Hello Darkness My Old Friend
My friend Nick, the ER doctor, called me the other day to tell me that one of my patients had died under his care. He didn’t have to do that, but he knew I had followed this woman for several years and knew her family well. She had nearly died under my own care a few years ago, but through outstanding work by the ICU and other nurses, had survived and gone home to her grandchildren and had seen the birth of her first great-grandchild. She had thanked me for saving her life, when in truth, I had been largely responsible for her getting in trouble in the first place.
I hung up after the call and was suddenly overwhelmed by a rush of shame, despair and a feeling of loss so powerful that I had to stop the car and cry. Images of dead and dying patients flooded my head for reasons that I still don’t understand. I felt as if I had wasted most of my life pursuing an illusion and that the cost to my family and myself had been too high for too small a gain.
I have been shedding a lot of tears lately. Those who have read these posts or who have read my novels know that I am at heart a hopeless romantic. Even my cynical, curmudgeonly rants are based in a vision of how things should be rather than the pragmatist’s view of how things actually are. I have always been sentimental, but as I have aged, I have found my control slipping. I tear up at trivial things. I’m liable to cry at the movies or over a piece of music. I’ve been known to get choked up over Hallmark commercials.
My chosen profession makes a science of the study of mayhem. We see awful things every day; unexpected death and destruction salted with heavy doses of sadness and futility. Yet our training and our ideal of professionalism forces those of us who chose this life to view those events through the artificial lens of detached objectivity. How can we analyze this patient’s course in order to learn from it? What could we do differently? We remain in control and dispassionate to the end. But that is a lie. Those events affect us no matter what sort of outward calm we display.
We all have regrets about our life choices, even the good ones. I know that. But my reaction to the regret I felt and the flood of memories of all the times I failed to save a patient was completely over the top and frightening. Somehow my worth as a person has gotten all mixed up with my worth as a surgeon. There seems no separation or balance anymore. I still haven’t recovered my equilibrium.
I have never placed much credence in PTSD as a disabling condition. I know it is a real response to traumatic events and that people may be profoundly affected by those experiences, but I always felt that one recovered by soldiering on and drawing on ones strength to learn from the traumatic event. I have often felt helpless and inadequate when faced with a patient who was so ill or injured that I could do nothing to help. You learn to deal with it, to put it in a box and do what you can and move on. Sometimes, though, the box is too full, or the walls are thinned by fatigue or age or by assaults from several sides at once and the whole thing opens up and dumps a load of pain on you. In those times, you need a safe place to cry, or to scream at the sky, until you can recover your self-control and resume the work. But the darkness never really goes away.
Age and the Trauma Surgeon, Part 3
I’m on day five of an eight-day run of Port–and-Starboard trauma call (Navy talk for every other night), and am feeling my age. There was a time when I could do this for weeks at a time and still have the energy to play or go out with my wife. Now I drag home at the end of my off day and collapse into a snoring heap. It hasn’t helped that I’ve had an elective schedule with a couple of complex surgeries on the days when I wasn’t at the Trauma Center.
I’m not complaining (much). I did this to myself so that I could attend a couple of conferences this month and pursue a personal hobby as a side trip to one of them. I also got to get reacquainted with an old friend and her husband, which I enjoyed tremendously. So there is a price to pay for fun and travel.
Aside from the physical toll this week has taken, there has been a mental struggle as well. I accept that I am a dinosaur and that the way that I approach the craft of surgery hearkens back to a bygone era when primary care doctors still saw their patients in the hospital and surgeons accepted full responsibility for the postoperative care of the patients on whom they operated. I feel old when I find myself out of step with the current style of patient care.
I missed a critical meeting this morning at one hospital because I was up to my elbows in surgery at another. The meeting involved a discussion with a group of surgeons who believe that it is OK for their Physician’s Assistant to see their patients after surgery and only involve the surgeon when there is a problem. Even the usually laissez faire Medical Staff president had a hard time with that and wanted a regulation requiring surgeons to see patients for at least 48hrs postop. The fact that we need such a regulation is appalling to me. I had intended to speak out strongly but patient care got in the way. I am awaiting word as to how the meeting turned out. But the mere fact that this is an issue leaves me feeling out of step and, well, old fashioned.
Then there was the surgery that I was doing rather than attending the meeting. My patient had a gallstone stuck in her common bile duct, the tube connecting the liver to the intestine. An attempt to remove it endoscopically had failed yesterday and so she needed surgical treatment. This is a procedure I have done hundreds of times. I’ve done it both with the laparoscope and with the old fashioned open technique. On this particular morning I was working with a surgical resident at the Trauma Center. It came out in our discussion prior to surgery that the resident had never done any type of common duct exploration, either laparoscopic or open. I was mildly surprised. While the procedure is done much less frequently than when I was in training, I hadn’t thought it rare. By the time I was at this resident’s level I had done 20 to 30 common bile duct explorations and was by that time teaching the procedure to my juniors. But no, it seems the operation has become so uncommon that a fourth year surgical resident hasn’t even seen one. Again I felt my age. Times have indeed changed.
