worth it, and consider an employed situation, volunteering, or switching professions. Worst of all, many physicians will remain in their trade, while playing other trades such as gambling with the stock market or real estate investments in order to make a reasonable income commensurate with ones’ education and overall “sweat factor” to get where one is. Remember, most physicians started as quite competitive throughout high school, college, and even competed seriously in medical school, if one desired a more challenging specialty. Residency could be quite variable, but usually seriously limited ones’ lifestyle in years past. As an example, I spent essentially 16 years in “school” past high school to get to a point of being able to earn a living, and all the while accrued hefty school loans. Meanwhile, friends who started to work after high school were able to establish families, purchase homes, and become quite established. Others, who enlisted in the military or worked government jobs immediately after high school were 4 years from retirement by the time I was able to earn my first dime. I don’t pull out too many Kleenex when people complain about doctors’ earnings. But, what about legal dis-incentivation? It is not infrequent nowadays to see articles in surgical journals lamenting that certain surgeries are safer at high volume centers, and even though one may examine their own track records and see competitive  morbidity and mortality rates, the pressure is still extreme to transfer those patients on. When deciding to tackle a more complicated case, the reimbursement is no higher than a simpler case, yet the amount of time spent could be quadruple to ten-fold. At the same time, one is not legally protected for medical “heroics”, but could always be faulted for assuming care of certain patients. Thus, there is every reason to stick with simple cases, and transfer off more complicated, high risk cases. This does a terrible service to many patients, where travel away from families and known surroundings and a known medical community makes life more difficult, and often increases the risks to the patient. I have often seen where patients go off to these “centers of excellence” only to receive vastly inferior care to what would have been provided back home in a smaller hospital. The legal climate offers me no incentive to attempt to retain these patients.

5. The rise of public medical pseudo-professionalism with de-professionalization of physicians–Patient empowerment is a good and a bad thing. It is good when a patient comes to a true specialist and then gets a more complete picture of their current illness or situation. It can be bad when patients determine that they are more knowledgeable than the physician. I wish to add one caveat here. Patients always know themselves best, so that a decision for or against a medication or a surgical procedure is something that they need to choose in their own mind, and it is not good for a physician to force a treatment plan on a patient against the patients’ better sense, no matter how wrong it may seem to the physician. Contrary, when a patient attempts to force the hand of a physician for a treatment that the physician feels to be wrong, you could expect only trouble if the physician gives in. Much public pseudo-professionism is a result of a combination of the internet and big Pharma direct patient marketing. Another way in which pseudo-professionalism manifests itself is with the “2nd opinion”. In the past, a second opinion was often required by an insurance company. Now, many websites encourage seeking a second opinion. The problem with the second opinion is that a patient will never be able to adequately and critically choose between two doctors without a large amount of personal health care experience. Rarely is second opinion thinking correct. I have had patients turn me down because their second opinion physician gave them a kinder hug at the end of the session, or had a slicker office, or had better name recognition from advertising. When I discover that I’ve just wasted an hour or more with a highly anxious patient who just saw me as a second opinion and now is even more anxious in needing to decide between physicians, I will ask them for what criteria they would be using to determine who would be the best physician for them–typically, their answer betrays the other physician promising false security or over-rated expectations of what is physically or humanly possible. Therefore, I refuse to see second opinions, and will immediately cut off a second opinion visit unless the patient swears that they intend to stay under my service. I am not an entertainment committee to amuse the curiosity of needy patients. They can watch a medical soap on television for that.  Meanwhile, while patients become the “professionals”, physicians are rapidly loosing their concept of “professionalism”. I already railed about physician advertising, the loss of a true moral creed for physicians, and increasing dishonesty with physicians. Since the advent of the 80 hour residency workweek, personal time and comfort has taken a strong priority over the care of the patient. I was taught that one always sacrificed personal time when a patient needed your care. Residency meant almost never planning an event, since your primary responsibility was for your patients, and not the movie or restaurant you would be attending that evening. It was considered immoral to be an employed physician, as that meant confused loyalties. All of that is gone, and physicians have become nothing more than highly intensively trained plumbers or electricians. We are no longer professionals, but sophisticated and highly educated blue-collar workers. In return, we no longer have the right to expect to be treated like professionals.

Concomitant with these changes among health care professionals and patients, are changes that are occurring throughout our society, which influence medicine and the attitude of physicians.

1. Loss of personal integrity. I am called by the chart reviewer and asked to up-grade a person’s admission for no reason other than increased reimbursement by Medicare, and Medicare would allow it. The whole idea seemed quite dishonest to me, or at least encouraged serious inconsistencies, that would leave us physicians always wondering from moment to moment whether we were being “honest” rather than violating some crazy medicare rule. Physicians no longer desire integrity as a supreme quality. Efficiency and profitability come first.

2. De-personalization of others. While walking home one day recently, I passed a number of people, and would usually smile at them and either nod my head or say hello to them. The typical response was for the passerby to walk on, head slightly turned away from me, and not even acknowledge the presence of another person. De-personalization has affected medicine in many similar ways, so that people have become more and more fragmented, consisting of lungs and livers and intestines. This attitude has been true of the past, but distinctively truer now, and more obvious on the wards.

So, where does that leave me? In a sense, I dread being back in the bathtub of medicine, since the water now has become quite filthy. The next feuchtblog will talk about who is responsible for breaking medicine. I might eventually write a blog about my thoughts regarding what could be done to fix the healthcare crisis that we are in.

Don’t Let the Goats eat the Loquat Trees, by Dr. Thomas Hale ????

I really wanted to give this book 5-stars as I truly enjoyed reading it. Thomas Hale is a wonderful writer, mixing an entertaining style with a story line that is quite fascinating. I truly appreciated his frank, honest style, that seemed to hit home with the experiences that I had in Bangladesh, with the overwhelming number of patients, the extreme poverty, the prejudices against Western medicine, the personal struggles, the struggles with natives and their own peculiarities. He never paints himself as the miracle doctor, and seems to spend more time describing his failures than his successes. The book starts out as a chronological narrative for several chapters, which left me ready to put it down. He describes himself and his wife as not having a clue as to exactly where they were going, or under what conditions they would be living. The first thought was that I was reading the story of a quasi-clueless but deeply atruistic missionary dragging God along as the magic puppy-dog who bales him out of every trouble created by dumb decisions. This book ended up being anything but that, and reflected a very pragmatic, hard-working surgeon who had a very realistic sense of what he could expect and accomplish in Nepal. Much of the book was written in non-chronological order, but with chapters divided into various topics, such as the living conditions, certain events, and philosophical reflections. I enjoyed the chapters where he vignetted various patients.  So, my criticisms. 1) I get a flavor for his character, but read almost nothing of his wife, kids, other doctors, or other people involved in his life. 2) He speaks some of Christ, but little about the intention to bring Christ to the Nepalis. I am not certain whether his motivations were altruistic vs. Christ oriented. 3) The final few chapters entails rhetoric of a Malthusian nature, with him fretting over population growth and food supply and wealth distribution. It seemed like a chapter right out of the clueless mutterings of Tony Campolo, Thomas Sines or Ron Sider. Overlooking the criticisms, this is a fun book to read and reflective of what it is really like to be a missionary surgeon. I hope that someone like Dr. Kelley offer an autobiography of their own experiences in the field, which certainly would be as enthralling, but leading toward a more appreciative conservatism and reflective of a work of God in the mission field.