Apr 14

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Apr 17

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 amount of mistakes.

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.


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Apr 02

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.

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Mar 13

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.

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Mar 12

The Society of Surgical Oncology Meeting in San Antonio, 01-06MARCH2011
Dr. Tate is pictured in the photograph trying to remember the Alamo. We remembered it for several minutes, then paused to enjoy a cigar while sitting on park benches just across from the Alamo. We inquired of the status of PeeWee’s bicycle in the basement of the Alamo, and learned that the Alamo actually has two small basements, large enough to hold a bicycle. You can’t believe everything that you see in the movies. The meetings were long and arduous, but we were able to get 34 CME credits for this venture. The conference literally went from dawn until dusk, and so we did not have a lot of time to spend reflecting on the Alamo, but we did get around a little bit. The conference was at the large conference facility just next to the river walk. We’d go down to the river to eat our lunch.

You can see that we were dressed up to the hilt. This is sort of a snobby conference, as most surgical meetings usually occur in more casual attire. The pathologists were having their meeting next door to us, where I was able to encounter one of the Puyallup pathologists. Notice his more casual attire.

We were able to see the San Antonio imitation of the Seattle Space Needle.

It was one of the better conferences that I’ve gone to as of late. Most notably, it was announced that we must stop doing so many axillary dissections, and that while it would have been malpractice a week before to not complete an axillary dissection when the sentinel lymph node was grossly positive, we are now committing malpractice to do the same. The Surgical Oncology gods have spoken and we must obey. NCCN guidelines will be slow to correct the new change in practice recommendations, but we will be patient. So, I return to Puyallup full of vim and vigor, and will be plagiarizing one of the talks I heard in presenting to the other surgeons and oncology doctors the new revelations from the randomized trials.
p.s. too much academia becomes hard to endure…

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