In the end, I was unable to get the stone out with the laparoscope and had to do a traditional open duct exploration. It went well and the patient is recovering. The resident was tremendously excited, especially since I let her do much of the procedure herself. Watching her bounce out of the operating room as we wheeled the patient to recovery, I remembered many of my own first times and smiled. I may be an old curmudgeon, but I still enjoy teaching what I’ve learned.
Opening Day is April 6th this year. Spring Training is in full swing and hope is once again in the air. In other areas of the country, Spring is marked by the first green shoots of new plants or by the return of migrating flocks of birds, by the melting of snow and ice or by the onset of the rainy season. Here in Arizona, we don’t get much in the way of winter weather. It gets cooler and there is more rain during January and February, but by and large, shirtsleeves are the norm year round. For the past twenty-some years, I have marked the season by the return of Baseball.
I have always been a fan of the game. Not a fanatic, mind. For a long while my interest was confined to the occasional attendance of a Big League game and some passing attention to the World Series. I have always loved going to the ballpark and watching a game, any game. But I didn’t follow the stats or watch baseball on television (still don’t, but more because television misses much of what’s truly happening on the field).
Then in 1998 a friend convinced me to get season tickets to the newly enfranchised Arizona Diamondbacks. I rediscovered my love of watching live baseball. That same friend had played professional ball as a younger man (Triple-A minor league for the Oakland A’s), and became my baseball tutor. He taught me how to watch the game. He taught me that much of the most important action wasn’t between the pitcher and the batter but was out on the field, before the ball was even pitched. Observing the disposition of the players, their shifting of positions for each batter and in each situation, was as important as whether the pitch was a ball or a strike. My appreciation of the game and its science deepened and I now see far more than I did before his instruction.
Baseball and surgery have much in common. They are team sports played by individuals. You may be a great hitter or stellar fielder, but one individual can’t win a ballgame alone. Surgeons, no matter how proficient, rely on a team to help care for their patients. Big league baseball demands a high degree of expertise and craftsmanship. Subtle clues tell a batter what the pitcher will throw; fielders rely on intimate knowledge of the hitter’s proclivities and weaknesses to position themselves for each pitch; catchers do more than simply catch what the pitcher delivers. Big league surgery demands a similar degree of intuitive perception combined with technical skill.
Baseball is still a major release for me. The rhythm of the game lends itself to quiet reflection and observation, as well as a chance to cheer your own team and jeer the opponents. For the two or so hours I spent in the stands, I am released from obligations and cares. I have no decisions to make, other than whether to get a hot dog or a brat, and I can watch other professionals pursuing their craft with the same spirit I bring to my own.
So come April 6th, I’ll be in the stands with a dog and a beer, full of renewed hope and quiet enthusiasm. Play Ball!
The hospital where I do much of my elective surgery recently terminated the contract it had with a large Hospitalist group and announced plans to hire Hospitalists directly as hospital employees. A less publicized part of that move is an attempt through the credentials and bylaws committees of the medical staff to terminate the credentials of physicians who are associated with that group under an ‘exclusive contract’ provision in the hospital bylaws. In essence that provision states that certain areas are recognized as being best served by an exclusive contract and that physicians credentials to admit and treat patients under those arrangements are contingent on the continued contract.
This has been traditionally applied to services such as radiology, laboratory services and pathology. More recently (20 years) it was applied to Emergency Medicine. At my hospital is has not been applied to anesthesia, cardiology or hospitalist services. The administration would like to change that.
Standing in the way is specific language in the current bylaws that addresses this eventuality for those areas where exclusive contracts have not previously existed. The proposed change in the bylaws language was put forth by several employed physicians and almost got through committee until a sharp-eyed private practice physician on the committee noticed it and had it removed. (No, it wasn’t I who did that, but I applaud his vigilance)
Why should I care? After all, this is about Hospitalists. I rarely, if ever, use them for my own patients and the group involved does not consult me with any regularity. It would seem that I don’t have a dog in this hunt. But I do. And so does every private practice physician or surgeon who sees patients at this hospital.
This is just the latest in the low level war between private practice and the big healthcare companies (and their silent partners in the government). Under the guise of CMS/Medicare requirements, ‘best practice guidelines’, hospital service contracts, and the control of information through the Electronic Medical Record, BigHealth has made the hospital a hostile environment for the solo private practitioner. They have almost completely driven out the Internists. They are limiting the freedoms of the General Surgeon, and have made specialists into mere technicians.
To be sure, we have allowed this to happen to ourselves through complacency, inability to cooperate with each other and a willingness to cede authority to those with the desire to take it. Unfortunately, those willing to take that authority are employees of or shills for the company. The voice of the private practice doctor has nearly been stilled in favor of ‘clinical consensus groups’ and case managers who dictate everything from antibiotic choice to lengths of stay.
There was an old custom during the Edo period in Japan. A Samurai would display his daicho, the two-sword combination of wakizashi and katana, on a wall or stand in the household common room. If the swords were stored with the hilts to the left, the House was at peace since one would have to turn the sheath around for a right hand draw. If the swords were displayed with the hilts pointing to the right, the House was at war.
I turned my swords to the left when I resigned from the Chairmanship of the Surgery Department after eight years in the job. Within six months, every change I had fought against during my tenure had come to pass and the restrictions on surgeon choice and freedom have continued to increase. Perhaps it is time to turn the hilts to the right again, although I fear it will end as a grand futile gesture.