Thursday, February 12, 2009


Separated by about two hours on different continents two of the finest mind in history were born two hundred years ago today.

Abraham Lincoln (1809 - 1865) "Nearly all men can stand adversity, if you want to test a man's character give him power."

Charles Darwin (1809 - 1882 ) "It is not the strongest of the species that survives, nor the most intelligent, but the most responsive to change."
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Tuesday, February 10, 2009

Green eggs and surgery

With office surgery suddenly being the rage in my speciality, I have had to ask myself whether I will begin to do procedures currently done at an outpatient center in one of my exam rooms. Many reasons are cited by my colleagues for this change in practice. I believe I have heard most of them so here is the list:

"It is more convenient for the patient." (Some of these doctors practice in a fifteen story office building with basement garage parking. The surgery center is a single floor with a drive through for picking up the post operative patients.)

"Patients are more comfortable at their doctor's office where they are familiar with the staff." (But these doctors hire a company to come into their office one day per week to accomplish these procedures and when was the last time you were 'comfortable' in any doctor's office?)

"It will cost the patient less." (The co-payment if the patient has insurance is the same. The surgeon charges the same. The people who own the traveling surgery center bill also.)

Last but certainly not least is the one true reason that I suspect physicians are now doing office surgery: "I am making three times as much money doing the same procedure." For some reason, probably that insurance companies have not caught up to the billing procedures, the reimbursement for an in-office procedure is much higher. About three times as much in fact as the reimbursement for the same procedure in a surgery center.

Yes, endometrial ablations are being done in doctors offices to lessen or stop menstrual periods so that the surgeon can receive as much as three times what they could for doing the same procedure at an outpatient surgery center.

I had this exchange with a company representative for one of devices used:

LDM: "Well, I don't think I am ready to do these procedures in the office. What if I wanted to try your product at the surgery center?

Rep: "No problem! I have the equipment in the trunk of my car. Here's my card. Just call me and I will bring it over."

Thinking about this sparked the following in my mind:

The rep, let's call him Sam, is ready to help

"Where would you, could you do this?" I hear him yelp.

"It is all about patient safety can't you see.

"I took that oath saying primum non nocere*"

"But everyone is doing it this way," cries Sam with glee.

"That's what I told my mother but still she never let me."

Would I, could I do surgery anywhere?

Only if patient safety is optimal there!

*Latin for "first do no harm" in the Hippocratic oath
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Sunday, February 8, 2009

The best medicine

One of the most important parts of the education process for medical students and residents is the tradition of "rounds" with the attending physician. Called "rounds" for the way that the group progressed around the hospital seeing patients and discussing each individual case, this is a right of passage for all who enter the profession. Now having ascended to the position of attending physician on the teaching staff I try to remember when I was a student or worse the second year resident.

I say "worse" because medical students are not expected to know everything. Also medical students are the only ones who believe that interns (first year residents) know anything. Everyone, the attending physician included, expects the second year resident to know it all. Laboratory values, vital signs and X-ray reports maybe recorded on a three by five card in your pocket but as the second year resident you should have this information committed to memory on each and everyone of her patients.

Also the second year resident must be able to list the differential diagnoses for any disease that the patient might have from memory. In order to have such a mental catalogue of this information the grueling physical labor of residency is matched only by the mental agony of constant study. Soon even the resident dreams about patients, diseases and possible scenarios of complications.

While I was in medical school now some thirty plus years ago smoking was allowed in hospital corridors. One of our oncology (they specialize in treating cancer) attendings frequently lit a cigarette (go figure) on rounds. When I wasn't a member of the group, I would glance down the hall and see smoke rising from his entourage. Someone else had joked that Dr. L only smoked to disguise the fact that he was frying the second year resident.

When my turn came to rotate with Dr. L, I was very fond of the second year resident in our group. He was witty and very caring where the patients were concerned. An all round nice guy, my stomach churned for him one afternoon on rounds when the attending found an area of weakness. Unable to list the differential diagnosis for a rare blood disorder revealed by this particular patient's laboratory values the resident began to stall. A master a "roundsmanship" as we called it, he asked Dr. L to repeat the question. Then when he finally answered incorrectly and Dr. L began to be quietly berate him, he hung his head.

Finally, when the verbal lashing was over my hero did a most amazing thing. Thirty years ago the TV series Star Trek was big and the resident pulled his wallet from his back pocket, flipped it open, and said, "Beam me up Scotty. I can't take it down here anymore." Most of us were choking back a laugh and trying to hide our smiles when Dr. L did something that I, nor to my knowledge anyone else had ever seen. He burst in to a belly laugh. As a matter of fact, Dr. L laughed so hard he had to put out his cigarette AND he dismissed rounds thirty minutes early that day.

In addition to having diffused the tension, the extra thirty minutes allowed us all to run to the nearest copy of Harrison's textbook on Internal Medicine to look up the answer to Dr. L's. question. It also taught me that laughter is a valuable elixir even for the dispensers of medicine.
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