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Sid Schwab's blog

Stop, Stop, You're Killing Me

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Actually, you're killing us all. More conditions for which Medicare won't pay.

"Never events." What a great term. In case you haven't heard it, the reference is to complications or outcomes for which, in essence, it's considered (by Medicare) that there's no excuse. Should never happen. No how. And, incidentally, for which we won't pay. The list is expanding.

Trouble Ahead

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Whether entirely due to the effects of the eighty-hour work week or not, I see trouble ahead in surgical care in the US.

In my personal blog, and on those of many others, one can find alarms raised about the effect of the eighty-hour work week restrictions on the training of surgeons. For a few years now, my friends in academic surgery have been telling me of the changes they see: "Shift-worker mentality" (meaning people no longer considering it their job to maintain continuous care of their operated patients), and the dilution of specific surgical experience are the main concerns.

Res Ipsa Loquitur

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How a recent court case argues for single-payer health care.

Having nothing but time on his hands like any law student, esteemed reader of my personal blog Patrick sent me a link to a pdf containing the arbitration brief of a recent and widely publicized case.

Brittle Beauty

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Knowing the beauty and fragility of the human body. Scary.

I think my first real amazement in med school may have been learning about the nephron. Don't ask me to recount it in detail; that part of my brain has long since been emptied and refilled with concern about fiber and bladder trabeculations (another good med-school word.) Looking at it one way (a perverse way?) the essence of medical school is the building of a sense of wonder at the complexity and beauty of the human body, and the essence of becoming a surgeon is the realization of how breakable and disposable it all is.

Surgeon General

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Thoughts by a general surgeon on the muzzling of the surgeon general.

OK, this is going to be a little political, but it's related to surgery, and to me personally, if vaguely.

A recent Surgeon General of the US, David Satcher, was a classmate of mine in medical school. And the most recent one is a surgeon like me. In fact, he trained where I trained. Them's my bona fides.

I find the following outrageous, and as far as I'm concerned everyone but the most blindly partisan ought to share the feeling:

Soft Touch

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On the value -- and disappearance -- of the old-fashioned physical exam.

They told me in medical school that the diagnosticians of old could thump on a chest and detect a tumor as small as a centimeter. I'm not sure I ever believed it, but I've always had a love for the art of physical diagnosis -- of touching, feeling, listening to the body, and coming to an understanding. As technology invades and pervades, that art is becoming almost (not quite) superfluous and antiquated; an amusing throwback. Look at that old guy, touching his patient. Sweet, really, if a little creepy. Hasn't he heard of ultrasound?

War Story

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A doctor's view of what war does to people, why it ought to be the last of the last resorts, what "supporting the troops" really means.

"Doc, you gotta help me. I can't take it any more." In the midst of the assorted humdrum and the occasional catastrophe, that was the complaint I heard the most when I served in Vietnam. And mind you, compared to the grunts, I had it way good. I, and the people for whom I was a doctor, lived on a base, not in the jungle. It was up north a ways, not far from the DMZ, and 160 mm rockets thumped (when far away) and crashed (when close) their way across the base pretty much every night. "Oh, Rocket City," was what people said when I told them where I'd been assigned. Still, by some measures, you could call it cushy. And that's my point. War, even at its edges, ravages people. The threat of random rockets dropping through the roof of your barracks can lead to "I can't take it any more." Think of the guys on patrol in Iraq and what their job does to them.

Good Days/Bad Days

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If an athlete is expected to have bad days, why not surgeons? Many of us, after all, are practically human.

I watched a bit of the Pac - 10 tournament final the other day. A player for the Duckies was so "in the zone" it seemed anything he threw up went in. It was simply magical; I'd guess even some USC fans were mesmerized by what they were watching. You've seen something like it, I'm sure. A no-hitter where the pitcher has such control that he can do anything he wants with the ball; a running back who seems to move through the opposition as if they were paper posters; the gymnast who scores 10 after 10. A diver; a swimmer. It's another of those things that probably can't be studied, but it seems pretty clear: on some days for some people in some situations, there's a coming together of mind and body in such a way that leads to a level of control far beyond the ordinary -- even when "ordinary" for these extraordinary athletes is beyond anything the rest of us could even dream of. And, likely as not, another day not soon thereafter, those same people can't hit a shot, get the ball over the plate, stick a landing to save their lives. Of course, they're not actually saving lives. In the operating room, you need to pitch a no-hitter, sink all your threes, stick your landings every time. But is it a reasonable expectation, given that -- not unlike sport -- it's an intensely physical undertaking, translating very specific intention into very particular material result? If everyone else loses it once in a while, why not a surgeon?

Times are a' changin'

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A rumination about surgical training, then and now.

This may sound self-indulgent and egotistical (what? from a surgeon??) but bear with me: I have a point.

I think I can honestly say my patients did well to have me as their surgeon, even as my wife may have gotten the short end, husbandly, and my son likewise, fatherly. By which I mean I spent my career, for whatever reasons, highly devoted to my patients and my practice, at the expense of my family and personal life. I simply had no choice in the matter: it's how I was trained, and what I believed. I was never entirely comfortable ceding surgical care to anyone else, even my closest partners. And for the first few years in practice, until I realized the folly, I even abhorred medical help: I felt obliged to manage even the intensive care of my patients. For a while, I was probably as good at it as the intensivists (of whom there weren't a lot, early on). As time went on, and I (happily) had only the occasional critically ill patient, I came to realize I wasn't the best one for the job. But surgically -- well, I never felt my partners would take as good care as I did. It might also be true that they felt likewise, in reverse. One would hope that all doctors felt that way. Or so I think. Thought. Wonder....

Welcome

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An opening salvo for what is hoped to be a weekly column on surgical matters.

I'm honored to have been asked to write a column for the Medical Blog Network. It's my intention to post on a variety of subjects broadly related to surgery, and it's my hope that it will provide useful information for readers. And entertainment.

As I feel my way around here, finding what's going to be most useful, let me be so self-centered (what?? A self-centered surgeon??) as to refer the reader to my personal blog, www.surgeonsblog.blogspot.com, wherein the reader can learn a bit about me, and get a taste for what I may have to say here. Testing the water, I began here with a cut-and-paste job from my blog. I don't plan to make it a habit.

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